Journal of Rural Medicine and Medical Education

Issue No. 1, Winter 1999

Editorials and Essays Section

Why Don’t We Work Together? By Arthur Freeland, M.D.

The Rural Life Cycle

The Continued Centralization of State Educational Resources and the Potential Impact on the Location of Young Professionals – Robert C. Bowman, M.D.

Progress with Rural Training Tracks in Wisconsin – Hilary Scully, M.D.

Implementing a School-Based Hepatitis B Immunization Campaign, an RTT Community Health Project – Anne Thomas, PhD, RN, CS

Selection vs Socialization, Which Is Responsible For the Failure of Medical Education to Graduate Rural Physicians – Robert C. Bowman, M.D.

Rural Clinical Practice

Obstetrics and Procedures for Rural Practice – William Rodney, M.D.

Perinatal Round Table –William Crump, M.D.

First Person

Blizzard – Bob Boyer, M.D.

Goodbye Carl Dale Dewar, Wynyard, Sk.

Replacement Doctor

Inspirations

Best Quotes of 1998 On-Line

Colleagues and Contacts

Commentary and Critiques of Past Articles and Issues

1998 Group Report for the STFM Group on Rural Health

Why Create a New Journal?

Responses to Journal of Rural Medicine and Rural Medical Education Proposal

Editorial Board

Editor

Robert C. Bowman, M.D.
UNMC Department of Family Medicine
Director of Rural Health Education and Research
983075 Nebraska Medical Center
Omaha, NE 68198-3075
(402) 559-8873 or fax at –8118
comments to rbowman@unmc.edu
www.ruralfamilymedicine.org for STFM Group information
www.unmc.edu/FamilyMed/rural/rural.htm for additional information

Editorials and Essays Section

Why Don't We Work Together?

Arthur Freeland, M.D., Warrensburg, Missouri

From the RuralMed bulletin board by author’s permission

In previous (email) communications, rural physicians in this nation have explored many options. This response from one year ago highlights some of the obstacles to working together to improve rural practice. Other countries with more rural geography, have faced these issues longer and may help advise us. As always, the major problem is communication/networking. Rural physicians are an independent and unruly bunch, and we often believe ourselves to be too busy for strategic planning. Most are certainly unable to attend regional meetings with any regularity. (little coverage and the overhead goes on . ..)

The evolutionary solution that appears to be fueling much of the organizational advance in Canada and Australia is "rural datification". As rural physicians can actually have meaningful "asynchronous conversations" with their colleagues, a spleen venting session at the keyboard can turn to a constructive conversation resulting in home grown solutions to rural problems.

Unfortunately, a majority of small communities across the US are still unable to connect to an internet service provider without a long distance phone call. Add to that the natural inertia that we rural dinosaurs have in adopting and using new technology, and you have lots of good people developing local solutions that never get communicated or generalized. And there is certainly no unified response to rural issues. The National Rural Health Association is becoming more physician friendly (but certainly still no where near "provider-centered"). Rural electric cooperatives, where they still exist, have largely served their initial purpose and should be encouraged to work on rural datification. Telemedicine is an urban favored approach that does nothing to improve the rural medical infrastructure, but it does have its purpose, and requires dense data transmission capability and equipment that can then be used for less technology intensive communication that will support the local providers.

State universities with rural missions already have computing infrastructure and should be encouraged to develop and offer electronic networking to rural providers (perhaps in their interest to offer same to all state physicians). In many places, students on required rural rotations have kept in contact with their medical school electronically and have reciprocated by "training" their rural preceptors on personal computers, some of which have been provided by AHEC's or universities so the preceptor's office has fixed abilities to do things like search Medline.

The question in my mind is not "Do we need a separate organization to speak for rural clinicians?" but "Is such a thing even feasible?" Until communication is improved we will remain small, somewhat paranoid islands in the corn (or wheat, or sagebrush). Apologies to all, this initially very focused post became one of those "vents" of which I speak.

Information on how to subscribe to RURALMED is available at http://www.mcgill.ca/cc/listserv

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The Rural Life Cycle

The Continued Centralization of State Educational Resourcesand the Potential Impact on the Location of
Young Professionals

Robert C. Bowman, M.D.

Perspective

Many rural leaders lament the disappearance of the 20 - 44 year old age group from their communities. The energy and leadership of this group contributes much to life in small towns. This group includes business leaders, young professionals, parents, and consumers. Rural organizations and business leaders continue to devote much time and effort to understand this problem. State government is also interested, but it may have difficulty with this issue. The reason is that the state may have a conflict of interest. Various state policies may contribute to a redistribution of resources in education and other areas. As a result of these policies, young people may be choosing other locations to live.

My background includes rural practice and academic positions in several states. My career focus has been rural medical education, with a focus on what needs to be done to get the kind of physicians that will go and stay in small rural communities. This focus involves more than just medicine and education. The following are impressions gained from personal and internet interactions in small towns, at small colleges, with health profession advisors, with rural sociologists, and with rural educators and students. I share them with you for your consideration and personal reflection. It all began with rural practice in Nowata, Oklahoma, my best education....

The Global Impact, Inch By Inch and Step By Step

During my years of rural practice, I watched the state and federal government reduce services in small towns in multiple areas. These included the welfare office, home extension, and public health. Cuts in the state-funded medical school resulted in closure of the rural-oriented family practice residency where I taught part time. I talked to teachers and they were also concerned about the redistribution of education funds. Our town lost teachers, police officers, and others to towns that paid more or had more resources. The state did little to level the playing field. The cuts to various programs were small, but in multiple areas.

Economic problems in the agriculture and oil fields eventually drove over 1000 people out of my county and me out of rural practice. I recharged the grandparent batteries in Houston, teaching family practice residents at Baylor. During my early faculty years, I researched rural health, did locums, and kept up communications with small towns. I turned to rural policy at the state and national level. State politicians were polite, but committed no funds to assist rural communities with recovery. I watched as urban hospital networks acquired, abused, and dumped rural hospitals. My dreams of teaching rural health at Baylor fizzled as funds were cut and as I realized that my rural community was the best rural teaching resource.

After leaving rural practice, the subject of rural physician retention kept me occupied most of the time. I wondered how I or others like me have stayed longer. Initially I gained some peace of mind when I heard about many others like me that departed from the midwest because of the agricultural problems. At this stage I was much like our current medical leadership, focusing on the economics of the situation and the perceived lack of lifestyle as a reason for not recruiting and retaining rural physicians (Cohen). This was reinforced as I watched urban Texas recover from the economic devastation of the mid-1980's, leaving rural Texas far behind. I remember wondering if rural and disadvantaged folks took a beating with every such economic disaster.

Over the past decade I began to question the economic and lifestyle arguments. The lifestyle argument was simple to contest. As I traveled to rural communities in different states, I saw a great variety of people, leadership, values, and resources. I found out that rural areas have a different culture; they don’t lack culture. Each area has its own recreational and social attributes, rural or urban. Surprisingly some of my best sources in this discovery were urban people who moved to rural locations. They saw the social life that home folks did not appreciate. In fact many rural people regarded kids returning home after college as failures. It became clear that there were kids who really loved rural life while others wanted an escape. My research showed that there were programs that selected those who loved rural areas and these programs were successful.

Clearly part of the problem was that we weren’t admitting the right students. Medical schools said they were trying harder, but without results. In the last quarter of the century senior medical student interest in rural practice declined to record lows. The attrition rate was faster than just a decline in rural economies and population. Something had to be going on even before medical school.

