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Rural Practice: Graduate Medical Education for (Position Paper)
Beyond Quality to Excellence in Rural Medical Education
The proceedings of previous summits in 1990 and 2000 reveal that challenges to rural* medical education stubbornly persist.i,ii Rural physicians continue to demonstrate a satisfaction with practice and a passion for service. Yet, after 30 years of policy initiatives, incentives, and rural-focused programs, the number of physicians in rural practice remains virtually unchanged and insufficient for the needs of rural communities.iii Like the persistent poverty that is present in many rural areas, the successful training, recruitment and retention of rural practitioners continues to elude policy makers. Current methods for selecting and training medical students and residents do not appear to be alleviating the shortage. Both the NRHA and the AAFP have been advocates for the health of rural populations and continue to promote the development and funding of programs that will address this rural health provider shortage.
In the intervening years since those summits, however, much has also changed. The intuitive propositions of those earlier leaders have now been borne out by a preponderance of evidence in support of:
- Medical school admission policies that target students with a rural background, students who are more likely to train in primary care and return to rural and underserved practices.iv
- Pipeline strategies for nurturing and sustaining interest in rural practice that provide early, frequent and extended learning experiences in rural settings at all levels of training.
- New programs in rural graduate medical education designed for rural places and implemented over the past two decades.v
Rural training tracks (RTT’s) have changed the scale generally thought necessary for a rigorous teaching program to one that fits rural communities. Although they account for only 52 positions among the 2,621 first postgraduate year slots available in family medicine in 2007, RTT’s are a demonstrated boon for both recruitment of practitioners and retention of experienced rural faculty, placing 75% of their graduates in rural locations.vi,vii,viii They complement the other 33 ACGME and 42 AOA residency programs located in rural areas in providing the 7.5% of family medicine residency training that occurs in rural areas across the nation.ix
From a peak of 36 such programs in 2001, rural residency training tracks now number 28. Most follow the original “1-2” configuration, with one year in the usually urban sponsoring institution followed by two years in the rural location. However, refinements to that structure have evolved and provide even more than the requisite 24 months of contiguous rural training, e.g. a sequential “6 + 30 month” pattern. Another example is the more integrated “2-2-2” program, which trains two residents a year for all three years of postgraduate education in the rural community, interspersed with immersion experiences in the urban setting of the sponsoring institution. Some RTT’s have evolved into full-fledged rural “4-4-4” programs. Two programs in North Carolina and West Virginia continue to innovate through formal involvement in the P4 Residency Demonstration Initiative, a collaborative effort between the Association of Family Medicine Residency Program Directors, the American Board of Family Medicine, and TransforMED, a practice redesign strategy of the American Academy of Family Physicians.
In all of this it must not be forgotten that many residency programs not located in rural areas have variously configured rural training streams or a rural training focus. Although the rural placement rates of these programs are lower than the RTT’s, by virtue of their much larger size and number they ultimately contribute the larger numbers of graduates to the population of rural doctors,
Other changes have altered the landscape of rural medical education. The Residency Review Committee (RRC) for Family Practice of the Accreditation Council on Graduate Medical Education (ACGME), in response to the urging of earlier rural medical educators and in the interest of fostering innovation, has become more receptive to residency program adaptations to the realities of rural places. More women and international medical school graduates are represented in rural education and practice. Critical access hospitals, Federally-Qualified Health Clinics, and Rural Health Clinics provide new venues for patient care and education and a safety net for rural communities.
Successful rural graduate medical education programs have also developed in specialties other than family medicine. Although it has been shown that the more specialized the physician, the less likely that physician will practice in a rural area, family medicine is not the only specialty integral to the health of rural communities. Rural-focused surgical residency programs have been established in New York, North Dakota, and Oregon.x The American Boards of Family Medicine and Emergency Medicine continue efforts to define the elements of training necessary to rural practice and reports of rural training experiences for residents in general internal medicine have been published.xi,xii Rural education is by nature more interprofessional, with physicians, pharmacists, dentists, nurse practitioners, and other health professionals learning side by side.
Finally, there is an increasing recognition for the value of context in training, career satisfaction and retention. Experiential place integration, an active developmental process based on three 'principles' - security, freedom and identity – first described by Cutchin, is a sound theoretical basis for place-based education and policy.xiii The pedagogy for rural medical education is best anchored in the experience of rural places, complemented by facilitated reflection and intentional learning from that experience.
