April 2000 • Volume 6 • Number 4
Getting FPs to small-town America
Rural training tracks rise to the occasionBY SHERI PORTER
OmahaGood ideas survive. So it's no surprise that "one-plus-two" residency training has enjoyed stellar growth in the past decade.
Today, the nation has about 30 accredited rural training track programs, an increase of more than 60 percent since the rural training track concept popped onto the scene in the late 1970s. Most RTT models feature the "one-plus-two" format -- one year in a university hospital setting, followed by two years in an outlying location.
Above: Resident Terry Becker, M.D., chats with Patricia Neville after her yearly physical in Ravenna, Neb. Left: The clinic in Doniphan, Neb., stands out -- the building sits smack at the edge of a cornfield.The idea is to grab residents who relish the thought of life in rural America -- and get them in that setting as quickly as possible.
"If we train residents in Omaha, it becomes difficult to get them out to a rural practice. We need to train people in rural areas," says James Stageman, M.D., director of the family practice residency at the University of Nebraska Medical Center in Omaha.
"The perfect applicant is someone who is from rural Nebraska," he adds, because residents with roots in small communities are often anxious to return to that setting.
A dire need for physicians in underserved areas is fueling the growing trend of RTTs. Stageman says the University of Nebraska program has a mandate to train and place rural physicians.
The residency program convinced two residents to pioneer its first rural site in Grand Island in 1992. Eight years later, the program lists 19 graduates with six more expected in July -- and all but four of them will have stayed in-state.
Nebraska claims the largest RTT model, with 24 slots. Residents spend their first year in Omaha. The last two years give them experience in one of four community hospital sites stretched out across Interstate 80: Grand Island, Kearney, North Platte and Scottsbluff, just short of the Wyoming border. In hub-and-spoke style, each hospital also helps fund a clinic in a small neighboring community.
Todd Woollen, M.D, second-year resident, fills one slot at St. Francis Medical Center in Grand Island. He sees his own private patients in Doniphan. Woollen grew up in Alma, Neb., population 1,200, and he likes the feel of this small community. "I'm treated like a physician," he explains. "Here, you grow into your role as a physician more rapidly. I can't imagine a better way to train."
Residents in the rural sites give an overall positive assessment of their "one-plus-two" training.
They agree that the university setting provides more didactics, ample access to subspecialists (who are in short supply in small communities), plenty of patients, a diversity of cases and the latest in technology.
Terry Becker, M.D.:
"If you're not self-motivated, you shouldn't be here."But the residents have been happy to leave the traffic of Omaha behind. They have enjoyed slipping into their local communities and building relationships with doctors and patients. Hospital staff in Kearney and Grand Island are described as willing teachers -- who view working with residents as a refreshing change of pace.
Second-year resident Mark Becker, M.D., sees his private patients in the Ravenna clinic. "Your responsibility level for the initial decision making increases in a rural setting," Becker says. While he recalls stimulating interaction with the large pool of residents in Omaha, he doesn't miss the competition for training opportunities.
At Kearney's Good Samaritan Health Systems, Becker says he is first in line for hands-on experience -- whether it's maternity care or care of children. There's no pecking order here.
The RTT model is not for everyone. Third-year resident Terry Becker, M.D. (not related to Mark), grew up in Kearney and will join a practice there this summer. He advises students to take a hard look at themselves. "If you're not self-motivated, you shouldn't be here," Becker says. Rigid university hospital schedules are absent in rural Nebraska.
There's also the danger of culture shock. Most residents in the Omaha program hail from non-urban Nebraska. But when it comes to relocating, spouses' feelings count, too. Nobody understands that better than Richard Fruehling, M.D., associate director of the RTT in Grand Island. Fruehling and his wife host a social evening once a month, usually at their home. They invite residents, spouses and often children. The evenings are designed to promote camaraderie within the group, says Fruehling, and "to remind them there's more in life than medicine."
The success of the RTT program in Nebraska is directly tied to one of the first rural models, accredited in 1986 at the family medicine residency in Spokane, Wash. "Not only were they pioneers, but they were willing to share their experiences with others who were trying to develop programs," says Michael Sitorius, M.D., chair of the University of Nebraska family medicine department.
The concept of rural-based residency training has grown widely, says Robert Maudlin, Pharm.D., assistant director of the Spokane program. "We learned if you want graduates to practice in rural areas, immersion in rural life and mentorship by rural faculty gives them a head start."
FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.
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