After many years of struggling with these issues, I began to put the pieces together. A breakthrough came when I was visiting with professors involved with the RHOP program (Rural Health Opportunities Program) in Nebraska. Programs such as this have been created based on research demonstrating that doctors that go and stay in the smallest towns were from similar size towns (Wigton, Rabinowitz). RHOP admits college freshmen to medical school (6 slots a year out of 120) from two rural state colleges, Chadron and Wayne State. They attend the rural college for 4 years and then move on to the health profession school. One problem with the program is that students run into complications on the way to rural practice. They may fall in love with a subspecialty or an urban spouse, making a rural choice difficult. RHOP seemed to have great promise, but it was only a few students a year, with few actually staying in a small rural pathway. Then I found out that there was more to the program than meets the eye of the academician or politician.

When I visited Wayne State I talked to a professor who taught microbiology. She mentioned that during the seven years of RHOP, the number of A grades in her Microbiology class had gone from just 2 to 14 well-deserved ones per semester. She noted that the quality of the students, both RHOP and non-RHOP, continued to improve. She attributed this to increased competitiveness between the students. Other science and math professors echoed this viewpoint. Enrollment at both schools had increased at a time when other small colleges were losing ground. This sounded like a fairly good benefit for little cost and the extra efforts of a few faculty, but I began to wonder....

What was it about this insignificant program that made such a difference in the college?

It dawned on me that RHOP was one of the few factors that leveled the playing field. For once, these small colleges had an advantage over the large urban colleges as far as admissions. Because of the program, the students attracted more competitive students, this resulted in improved education at the college. This was a positive feedback loop because as the students got better, more were admitted to further professional training. This was quite a change from the past. I asked myself how things had been deteriorating for so many years?

Do State Policies Encourage Centralization of Educational and Other Resources?

Shortly after the Wayne State visit I got a form letter from the President of the University System noting politely that it would be necessary to revise the class offerings at many of the schools so that the system could be more efficient. This would involve closing some classes and consolidating others. This looked like his usual annual letter, but now I realized what was happening to higher education. Given previous experience, these dollars would tend to remain centrally at the larger colleges and the small colleges would suffer disproportionately. Some of the most-specialized, least-attended, and most costly courses were the ones involved in the preparation of professionals.

There was now little doubt that centralization policies were forcing

pre-professional students to attend larger and more urban colleges.

With the current policies students attending the smaller colleges would not get "the right stuff." They could not compete with other students as well. This would result in fewer specialized courses and instructors, less health career encouragement, and potential of failure for those admitted to professional schools.

How Can Centralization Result in Fewer Professionals Returning to Rural Areas?

1. Students from smaller schools may not be as competitive.

2. Centralization forces rural students into more urban locations for college and results in students who are socialized into the urban life style.

3. Even the most rural-oriented students are more likely to meet urban-oriented spouses at urban locations, making it almost impossible to return to a rural location given current attitudes.

4. There is also increased potential at larger colleges and in higher education courses to meet a spouse with a more specialized career. Small towns know all too well that it is a major challenge to recruit and retain families that include dual professionals.

It is not surprising that the medical literature reflects these concepts. The longer the training in urban areas, the lower the probability that graduates will choose rural locations. Spending more time in urban, higher education centers erects barriers to a rural return.

 

Do Health Advisors and Faculty Play a Role in Centralization?

Students depend on others for their information about health careers. They talk to other students, faculty, and health advisors. Some of these contacts are official during classes or meetings. Some contacts are at the request of the student for special needs or advice. Faculty or advisors also initiate some contacts to encourage, advise, or support students. Advisors sometimes face some difficult challenges. Internet discussions reflected a "gatekeeper" function.

1. Advisors want to encourage their college students to apply for the career of their dreams, but they realize that some students may have great difficulty in pursuing their dream.

2. Advisors have a vested interest to make colleges look good to students and parents of potential college freshmen so that they can continue to get the "best and brightest" to come to their school.

This means that there may be a tendency to ignore or discourage some students from applying who are more likely not to get accepted to professional schools. It was easy to identify students with the grades. It was more difficult to identify those who had great gifts in other areas, but average scores. In my own experience, I did not apply to medical school until the college advisor encouraged me. I can see how encouraging "the best and brightest" might displace others with less statistical recognition and perhaps more dedication to medicine as a serving profession. Some advisors go out of there way to identify students that they feel would make great physicians, but they admit that they have difficulty when these students have borderline grade points or admissions scores. Even before college, students who have health career exposures may have an advantage. Teachers and counselors may have important impacts at the high school level or sooner. Work with rural high schools revealed that many students had little health career exposure. Students reported that counselors were busy with the more challenging kids. Their statements are backed by research (Matthew Project). The advantage for professional careers has increasingly moved to urban kids or students from professional families. Unfortunately these students are not as likely to return to rural areas.

I began to look for other evidence that state policies were a contributor. I did not have to look far.

What About the Effect of School Consolidation?

States have faced major challenges regarding health and education. Nearly all have regarded small school districts as inefficient. School consolidation is seen as a way to improve education and decrease costs, but are there side effects from this "treatment?" I talked to a rural sociologist who works regularly in the health and education fields. He was talking to various rural education groups and they related to him that voluntary (and state-imposed) school consolidations were having an impact on the leadership opportunities for students. When 3 small high schools reduced down to one, that meant 2 less quarterbacks, 2 less class presidents, and similar decreases in leadership positions for other rural students.

School consolidations also impacts the type of students that become "the best and brightest" and are therefore eligible for professional schools. Studies show that smaller schools do seem to distribute educational resources more appropriately. This benefits the disadvantaged and, to some degree, restricts the affluent. Larger schools and districts benefit affluent students on the whole moderately, but they compound the negative effects of poverty on the educational achievement of poor students. These results apply whether the school is in an urban or rural place. Thus the New Testament prophecy from which this project derives its name (Matthew Project) is fulfilled: The rich get richer, while the poor get poorer. In other words, smaller schools and districts currently penalize their own "best and brightest" which diminish their chances of professional school. Students from larger schools in larger towns are more likely to be admitted.

The process of consolidation to increase school size would increase the potential for affluent students and increasingly impair the chances of those who were in poverty. Continual increases in the size of schools, coupled with the retraction of affirmative action programs, may insure that primarily the affluent students from the largest school districts will do well enough to enter professional school. Since we already know that those higher on the socioeconomic scale are least likely to choose generalist careers and underserved areas for practice, this would mean fewer and fewer rural professionals. Even the rural students would be affected by school consolidation. Rural students facing consolidation are often forced to attend more distant schooling and have fewer connections to their rural community and with less appreciation of community interactions. Rural students attending larger, more distant schools would have less opportunities for extra-curricular activities and leadership experiences. The statistics regarding the declining interest in rural practice were beginning to make sense.

I then began to ask myself if we depended on rural areas for future leaders for our towns, states, and nation. Many of our greatest political leaders have come from rural backgrounds. In the American Academy of Family Physicians (AAFP), almost all of the AAFP presidents and Doctors of the Year have been rural doctors and most came originally from rural communities. What was there about this rural influence that made such a difference? I reflected on other rural people that I have met, from physicians to babysitters to hair dressers. National leaders who were raised in rural areas also came to mind. Rural people seemed to me to have a better work ethic and dependability. When talking with some rural science teachers I had new appreciation for the way their schools were resisting school consolidation at great local cost. They wanted to preserve these opportunities for their students. It certainly looks like state policies are diminishing the quality and quantity of leaders for small towns, the state, and the nation. Rural areas are increasingly denied the very assets that they develop!