In the immediate future, rural residency programs will continue to face the challenges of (1) student recruitment in the face of declining student interest in generalist careers, especially in rural practice, (2) faculty recruitment in the face of declining numbers of rural physicians with a wide range of skills and an interest in teaching, (3) the lack of sustainable funding inherent in the governmental and institutional policies supporting medical education.
To overcome these challenges, the industrial pipeline metaphor must be transformed into something more organic, coherent, sustainable and community-anchored. A pipeline that leaks must be replaced with a stream that is self-renewing, replenished by multiple tributaries, and under girded by a rising water table of community support and endowment funding. Rural medical education must be readily adaptable to changing conditions, aligned with the interests of multiple stakeholders, efficiently linked to desired outcomes and workforce needs, self-renewing and less dependent upon external funding.xiv Academic institutions and communities will benefit from a medical education enterprise that is distributed, rooted, and nourished in diverse underserved communities, is interprofessional in nature, and is adapted in scale and scope to the population it serves.xv
Structure and content of postgraduate rural training:
- Cumulative rural training experience for all medical students and residents with an interest in rural practice should be at least six (6) months in duration.xvi
- Knowledge and skill acquisition in the following areas especially relevant to rural practice:
- Maternity care
- Orthopedics and sports medicine, including basic fracture care
- Surgical and procedural skills, including colposcopy, ultrasound and endoscopy
- Trauma and other emergency care and stabilization, including training in ACLS, ATLS, NRP, PALS, and ALSO
- Critical care in a rural setting
- Occupational health and safety, including recreation, agriculture, mining, and forestry
- Behavioral health and psychiatry, including access issues unique to rural practice
- Practice management in a small practice setting
- Telemedicine, the electronic health record, and other electronic tools and resources
- Public Health, including basic definitions, resources for rural health, access and barrier issues, funding and delivery of rural health care, interdisciplinary teams in rural health, health outcomes and disparities in rural populations, strategies for delivery of care, and cultural competence (UW Competencies)
- Community-oriented primary care
- Adaptability – how to shape one’s skill set to the needs of the rural community
- Improvisation – how to deliver quality care within the resources and skills you have available in the moment
- Life-long learning – how to continually acquire additional knowledge and skills as needed
- Collaboration – how to get help from others and work together
- Endurance – how to sustain oneself in rural practice
Medicare funding and definitions of rural training
The BBA (Public Law 105-33) placed a cap on the number of medical residents that are eligible for Medicare direct and indirect GME payments. This limitation has negatively impacted the availability of funding to support rural residency programs. In the BBRA (Public Law 106-113), an exemption for RTT’s was included that was intended to exempt both “1-2” rural and “integrated” RTT’s from the GME funding freeze. Unfortunately, the lack of an accepted formal definition of an integrated RTT has prevented the Centers for Medicare and Medicaid Services (CMS) from exempting those programs from GME funding restrictions. In its rulemaking, CMS asserts that the BBRA does not adequately define an "integrated rural track" and that there is "no existing definition" of this entity. CMS has essentially limited the application of the exemption to 1-2 programs. Subsequent reallocation of residency slots under the Medical Modernization Act of 2003 (Public Law 108-173) did not benefit rural programs as predicted.
So that the exemption for the Integrated RTT may be implemented by CMS, a definition for the Integrated Rural Training Track has been developed by the NRHA Rural Medical Educators group and should be adopted by both CMS and the ACGME. NRHA supports the following definitions of residency programs training physicians for rural practice in any specialty:
- A traditional rural training track, with at least 24 months practice experience in a rural setting
- An integrated rural training track with the following required components:
- At least four (4) rural block months to include a rural public and community health experience. During a rural block rotation, the resident is in a rural area for a minimum of 4 weeks or a month
- A minimum of three (3) months of obstetrical training or an equivalent longitudinal experience
- A minimum of four (4) months of pediatric training to include neonatal, ambulatory, inpatient and emergency experiences through rotations or an equivalent longitudinal experience
- A minimum of two (2) months of emergency medicine rotations or an equivalent longitudinal experience
Congress and CMS should take the opportunity afforded by the relatively small number and size of rural programs to streamline I&R reporting and simplify GME funding of actual resident FTE’s, recognizing that in addition to educational tasks, resident physicians devote at least 40 hours to patient care weekly. They should provide such funding directly to rural programs, decreasing bureaucratic inefficiencies and affording an opportunity for increased accountability, linking funding to both outpatient and inpatient care and to training outcomes.
