November 01, 2019, 10:02 am Sheri Porter – Randall Longenecker, M.D., is quite familiar with the challenges rural training tracks in family medicine residency programs face each day. "I like to say I'm the only program director in the world who has conceived, birthed, raised to adulthood and laid to rest a rural training track in family medicine," Longenecker confided in a recent interview with AAFP News.
This family physician began developing a rural training program at Ohio State University in January 1997, and the training site at Mad River Family Practice took its first resident in July 1998. The program closed in 2012 due to lack of funding from the supporting hospital.
Fast forward to September 2019, when an article published in Family Medicine titled "Family Medicine Rural Training Track Residencies: Risks and Resilience" detailed findings from interviews with 21 rural training track leaders representing 22 functioning programs, as well as two programs that closed -- including Longenecker's.
Longenecker pointed out that Schmitz and Patterson performed the qualitative analysis while he helped conceive the idea for the study, interpret the information gathered and write the manuscript. "I was not the lead author because I represented one of the two closed programs named in the study," he said.
Study authors Davis Patterson, Ph.D., of Seattle; David Schmitz, M.D., of Grand Forks, N.D.; and Longenecker, of Athens, Ohio, set out to better understand threats to the sustainability of rural training tracks, as well as factors that enable their survival.
In 2014 and 2015, the study authors requested phone interviews with 28 operating or recently shuttered rural training tracks; 24 programs participated. Initially, two of the authors spoke with leaders of the programs that closed in 2011 and 2012 "to understand the dynamics, timing and relative importance of closure factors." Suggestions for promoting resilience also were solicited.
Following those conversations, study team members interviewed program directors and rural site directors at the 22 functioning programs. Responses were recorded by hand and notes were reconciled after the conversations.
"We defined resilience as 'the capacity to endure and overcome hardship,'" wrote the authors.
Functioning programs' longevity ranged from less than one year to 31 years.
Researchers asked respondents to
Respondents were also asked to identify their top three assets and risks. Some of the discussion on the top themes is detailed below.
Study authors identified nine themes from the interviews and listed them in order of most to least mentioned; those themes were leadership, faculty and teaching resources, program support, finances, resident recruitment, program attributes, program mission, political and environment context, and patient-related clinical experiences.
Leadership was the most often mentioned asset and subject of advice; it was also cited as a common risk factor. Through the interview process, authors learned that "a change in leadership in the hospital, sponsoring institution or program could critically affect program success."
Additionally, program or rural site directors were at risk of burnout when there was insufficient staff on hand to share the workload. Respondents also reported difficulty recruiting program leaders and cited frequent leadership turnover as a risk.
One respondent commented that it was important for leadership to be forward thinking and proactive; another noted the importance of succession planning. A third mentioned the need to "keep things in continual motion … make sure you have someone keeping all the plates spinning."
Faculty and teaching resources was second in line of the most commonly mentioned themes; paid and volunteer faculty were the most valued rural training track resources. Respondents talked about faculty dedication, described long-standing faculty as embedded in the community and said faculty were "a community of skilled, experienced clinicians offering residents a broad scope of training."
Program leaders noted the importance of "recruiting faculty who were a good fit for the program and the community."
On the other hand, challenges involving faculty and teaching resources were an often-cited risk. "Rural communities already struggling to recruit providers similarly find recruiting and retaining faculty difficult," wrote the authors.
Program support was mentioned using many different examples of the kind of support respondents' programs needed and received.
One commenter said, "Keep educating the community about what you're trying to accomplish over time and not just at startup … here's what we're doing, here's what our finances are looking like. If you lose any one leg out of that table, you start leaning and things start rolling off the top."
Another program leader talked about the importance of involvement with the local Area Health Education Center, the state department of rural health and state legislators.
"We have a community foundation that helps support the clinic," said another. "Having that strong community support keeps the program resilient over time."
Another respondent said, "The biggest strength is the level of community buy-in, and that includes the hospital."
Finances also played a fairly significant role on the list of assets and risks, according to respondents; in fact, it was noted by the highest number of respondents as the biggest training track risk.
"Managing financial risk is a key preoccupation of RTT leaders," wrote the authors. Respondents cited good partnerships with sponsoring organizations, as well as stable and diverse funding sources "such that programs were not overly dependent on any single source."
Authors noted that rural training tracks in mostly rural states often have greater state government awareness and thus better financial support. Authors also found that patient populations in rural training tracks often are poorer, "resulting in a payer mix that generates low revenues."
Interview comments made the role of finances quite clear: "Finances are far away the number one vulnerability," said a respondent. "Top five (risks) are funding, funding, funding, funding, funding," said another.
As executive director of the Rural Training Track Collaborative, Longenecker has a strong interest in sustaining rural training tracks as a strategy in rural medical education.
"At no time in my career has there been so much focus on rural graduate medical education, and it is important that we address the challenges with workable solutions," he said. "It was important to learn how, in the face of many obstacles, rural programs have avoided closure."
He said that even though he and his co-authors demonstrated the importance of community resilience and social capital, he was surprised at the variety of challenges. "There is no one mortal threat to these programs," said Longenecker.
He encouraged readers to take away this key point: "Hardship is a necessary ingredient in building resilience, and if rural training tracks can avoid closure, they will be stronger for it."
Looking ahead, Longenecker said, "We need to continue to strengthen rural training tracks and other rural programs, including recent efforts by the Accreditation Council for Graduate Medical Education, to better accommodate and support residency training in rural and underserved communities." Graduate medical education financing also needs to be reformed, he added.
Study co-author Schmitz serves as a professor and chair of the department of family and community medicine at the University of North Dakota School of Medicine and Health Sciences in Grand Forks.
Schmitz said family physicians play a critical role in delivering high-quality and low-cost care to rural America. "We must continue to increase awareness of that and continue to point to the evidence that supports the concept that 'training in the sticks, sticks,'" he said.
"It is the proof of mission for these programs that creates the resilience of community of practice to overcome the challenges and see the outcomes that benefit so many of our friends and neighbors in rural communities," he added.