 

Compounding the Injury: The Importance of Other Young Professionals in Small Towns

My best friends in rural practice were other young professionals: the teachers, ministers, and business people in various community and church groups. Without these folks I would have been far less likely to go and stay in rural practice. The departure of key friends in this area also heralded my own rural departure. The town became less desirable to us as young professionals when we faced such losses. With fewer young professionals choosing rural areas, small towns become less and less desirable to others with similar backgrounds.

 

Why Is There Variability in Admissions Selection for Rural Background and Interest?

It is interesting that this article is near the end, but medical school admission procedures have not been discussed. Most medical education experts start with the admissions process, but others feel that starting with medical school is too late, particularly if the desired outcome is doctors that go and stay in rural practice. Studies show that schools with a rural mission graduate more rural physicians, but few schools or programs have a rural mission. Schools with a rural mission usually include rural physicians and others from rural communities on admission committees. Some medical schools work with college advisors, but there is little education of college level advisors or admission committee members to help them identify and encourage those most likely to go into rural practice.

Admission committee members are often aware that students play a game in order to increase their chances of getting admitted. Students will mention that they are interested in rural practice, primary care, or family practice. Some also include altruistic goals such as serving the underserved. Unfortunately few, if any, admissions teams spend the time to truly examine such interests and previous indicators of such interests. Even a casual question about student recreation needs might turn up a number that were not compatible with the rural practice. By gauging the student's response, the committee member could better identify students with true rural interest.

There is controversy about admission procedures. Those with the highest grade points and Medical College Admission Test (MCAT) scores may not be as interested in rural practice (Harris). In some states, rural education may not be good enough to prepare students for the rigors of college and professional school. MCAT scores do vary by state, almost by educational expenditures and the rural nature of the state. The south tends to score lowest (among all students taking the MCAT), followed by the midwest, with the north and east higher. More students in the south score in the 8 range, the number considered a minimum without increase risk of academic problems. This means that states such as Kentucky may struggle to get students with rural backgrounds that can do well enough on the MCAT to justify the "risk" of admission, especially if the two or more state schools compete for the same students. Pennsylvania, on the other hand, may have many more students from rural communities because the state has a much larger rural population and a higher standard of education. This may have allowed Rabinowitz in his Physician Shortage Area Program (PSAP) to choose those with a much higher degree of rural and family practice interest. He strongly believes that selection is everything and subsequent training is less important. The PSAP program, involving 1% of the medical student population of the 5 medical schools in the state, has provided 21% of Pennsylvania’s rural family physicians (Rabinowitz).

It is possible that rural students are desperately trying to catch up to their urban peers in college. Studies in Kansas City did compare urban and rural students and by graduation, there were no significant differences. Students in Minnesota's Rural Physician Associate Program (RPAP) are mostly from rural areas and start out lower on MCAT and GPA, but equal or exceed non-RPAP students multiple areas at graduation. The top student in one Illinois medical school started with MCATs in the 6.7 range and ended at the top of the class. It may be that rural background students need a different MCAT scale for admission. More studies need to be done in this area.

For most schools the risk of admitting those with more likelihood of choosing rural practice may be too high. Students who did not make it would cause problems for the school because the state's cost of training would be wasted. The admissions committee would have to suffer the stigma of having admitted failing students, even if they truly attempted to admit those most needed by the state. Students likely to be on probation would need some counseling and some real teaching. They would take (horrors!) much faculty time and effort. Schools that required boards to be passed for continuation would have students taking the test over and over. The school would suffer lowered national board score averages and a higher licensure failure rate. Admitting more rural-likely students would damage the school "image" and increase the potential for increased surveillance by accrediting bodies which would be more costly, etc.

Finally there is evidence that the best and brightest may not be the best. A recent article about Florida family physicians noted that those with the higher board scores were sued more often. Higher scores may not correllate with being a better physician. Perhaps those with higher scores relate to things rather than people.

State Recommendations

1. States need to examine educational policies to see if they are damaging their own futures by consolidation of local school districts and centralization of higher education.

2. States should attempt to education young professionals in as small a location as possible, to enhance the potential for a rural location for graduates as well as to distribute state educational and economic resources more equitably

Medical School Recommendations

1. Medical schools should work with small colleges and vice versa to insure that the state has doctors and other professionals that go and stay in rural communities.

2. Admissions committees should look at their data and see if they can take more risks with students that are more likely to choose rural or underserved locations. If the school anticipates a decrease in class size, this is a prime directive to prevent even more loss of future rural practitioners.

3. Medical schools should be prepared to work with students that are more likely to go where they are needed. They may need more preparation, advice, or time in order to complete medical school.

 

National Recommendations

1. National studies are needed to relate rural and underserved outcomes with various types of backgrounds and interests prior to professional training. Studies should confirm or deny that students from rural backgrounds or small colleges have potentially lower overall risk of academic failure, given similar predictors. This would allow admission committees to take more risk with more future benefit.

2. Medical education must address factors within institutions that socialize students to choose urban and specialty careers.

3. Accreditation should include an evaluation of a medical school’s attempts to graduate physicians that will meet the nation’s future needs, especially for rural and underserved locations.

4. Successful rural models should be replicated in several medical schools as soon as possible. Medical education leaders should choose these positive examples and promote them rather than blaming rural economies and lifestyles for the nation’s failure to address the rural physician shortage.

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Progress with Rural Training Tracks in Wisconsin

By Hilary Scully

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Implementing a School-Based Hepatitis B Immunization Campaign

By Anne Thomas, PhD, RN, CS

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Selection vs Socialization, Which Is ResponsibleFor the Failure of Medical Educationto Graduate Rural Physicians

Robert C. Bowman, M.D.

If push came to shove and the governor, senator, etc., blamed your school for not graduating enough rural physicians, you could blame the lack of rural physicians on a multitude of other rural problems. These include low resources, poor organization, and inadequate finance, etc. Rural physicians in Canada were incensed by comments from a medical school dean that more government dollars to the medical school could address rural needs. They point to various government programs that have expended millions of dollars at the medical education level without producing more rural physicians. It is time to quit blaming and start working in multiple areas. The longest delay, however, is in the medical education pipeline, so it makes sense to work on it first.

Can We Select Better Based on Quantitative Data?

A study by Don Madison in Academic Medicine (69:10;825-831) did an extensive review of the class of 1986 at UNC-Chapel Hill regarding predictors of generalist careers. The best predictor was evidence of service orientation in the applicant's background or personal statement. The next best was socioeconomic status where lower status correlated with more generalist careers. Madison's work involved lots of time to compile the data, but the data used was available to the admissions committee members. Madison noted,

"Yet, having identified certain attributes that would appear to predict medical students' recruitability as generalists, it would not serve either their schools or society at large, were admission committees to discount those qualities that are desirable in all physicians simply because they fail to predict the decision to become a generalist. In the best of all possible worlds the majority of all entering medical students would end up as generalists, but all physicians - family practitioners, physiatrists, urologists, allergists - would be well-educated, highly intelligent, well-rounded, personable, honest, altruistic, highly motivated individuals who had tested themselves prior to medical school in some tangible way against their goal of a medical career and a service profession."

Are Rural-Interested Students Different?