Academic support and rural leadership
Faculty living and working in rural places are core to the mission of rural medical education and as such should take the leadership role in advancing training in these settings. They should be recognized with faculty appointments commensurate with that role, encouraged and supported in the scholarship of practice, education and community engagement, and generously included in key decisions and strategic planning within the academic enterprise. Visits to the rural location by university leaders and visits by rural faculty to urban centers are integral to building mutual respect, sharing understanding of the realities of both rural and urban contexts, and establishing trust. The challenges of time and distance can be addressed in part through telephone and videoconferences, but these can only complement and do not substitute for in-person meetings.
Accreditation of rural programs
Community investment in rural training
Medical education anchored in rural places, nourished and funded through significant federal, state and local community support, and meaningfully connected to both regional academic institutions and local physicians in practice has great potential to address both present and future needs for physicians who provide care to our rural populations.
* For this document, rural is defined as located either in a non-metropolitan area or a rural-urban commuting area code of 4 or greater.
i Rural health: a challenge for medical education. Proceedings of the 1990 invitational symposium. San Antonio, Texas, February 1-3, 1990. Proceedings. Supplement Article in Academic Medicine December 1990. 65(12): S1-126.
ii Rural-based Graduate Medical Education: A Workshop. Proceedings of a conference. February 16-18, 2000. San Antonio, Texas, USA. Theme issue of J Rural Health Summer 2000; 16(3):196-306.
iii The Family Physician Workforce: The Special Case of Rural Populations, The Robert Graham Center Policy Paper number 31, July 2005.
iv Hyer JL, Bazemore AW, Bowman RC, Zhang X, Petterson S, Phillips RL. Rural Origins and Choosing Family Medicine Predict Future Rural Practice, The Robert Graham Center Policy Paper number 49, July 2007.
v Krupa LK and Chan BT. Canadian rural family medicine training programs: Growth and variation in recruitment. Can Fam Physician June 2005; 51(6): 853.
(Published online 2005 June 10 and Accessed 9-1-2007)
vi Fryer GE, Dovey SM, Green LA. The effect of accredited rural training tracks. Am Fam Physician 2000; 62:22.
vii Daniels ZM; Vanleit BJ; Skipper BJ; Sanders ML; Rhyne RL. Factors in recruiting and retaining health professionals for rural practice, J Rural Health, Winter 2007; 23(1):62-71.
viii Pathman DE, Steiner BD, Jones BD, et al: Preparing and retaining rural physicians through medical education. Acad Med 1999; 74:810-820.
ix Hart LG, et al. Pathways to Rural Practice: A Chartbook of Family Medicine Residency Locations and Characteristics, WWAMI Rural Health Research Center, August 2005.
x Doty B; Heneghan S; Gold M; Bordley J; Dietz P; Finlayson S; Zuckerman R. Is a broadly based surgical residency program more likely to place graduates in rural practice? World J Surg Dec 2006; 30(12):2089-93.
xi Stoever J and Champlin L. From the American Academy of Family Physicians: New Policy, Dual Residency Programs Support FP’s Who Provide Emergency Care, Ann Fam Med July 2006; 4(4): 375–376.
xii DeWitt DE; Migeon M; LeBlond R; Carline JD; Francis L; Irby DM. Insights from outstanding rural internal medicine residency rotations at the University of Washington, Acad Med March 2001; 76(3):273-81.
xiii Veitch C and Crossland LJ. Exploring indicators of experiential place integration in a sample of Queensland rural practitioners: a research note. Rural and Remote Health 2 (online), 2002: 111.
xiv Education, Training and Recruitment, AAFP Government Relations, March 2007
xv Edwards JB; Wilson JL; Behringer BA; Smith PL; Ferguson KP; Blackwelder RB; Florence JA; Bennard B; Tudiver F. Practice Locations of Graduates of Family Physician Residency and Nurse Practitioner Programs: Considerations Within the Context of Institutional Culture and Curricular Innovation Through Titles VII and VIII, J Rural Health Winter 2006; 22(1):69-77.
xvi Chan BT; Degani N; Crichton T; Pong RW; Rourke JT; Goertzen J; McCready B. Duration of rural training during residency: rural family physicians prefer 6 months. Can Fam Physician, February 2006; 52:210-1.