Some studies have noted that higher admissions test scores are associated with a reduced probability of rural practice choice (Dona Harris, studies in Utah). Others note that rural background students have somewhat lower grade point averages, but more extracurricular experience. I have done some brief work with national data on senior medical students (1995 AAMC Graduation Questionnaire) and have found several differences in students who are interested in rural practice. Twice as many rural-interested students took rural and international electives when compared to their classmates as a whole. Twice as many did volunteer work during medical school. Rural-interested students thought basic science, research, and hospital teaching was a bit excessive, and thought clinical skills, geriatrics, preventive, HIV, public health, and primary care issues lacked enough emphasis. Twice as many were dissatisfied with their medical education as compared to peers. Rural students also expected substantially less future income. In the process of upgrading our applicant pool regarding rural interest, we would also be likely to get the kind of students that are interested in primary care, geriatrics, service, social issues, and leadership. I guess I am fortunate to work with these folks as students, faculty, and colleagues. I can't think of a better group to work with. Couldn't we have a few more come our way?

Should We Select for Qualitative Characteristics in Physicians?

Studies of physician workforce (COGME, Pew, and others) have noted that we need more students to be interested in primary care, chronic care, care of the elderly, and prevention of disease. Some have begun to raise questions whether the "best and brightest" are well equipped to deal with many of these situations. Physicians who are quick to diagnose and great at cures may not be interested in plodding along, relating to others, supporting, or maintaining.

Perhaps many of our problems in rural areas are that even rural physicians are too ingrained in the "curative" mode and less interested in working out relationships and problem definition, with solutions worked out in the future with others rather than immediately on your own.

In my own experience at residency, our resident group was a select group of the best and brightest, and we nearly wrecked a fine community-based residency program that had done quite well with average folks who related well. Seems like the ability to communicate and the willingness to serve are more important, at least to primary care and rural practice and hopefully to all medical careers.

Is Selection the Problem, or Is the Real Culprit Socialization During Medical School?

Further listserve deliberations centered on the issue of whether medical students were either selected for the wrong characteristics or whether they were socialized into non-caring roles (as per anthropologist Melvin Konner and others). Frankly, I think it is a little of both. Experienced faculty lament those lost to medical school socialization. On the other hand, even the most cavalier students seem to fall in step when our small group discussion involves them in a personal fashion. Poverty and medicine gets some polite attention when presented in didactics and brief discussion, but students shine when they debate the ethics of our medical education system in which the least-trained practice their skills on the poor or disadvantaged - those with little on no ability to complain.

It is also easier to do quantitative presentations than qualitative experiences. It took me two years and 10 presentations to get superior evaluations from students when I talked about teenage pregnancy. It took me two months and two talks to get there when teaching the same students about electrocardiograms. Good educational experiences often take time and multiple resources.

When Bob Boyer, a rural FP from Kingman, Kansas, tells his stories about rural practice at the national meeting of family practice residents and students, we always have a few of the residents comment about how they have been recharged and refreshed. Their faith in their primary reasons for becoming doctors has been restored. To me these are all signs that medical education has a negative socialization effect. School missions, attitudes, curricula, and reward systems all influence students along with selections. If the same students can respond, even at senior levels, there is a reason for change.

Can We Modify the Socialization Process?

Having taught at some of the newer medical schools, there is a different attitude and mission that does seem to influence students. There are different relationships between faculty and departments and students. Students there are more open to cultural, interdisciplinary, public health, primary care, and rural items. Obviously we cannot continue to build more medical schools, but we can reconstruct the medical education process. It is unlikely that we can modify the major medical centers, but we can move students out of these areas for training. Many are overcrowded and give students a passive style of training that is poorly suited to rural practice where decisions have to be made more independently and where more procedures are done.

At medical centers, rural student interest groups can band students together to resist urban and specialty pressures. Rural rotations, particularly the longer ones such as RPAP in Minnesota, can get students away for some time. Rural campuses for the first or last two years can also be a help. Basic science faculty could also be rewarded more for teaching, especially if this involved developing web-based teaching modules so that students did not have to live in urban areas.

Faculty need to be made aware of rural needs through focus groups and visiting rural practices. Academic medical centers could contract with rural networks for specialty care to preserve or increase their patient base, rather than ignoring rural practitioners and giving them little or no information about patients when they come to the centers for care.

Medical schools should improve efforts in doctor-patient communications, community-based care, and physician leadership skills so that those considering rural practice can build the skills and confidence needed for a rural practice choice.

For the most difficult populations, medical schools will need a different type of preparation. Natives and many Asian populations have a great need for physicians to be able to deal with the spiritual aspect of health. Why should a native go to college, medical school, and residency to become a second class healer, one who cannot deal with spiritual issues? Also the urbanization that occurs would inhibit a return to the reservation or underserved population in need. Admitting urbanized natives or other minorities is less likely to meet the needs of the truly underserved.

What Are Medical Schools Doing?

Other than a few models, medical schools are doing little. Few, if any, have the kind of comprehensive program that reaches out to rural secondary education and extends to graduates in practice.

There are pre-admission programs in some states (Kentucky PEPP) that have worked for years successfully to bolster rural admissions. In more recent weeks I have had a chance to tour rural medical education programs in Minnesota (Duluth and RPAP), Rockford Illinois (RMED), and Missouri. At each location, there was a similar effort to work with small colleges, agricultural schools, and even rural high schools to get more rural applicants. Some states such as Missouri were also targeting the gifted health-oriented students with scholarships to state colleges to keep them from leaving the state.

There are still major barriers with admission committees. Few have significant training. With busy schedules in many other areas, few have time or motivation to take up the challenge of shaping the next generation of physicians. Rabinowitz has demonstrated that a small program with 1% of Pennsylvania’s medical school graduates can produce 21% of the state’s rural family physicians (http://www.ama-assn.org/sci-pubs/journals/archive/jama/vol_281/no_3/oc80057a.htm). Selecting for rural and true family practice interest can help with retention.

Few also help the "right" candidates improve their chances of admission, even though rural and minority studies show that this is possible and desirable. Nearly every medical school has a program to enhance their minority admissions. Studies at UTMB Galveston note that minority applications and admissions can continue or increase with these programs despite the reversals of affirmative action. There is reason to believe that more and better rural candidates can enter, especially rural candidates who are also a member of an underserved minority.

What Happens If We Graduate Fewer Physicians, Will We Have More or Less Rural Physicians?

In the past the nation increased the number of medical students so that we could produce more physicians. The "Trickle Down" theory pledged that the excess physicians would eventually distribute to the smallest towns. One Rand Corporation study noted that this theory was working, but the authors later retracted their work as invalid since they excluded the smallest towns and practices from consideration.

We have now entered another era where various groups clamor for less physician production. We know that the more physicians that we allow to graduate or come to our country, the higher the national health bill. Physicians have themselves to blame. The primary rationale for foreign immigrant physicians and non-physician practitioners has been the failure of medical schools to meet the needs of the underserved. Now the nation faces a number of provider excesses. Physician assistant graduation levels will soon be double the numbers of family practice graduates per year. Nurse practitioners continue to expand with no end in sight. Various workforce studies cry out for a reduction in medical school class sizes.

Medical school student reductions could worsen the situation for rural health. The only study of reductions in class size noted that decreasing the class size of U.S. medical schools in the 1980's resulted in a decrease in the family practice match when these matriculants graduated (Fahey, Sachs, Bauer in Academic Medicine 67:10;680-684). One explanation of this is that those admitted from the ranks of the "best and brightest" nosed out those interested in family practice as well as primary care, rural, and those with the service orientation that perhaps distracted them from the kind of effort that resulted in higher GPA and MCAT.

We do know that we are graduating fewer rural physicians from family practice residencies (from 680 a year to 580 in the past decade). This has happened in a decade with great increases in the number of family practice residency programs, the number of graduating residents, and the number of programs with rural training. Increasing the number of generalists has not resulted in more rural physicians in needy areas of the nation. Now, more than ever, we should try to select the kind of physicians that will go where they are needed.

What Questions Should We Be Asking?

Unfortunately there is little data and analysis of the more qualitative effects. We are currently not asking the right questions or studying the right outcomes. I heard of a study of cows the other day. Researchers were trying to differentiate cows that might do better in relatively plush lowlands from those that would do better in highland locations. It seems that some cows do more damage to certain types of grazing lands. Who would have thought of such a concept? Someone did and has devised a tracking system that will help analyze and select cows that use certain types of land more appropriately.

How much more information could we collect and analyze on the more responsive students and residents, if we committed to the process of evaluation at all stages from before training to after graduation? What more could we do if we fed that information back to admissions committees and others involved in preparation and education as Madison and others have suggested. Currently most medical schools shred much of the information about their graduates to protect themselves from future legal issues.

What if we stopped listening to the lawyers and kept admission information to use for future admissions. Is a rare lawsuit over the quality of graduates worth the lack of information that could shape the next generation of physicians?

How Could We Get Better Information?

The current process of GPA, MCAT, statement, and interview is just not adequate. Just as we know that a few days are just not enough to help recruited candidates find out all they need to know about a small town, one day is just not enough time to examine a candidate for medical school. Quantitative data is just too easy to collect and use when compared to qualitative for busy people and schools with declining resources. We need a screening process that involves months, rather than a day. There are at least three ways to address selection of the "right" students.

  1. The first level to examine is pre-admissions. The vehicle for identifying qualitative student characteristics is long term community service projects. During these projects students would work independently and together with others to assess, problem-solve, communicate, manage, demonstrate caring, and document their ability to be responsible. Students would have to adjust to a different environment and a new role. Students would be socialized into service first, before formal education begins. Objective observers (a difficult task involving much selection and training) would assess student qualities. Although initial phases of this program would be experiments with outcomes to be determined in many years, the projects would act to help the communities assess and address health care or other needs (rural or urban) - a great need in many underserved communities.
  2. Another option is to admit students to medical school for a probationary status of a year or more. They would undertake a curriculum that required the first six months or year to be a screening process involving basic sciences and community projects, with continuation in the second year based on service, responsibility, communication, and performance. This would involve more work on campus and increased student stress levels. This would shift the discernment burden from admissions committee dealing with hundreds of applications to an evaluation committee dealing with far fewer numbers.
  3. A third option is to exclude students after the second year based on contact with small group leader-advisor-evaluators who saw their progress and work over a two year period. Again this would take time and resources for training. It would tend to "waste" medical center resources. Students would also be subjected to increased stress and small group leaders would be seen more as police than mentors. One advantage is that students could also take an active role in the evaluation process or their peers - valuable training for the future in an important area where physicians need to do better. Many schools have gone to the small group format for part of the curricula, but some have not taken group leader advice regarding problems with students that they felt were inappropriate for medicine. This would have to change in order for this process to work.

Obviously I favor the pre-admissions method. It involves a more deliberate reward system for those that can demonstrate service and communication. It involves more service to rural communities and less medical school resources. Whatever the process chosen, I feel confident that the students selected through a more intensive process would be a joy to work with now and in the future. They would be physicians who could help restore the public's faith in the medical profession.

There is an added benefit of a longer evaluation process. One of the most damaging and difficult physician groups to deal with is sociopaths. I attended the AMA Conference on Physician Incompetence years ago and the conference admitted that these physicians could not be identified or excluded by admissions or licensure processes. My experience has also taught that disciplinary actions only tend to help the sociopath learn how not to get caught. Long term preceptorships (4 months in one program and 9 months in another) are unique in that they identify both students and preceptors who are pathological or impaired. If a similar long term process assessed students before they were admitted, they could be excluded before they had a chance to make decisions that prioritize themselves over their patients. At this early stage, they would also be easier to screen as they would have less chance to adapt and play the game. Unfortunately for medical schools and the public, it is too late to do much about the students after they have been accepted.

In Summary

Various policies and practices exist that limit the numbers of medical school graduates that can truly serve rural communities and possibly the rest of the nation as well. We should work at all levels to encourage better preparation, selection, and training. Medical schools play a pivotal role not only in selections and training, but in advising the state about preparation as well. Rural faculty are in a unique position to influence the many levels and encourage solutions that are efficient and effective.

Recommendations

  1. It is time to reassess the centralization and consolidation of educational resources. This process may be a key factor why young people are unwilling to choose rural locations. Medical and other professional schools and their faculty must be willing to influence the distribution of state educational resources in order to meet the needs of all citizens of the state.
  2. It is time to reassess admissions, not just to look at rural background, but also the ability to communicate first, the willingness to serve second, with academics reserved for assessment after the first two priorities. This will need to involve a longer evaluation process. It is better to cut out those who can't communicate or won't serve, than be stuck with them. By doing this we will likely shrink class size without reducing needed professionals. Perhaps maybe even those who failed to get in would wake up and learn that communication and service were important qualities, especially for professionals.

Factors to consider regarding obstacles to a rural location

Community Level

* Improve education and job availability in rural areas to attract young professionals/spouses

* Health career orientation early at the local level

* Better organization/recruitment/planning in rural systems

* Combat local rural attitudes that local people and services are not as good. It is not a failure for kids to return to their home town to raise families.

* Support rural professionals locally with dollars and people

Higher Education: Colleges and Academic Centers

* Educate and train in the most rural locations possible

* Evaluate students more thoroughly for the right characteristics

* "Take a chance" on rural, minority, or service-oriented students

* Reach out to facilitate rural health needs,

AHC's should not be a burden regarding resources for health education

AHC's should help facilitate rural health systems organization

* Support students interested in rural practice with career information, advice, and student interest groups. A particular need is to address specific needs of young professionals, especially the unmarried, minorities, and females.

State Level

* Combat centralization of education resources at all levels

* Prioritize rural economic development

* Retain gifted students and return them to rural communities

* Continue to value educational activities even though some students will leave rural areas and the state.

See also WORLD ORGANISATION OF FAMILY DOCTORS POLICY on TRAINING FOR RURAL PRACTICE listed at http://www.cfpc.ca/carmen/woncapol.htm

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Rural Clinical Practice

Should We Routinely Screen for Placenta
Previa with Transvaginal Ultrasound?

William Rodney, M.D.

 Among 6,428 cases, the placenta extended at least 15mm over the internal os in 156 (2.4%). In eight of these patients placenta previa was present at delivery. Two cases were not identified (sensitivity 80%, specificity 5%).

Reference: Taipale P, et al. Obstet Gynecol 1997;89:364-7.

Comment (WMR): Universal screening of pregnancies with hopes of preventing maternal health via early detection of placenta previa is not indicated.

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First Person

Blizzard
Robert Boyer, M.D.

 Goodbye Carl
Dale Dewar, Wynyard, Sk.

 Today I had another of the unusual and unique experiences of rural family medicine. I supervised a code on a dear friend!

As I recall the event, I am quite surprised at how shaken I was after he was pronounced "dead" ---- and that is a hard way to think of Carl. He was riding his bike a week ago; he shingled my house. He was 82 and he had to go someday. Perhaps, as Bill (my partner) said, "it was good that you were there to have the chance to bid farewell"

But Bill has never seen ambulance drivers and hospital workers run a code.

I had to go back into the room and "make sure" that Carl was really gone when everyone else was doing the paper work.

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REPLACEMENT DOCTOR?

The following letter was dictated to me by a much loved, 41 year old physician, who has given her life to the physical, mental and emotional health of the citizens of Miller County, Georgia. It would take volumes to tell you all she has done for the community, the lives she has touched, the services she has anonymously donated, the time, energy, and love that she freely gives to anyone in

need. She has loved the unlovable, treated patients that no one else would touch, delivered thousands of babies, all the while never judging, nor being critical of anyone for anything. She is a valued asset to humanity by her demonstrations of unconditional love for her fellow man, with no regard for race, creed, color, or financial status. As a very small example, one of her pediatric patients needed to be referred to a medical center, miles and hours away. The family had no money, no transportation -- she gave them the keys to her own vehicle, along with gas, food and money to make the trip.

Multiply this type behavior times 16 years and you will see Peggy Rummel. She is facing death now, very soon, and I am in shock that what she wants most is to replace herself. I regret to report that if I were in her position, I would not give a thought to whom would be taking my place at work. I visited her yesterday, and of all the things I would be willing to do for her, the only thing she asked is that her plea be made public. I gladly do so and ask that you respond to her as soon as possible, as she is not going to live long now, her only peace seems to be a ray of hope for the preservation of Miller County Hospital. Thank you for sharing this message. -- <acushla@surfsouth.com>

To the People of the World:

Colquitt, Georgia, is a small rural town. We have been trying to grow enough to stay alive without loosing the good parts of country living. We wrote and produced a musical called "Swamp Gravy" that was selected as Georgia's Folk play, performed at the Olympics, and at the Kennedy Center in Washington as a fund raiser for education. We are building a museum honoring all the people in the rural south. We turned a flophouse into a fourstar bed and breakfast.

We are trying to keep our young people home. We placed 15th in the nation for Quiz bowl compassion, have impressive high school/college ratios. Colquitt is working hard to expand in the right ways. Unfortunately, as much as I love Colquitt and Miller County, I have failed my home.

I am one of three doctors in the county. We lost half our staff last year, and are about to close if something is not done quick. The hospital and county have been recruiting, but the earliest we can hope for is two years. It was going to be hard work, but I knew I could do it.

I was wrong. Last week, I found out that I have hepatocellular carcinoma in the final stages. I've gone from a full time practice and ER call four days a week, to barely making it across the room. I won't lie, I am really mad about loosing my family so quickly. No one can help me but God.

I do hope however, that you can help me find a replacement doctor. The people here are so great, they would welcome a doctor openly. They have been so good to me and my family since we arrived 16 years ago. They deserve a break.

Maybe there is someone who would love a ready made practice. I have seen miracles happen, and this one can too. Please, I am so afraid we will loose our hospital and emergency room. My OB's will have to drive 20 miles for a check up, some emergencies can't wait that long. We are trying so hard to survive. Would you let people know of the opportunity here?-- Peggy Rummel, MD <prummel@surfsouth.com>

Contact persons for information about the Medical Practice in Colquitt, Georgia, USA are:

Sandy Rathel, Acting Administrator of Miller County Hospital

Chair of Physician Recruitment Committee 912-758-5585 OR

Ann Addison, PA, MSN, FNP-C, Miller County Health Department

912-758-3344

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Inspirations

Favorite Rural, FP, Teaching, and other Quotes

Americans can always be counted on to do the right thing, after they have exhausted all other possibilities. Winston Churchill

"I tell you the old-fashioned doctor who used to cure you of all illnesses has quite disappeared. Now there are only specialists and they all advertise in the papers."

F. Dostoyevsky The Brothers Karamazov 1880 via Joseph Merrill M.D. and Family L

"A teacher is one who makes himself progressively unnecessary." Thomas Carruthers

I cannot recall reading of drive-by shootings in Wyoming. I am tempted to accredit this to the assumed high risk of high caliber, highly accurate return fire. Bill Woodhouse FP

Everything gets smaller as you move closer to the resident side of the clinic. Ed Mantler, FP resident,

Editor’s note: Hopefully his recent graduation has not inflated his ego.

 It has reminded me of the comment made by Steve Bogdewic one day in a faculty meeting where we were all complaining about how unappreciated we were by our Dean, how we all busted our butts with no additional resources or institutional support, etc.

He basically reminded all of us that Family Medicine is still very much the new kid on the block in academic medical centers, that we are basically still on the Conestoga Wagons crossing the Great Plains eating sourdough hard tack and drinking bad coffee, wishing we were in San Francisco drinking great wine and eating Pacific Salmon.

We bought a small model of one of those Prairie Schooners and placed it on our conference table for every one of our faculty meetings after that just to remind us of the need to be patient while we fight off the Indians, endure cold nights out on the plains on our way West.

Michael L. Parchman, M.D. - Donner, party of 50, this way (sorry, couldn't resist a Patch Adams addition, go see it)

 Our deepest fear is not that we are inadequate.

Our deepest fear is that we are powerful beyond measure.

It is our light, not our darkness that frightens us.

We ask ourselves, who am I to be brilliant, gorgeous, talented and

fabulous? Actually, who are we not to be?

You are a child of God. Your playing small doesn't serve the world.

There's nothing enlightened about shrinking so that other people won't feel insecure about you.

The wise family physician is one who knows how much he/she is but is more concerned with how much more he/she can become.

Hunter Woodall, Family Physician!

thanks to those who contributed

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Colleagues and Contacts

WEBSITES

From Family-L listing - Craig Gjerde - The Canadian Journal of Rural Medicine (CJRM) is a peer-reviewed journal, available in print form and on the Internet, focused on rural health. Produced by rural physicians on behalf of the entire rural community, it is intended to complement existing primary care journals. http://www.cma.ca/cjrm/index.htm

WORLD ORGANISATION OF FAMILY DOCTORS POLICY on TRAINING FOR RURAL PRACTICE listed at http://www.cfpc.ca/carmen/woncapol.htm - This is a very comprehensive listing of what it will take to graduate more and better rural physicians.

OFFICE OF RURAL HEALTH POLICY PUBLICATIONS LIST as of September 1998

Some examples listed, full listing at http://www.nal.usda.gov/orhp/publist.htm

Directories

1.Rural Health, Mental Health, and Substance Abuse Resources Directory 1996.

2.Directory of State Offices of Rural Health and Rural Health Associations 1998.

3.Federally Funded Rural Health Research Centers 1997.

4.The Federal Telemedicine Directory 1998.

Fact Sheets and Resource Guides

6.Rural Health in the United States. A comprehensive look at the current state of rural health care in America. Many charts, tables and maps. Forthcoming from the ORHP-funded Rural Health Research Centers. Oxford University Press. Spring 1999.

7.Definitions of Rural: A Handbook for Health Policy Makers and Researchers. University of North Carolina Rural Health Research Program. July 1998.

8.Mapping Rural Health: the Geography of Health Care and Health Resources in Rural America. 1997. A book of maps, 44 pages by the North Carolina Rural Health Research and Policy Analysis Program. University of North Carolina, Chapel Hill. (Single copy requests only)

Training and/or Recruitment for Rural Practice

32.Barriers to Residency Training of Physicians in Rural Areas. WWAMI Rural Health Research Center, Working Paper #46. May 1998.

33.Impact of Federal Funding for Primary Care Medical Education on Med Student Specialty Choices and Practice Locations (1976-1985). WAMI Rural Health Research Center. April 1991.

34.Physician Life and Practice in Underserved Communities: Strategies for Recruitment and Retention. University of North Carolina Rural Health Research Program. March 1994.

For more information about rural health, contact the Rural Information Center Health Service (RICHS) at 1-800-633-7701 or Internet address: http://www.nal.usda.gov/ric/richs

Or contact the Office of Rural Health Policy, at 301/443-0835

Internet address: http://www.nal.usda.gov/orhp/

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Commentary and Critiques of Past Articles and Issues

1998 Group Report for the STFM Group on Rural Health

This year the STFM Group on Rural Health had the opportunity to gather steering committee members together at the STFM, NRHA, and AAMC annuals for presentations on the current status of rural medical education. Group members Tom Rosenthal, Rick Blondell, Jeff Stearns, Hal Williamson, Robert Bowman, Dave Acosta, Howard Rabinowitz, Don Pathman, and Deb Phillips compiled information from many sources. This and other information is available on the web at www.ruralfamilymedicine.org. This web site continues to expand under the direction of Deb Phillips. Deb was also active in the development of workforce guidelines for the National Rural Health Association (NRHA).

Steering committee members also had a chance to tour Minnesota, Illinois, Nebraska, and Missouri rural medical education programs. More states are working with small colleges, rural high schools, and rural communities to identify those interested in becoming rural physicians. Programs reaching out from medical schools are attempting to encourage rural students to consider health careers.

Howard Rabinowitz authored a landmark article for JAMA (1999;281:255-260), "A Program to Increase the Number of Family Physicians in Rural and Underserved Areas." This is the best response to AAFP and AAMC leaders who often assert that rural shortages are simply a matter of economics. Rural medical education can select and train physicians that will stay in rural practices long term. Such physicians meet rural needs, stabilize rural health systems, and contribute greatly to the health care and leadership of their communities.

The Group also impacted students and residents at the National Congress of Family Practice Residents and Students in Kansas City. Robert Boyer, a rural physician in Kingman, Kansas for 30 years and the first AAFP Doctor of the Year, continues to be an outstanding resource for those considering rural practice at all levels. He has spoken in Kansas, Nebraska, Iowa, Ohio, and Illinois and will do a 2 day retreat in Missouri, but more schools should access this valuable resource.

Plans for the next year include a web-based rural journal, working with STFM, NRHA, and Canadian associations. This journal will provide peer-reviewed articles, motivational items, and nuts and bolts examples of rural programs. The Group is working with rural program directors on this and other activities. The Group also plans a preconference session prior to the Seattle annual STFM meeting. Surveys of rural programs continue at the predoctoral and graduate levels and these updates will emerge as articles and web-based information.

We continue to look for folks that are involved with rural medical education and would be happy to help them contribute and take a role in group activities.

 

Jeffrey A. Stearns, MD
Assoc. Professor of Family and Community Medicine
Director, Rural Medical Education Program
Predoctoral Director, Dept. of Family and community Medicine
University of Illinois, College of Medicine at Rockford
1601 Parkview Ave.
Rockford, Il. 61107
Phone 815-395-5784Fax 815-395-5781
jstearns@uic.edu

Robert C. Bowman, M.D.
Director of Rural Health Education and Research
Associate Professor, UNMC Department of Family Medicine
983075 Nebraska Medical Center
Omaha, NE 68198-3075
(402) 559-8873 or fax at -8118
rbowman@unmc.edu
www.unmc.edu/FamilyMed/rural/rural.htm

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Why a Journal of Rural Medicine and Medical Education?

Robert C. Bowman, M.D.

The primary reason for the journal is that we need to begin training and influencing a new generation of rural physicians and faculty. A journal will help them to remember what was done and why. The next group of rural physicians will not ???, but will hopefully get a better job done with resource negotiation, replication of successful models, and program development. Somehow we must wed the leadership of the rural physicians in established organizations with the medical education and community contacts to get the job done.

I have watched the Canadians go from forming to storming to norming to performing in a short time period. A journal has really helped them to do more than just ventilate or theorize. I've learned some good academic and practice stuff from their journal at http://www.cma.ca/cjrm/index.htm.

The challenge of internet journals is to balance the practical and academic. The solution is to address both, having peer review for some and experiential for others. It also gives us a chance to influence the experiential folks to do more academic work and chastise academics to be more practical.

They need a place to get their feet wet.

They need a place to be practical

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Responses to Journal of Rural Medicine and Rural Medical Education Proposal

Robert C. Bowman, M.D.

On November 11, I emailed this proposal to 40 rural faculty and rural physicians. The following is a report on the responses

 Responses from rural faculty and physicians                              14

Total who promised articles or significant help with journal    5

                                                                                                      Yes Alternative No

Non-published program directors or RTT directors             6

Non-published predoctoral or predoc rural program directors    1

Rural family physicians                                                               1

Published academic leaders                                                       1     1

Published program directors                                                                     1

Published predoctoral or predoc rural program directors                     2                  1

 The individual responses are listed at the end of this transmission. I was the person who made an assessment of whether the person was published or not. A final comment came from our Canadian friends who noted that the clinical component was critical.

Analysis

The responses are fewer than hoped for and the reaction was mixed.

Established faculty in departments or academic centers feel that we should work with existing journals. Others, particularly program directors of RTT programs, feel that a new journal would help.

I cannot help but think that those with established sources of support or information sharing are less motivated. The chairs, main-stream program directors, and predoctoral folks are more established with committees and an annual meeting.

I have attached more explanation about the reasons for the journal for your review.

The strength of the journal would be

The weaknesses are also of major concern.

It is possible that AAFP and STFM could respond with resources such as committees and and a specific meeting such as the predoc meeting. So far AAFP has not been very responsive to rural requests in various meetings and communications. STFM has not been approached about a specific meeting, but has limited resources, as does NRHA. It may be that we need to strike out on our own and establish a presence, then entertain responses from organizations.

I am willing to do the journal with little help, but if done this way it will obviously lack the multiple perspectives and the quality that it could have. Neither would it have the academic acceptance

Plans

  1. Put together the initial issue on www.ruralfamilymedicine.org as a work in progress for comments, additions, and critique.
  2. Continue to solicit feedback from other physicians, faculty, journals (Journal of Rural Health, Texas Journal of Rural Health, others), associations, foundations, and government.
  3. Attempt to find rural physicians that will commit significant time to the effort.

11/11/98 Responses

9:20 journal proposed

10:40 first response, community physician and RTT program director, has no articles published,

positive response, referral to colleague with article about academic biases toward rural training

11:15 academic physician, predoctoral, published,

supports working with Canadian rural journal, publishing electronic and paper both

11:56 rural predoc program director, presentations not published

positive, wants to submit

1:15 rural predoc program director, some published

positive response ?have been disappointed several times when I submitted something very practical to ________ and gotten a typical "ivory tower" reason for rejection, so I would be pleased to have another publication venue. I've also been involved with the start-up of a new journal, and it's a lot of work. Most academics don't value an electronic jrnl very much, so that may be an issue.

1:54 rural predoc program director, well published

Have you already decided to do this? Is there enough material?

Most of our FP journals are having trouble staying in business?

3:05 RTT director, not published, positive, already submitted piece

3:18 FP PD, some admissions and AHEC, into new areas, still rural interest, wants to be on mailing list

4:52 Rural FP, not published

I was nearly overwhelmed by your message. The scope of this venture is daunting. I'm flattered that you included me in your list, but as long as I have the responsibility of serving on the state _______, I won't have time to do more than to encourage you in your task. A quick note from time to time is all I can offer.

9:36 Academic leader FP, well-published

Holy Cow Batman!!! What a major concept! Could I be so bold as to suggest several politically incorrect justifications for this idea.? First, academic family medicine in the universities is being bludgeoned into submission by generic 'primary care'. The community hospitals have been left to defend generalism within the medical specialty of Family Practice. Unfortunately there is such an excess of overly specialized subspecialists, that these subspecialists are now permeating the culture of medicine to the point of outlawing many of the diagnostic and therapeutic activities necessary for survival of the comprehensive care family physician. One notorious example after another could be cited. Remember all of the medical schools that were specifically funded in order to provide a safe haven for the training of family physicians?

_____________Journal_? What a joke? On the other hand, even if _______editors had the interest, where would they find the authors? Currently there are no meaningful rewards and incentives for publishing studies which support a physician who replaces general internal medicine, general pediatrics, and Ob-Gyn. God forbid, we would have to change the medical school. Worse yet, they might have to relinquish part of the 40 billion dollars they receive in annual taxpayer support. This is the key.

Although small journals can survive, there is the question of impact. Check out the Texas Journal of Rural Health[915 335 5119] published by Texas Tech. Now in year 7 or 8, each quarterly issue contains the format for and by clinically-oriented physicians.

FIND A POT OF MONEY FOR MEANINGFUL INCENTIVES AND REWARDS. MAKE IT A SPECIAL CLUB FOR THE ELITE FAMILY PHYSICIANS WHO PROVIDE CONTINUING COMPREHENSIVE HEALTH CARE UNRESTRICTED BY AGE GENDER, ORGAN SYSTEM, AND LOCATION OF SERVICE. CONSIDER THE THOUSANDS OF RURAL DOC FP ALUMNI WHO ARE BEING BILKED OUT OF MILLIONS OF DOLLARS IN DONATIONS BY UNIVERSITIES WHO OPENLY CONTEST TRAINING DEDICATED TO THE RURAL FP. IMMEDIATELY LOCATE AND RECRUIT SEVERAL LEGISLATORS WHO WILLING TO ATTACH THEMSELVES TO THIS IDEA. IF THERE IS NO UPFRONT COMMITMENT TO PUBLIC RELATIONS AND MEDIA SPIN, AN OPPORTUNITY WILL BE LOST. LOOK AT WILLIE NELSON AND THE FARM AID CONCERTS.

EXPLOIT NATURAL LINKAGES WITH AAFP, NCFPR, AFPRD, AND STFM. REQUEST AND STAFFAN EXHIBIT ANNUALLY. FORGET THE LEGALISMS OF COPYRIGHT. IF SOMEONE WANTS TO COPY SOMETHING OF MINE, I FEEL FLATTERED.

HAVE FUN . THINK ABOUT A CENTERFOLD FEATURE FOR PROCEDURE OF THE MONTH. FIND A POLITICAL ISSUE AND RUN WITH IT. FIGHT CLIA WITH THE PURPOSE OF RESUSCITATING THE OFFICE LAB. TECHNOLOGY AND QA/QI MSKR THIS MORE INEVITABLE EACH YEAR. 'Yes , your photos[REPLACE THIS WORD WITH LABORATORY RESULTS] will be developed in an hour. Would you like to wait? Former editors MIGHT BE OF HELP.

Of course I am interested in supporting this idea, but before I commit I'd like to see a bigger vision.

11/12/98 Responses

8:28 academic leader fp, well-published

You are an energetic person, for sure. This would be a massive effort. Have you discussed it with other fp editors. They could give you some insight into the effort needed. Also, critical to the success of such a journal would be good submissions. I understand from fp editors that the number of submissions are not increasing, in fact may have decreased. Would it not be better to have a continual series in one of the above journals with a rural editor such as yourself? That would reinforce our existing literature and give the publications broader exposure.

9:15 what about the ______Journal_____? I'd think it would be easier to try to get a special section in that publication rather than start yet another journal. Lets talk

9:21 rural fp, rtt director

I'd be happy to help. We are getting a little better established and I hopefully would be able to find some time to work on a project such as this. I've talked with ______ about this in the distant past and he said that it might be possible to devote an issue/year or have a supplement with the _____ journal. I would think that this would be a way that we could get the thing up and running quickly and at minimal expense. I would think that we could have a selected list of contributors that would contribute a paper on a specific topic if asked. Issues that I would feel comfortable curriculum; practical issues regarding training FP to work in rural areas; problems encountered with Federal reimbursement for rural FP training; Why multidisciplinary training is not working (in ______); Differences between rural and suburban/urban clinical practice; failure of evidenced based medicine in rural practice; many others.

 

9:46 Rural fp, rtt director, non-published

will help with this in any way I can. A suggestion I have follows a talk I recently had with another director. Our program is trying to mobilize an effort on the behalf of the RTT's to ensure that GME funding is maintained or enhanced for RTT's. We think we have a compelling argument, but also believe we cannot count on the other players such as AAFP and STFM to represent our interests completely. In discussing this with him we thought that getting as many of the RTT's together at one time would be a good way to plan a strategy. A meeting like that would also be a good venue to discuss other mutual interests such as the journal. Possibly one of the programs maybe even ours would be able to host such a meeting. What do you think? Some projects that we are working on that might be worthwhile for the journal include a telederm project. Computerized med records including a clinical data repository, rural mental health services, sliding fee schedules, Medicaid outstationing, a community hepatitis immunization campaign. We have begun a formal research arm and should have some results from that soon. Let me know what you want me to do

10:11 rural predoc director another response

Thinking about this further, this might be an opportunity to share something we've had going for about two years. Each Thu AM, our rural maternity fellow, a perinatologist, a Gen OB, and me have a "Grand Rounds" by phone conference call. Often the faculty, FP resident, midwife, and some nurses attend as well, and we give category 1 CME. The fellow presents a complicated OB case (usually one sent for tertiary care) and the perinatologist provides follow-up and we discuss the problem from all our perspectives. The result has been great continuity of care and outstanding learning, and the MFM faculty are very gracious (they're nice people, and they really need these referrals). We could contribute to the new journal in two ways: a paper summarizing the project for those who might want to replicate it as well as a regular "column" summarizing the previous month's conferences as a form of update for rural FPs doing OB (sort of like a newsletter, but more practical, more FP, and more scholarly). I would propose Case summary, followed by summary of discussion, followed by brief commentary by me. Feel free to forward this message along as needed and let me know if there is interest. Thanks.

 

11:00 rural doc recently rtt faculty

I have practiced in rural settings for 6 yrs including a two year stint in a medical mission in the Appalachian region of southeast Kentucky. With that said, it is obvious that I have a strong interest in rural medicine and in Academic medicine. I don't know exactly how, but I would be interested in helping you in some way with this effort. Let me know more specifically what you might need from me, and I'll see if I can accommodate. This sounds like a good and much needed idea.

Other responses:

Academic perspective of rural practice: there are two values, patient referral to university hospitals and support from rural community faculty to help with legislative lobbing. In ___there are a few researchers that value the rural communities as a site for data collection. I see this as a more typical urban view of rural with attention on what rural has to offer urban rather than a true value of rural for rural. I see this as a reality rather than anything worth confronting directly.

I like the idea of an electronic rural and frontier journal. Not all have electronic access, but there is a rapid growth and great interest. Having a valuable resource accessible gives added value to internet access. I would suggest more frequent, short, editions rather than long pieces. I still see too many documents following the printed format and with an electronic journal, I think emails with a "short story" philosophy of being able to get through it all at one sitting works best. My feedback from my contacts continues to emphasis the need to hit them fast and catch their interests with the USA Today type articles. Couple this with links to more indepth articles for those that need and want that detail.

I personally like the email reminders of a new edition or new content at a site.

Please keep me posted on how this idea is progressing and I would like to help, but at the present can't commit too much.

It is amazing how much we can accomplish when we do not worry about who gets credit for what we do.

 

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