There are a number of studies that address the training of Family Practice (FP) residents for rural practice. Some data is now beginning to surface regarding the needs assessment of rural providers (3). This report reviews those studies already available to educators, and what strategies the STFM Working Group on Rural Health are working on that enhance the preparation of residents for rural practice.

Issues

There are a host of training models that residency programs have developed and implemented over the years to prepare FP residents for rural practice. These models include the following:

1. Primary location in a metropolitan area with either required or optional away rotations at a distant rural site;
2. Primary location in a metropolitan area with a rural satellite clinic that serves as the residents family practice center;
3. Primary location in a metropolitan area with a rural training track (RTT) where the resident spends their first year in the primary site, and the last 2 years in a rural community (1);
4. Primary location in a non-metropolitan area;
5. Fellowship programs (2).

There is limited data on which program model recruits the most, prepares the best, and graduates the most residents into rural practice.

Most rural curricula are based on the anecdotal experiences of past rural providers who now serve as faculty or program directors. There is no standardization of rural curricula. There is also no collaboration about educational goals and objectives among rural educators. Data is beginning to surface regarding how well prepared rural providers perceive themselves to be for rural practice based on their cognitive and technical skills (3). But there is limited data on whether rural providers feel adequately prepared for the other important aspects of rural practice including the transition to a rural community with its unique traditional values and beliefs.

What We Already Have

The American Academy of Family Physicians (AAFP) have published two important monographs on educational strategies. First published in 1989, Rural Practice: You Can Make a Difference has recently been revised (4). Chapter 4 entitled "Rural Practice Issues" focuses on important aspects of rural practice that residents must become aware of for their successful transition to rural living and practice. In 1990, the AAFP also published Special Considerations in the Preparation of Family Practice Residents Interested in Rural Practice which is a survey of all FP Program Directors in the U.S. regarding what they believe rural training should encompass (5). Revised in 1997, the latest recommendations are divided into four sections: I. Hands-on experience; II. Practice management; III. Special clinical topics; IV. Community-oriented primary care. The AAFP has also published the Core Educational Guidelines for Family Practice Training, but no guidelines have been developed specifically for rural training.

A recent review of the literature found four significant studies assessing the needs of rural physicians.

Costa et al surveyed third year residents in all of the accredited FP residency programs in the U.S. regarding what factors influenced them the most in choosing the type of practice following residency (6). In their review of the literature, 24 influential factors were identified from 12 published articles. Eighty-three percent of the residents who responded had already decided on their practice location. They had a 68% response rate from residency programs, and a 42% response from all residents. Table 1 shows that the most important influential factors centered around their significant other’s desires and family issues.

Influencing Family Practice Residents’ Choice of Initial Practice Location, Fam Med 1996; 28: 214-9

Norris et al surveyed all rural FPs in the U.S. who were members of the AAFP regarding their needs assessment (3). Forty percent of the respondents felt that their preparation for rural practice could have been better. Table 2 shows those areas in which the authors felt that additional education for rurally bound students, residents, and fellows might be indicated. The surveyed physicians stated that these same areas were commonly seen in their practices (see "% including in practice" in Table 2).

Assessment of Rural Family Physicians, J Am Board Fam Pract 1996; 9: 86-93

Ideally, the authors recommended that residency programs that provide rural training should increase their emphasis on and provide special educational opportunities in their curricula in these areas.

Efforts By The STFM Working Group on Rural Health

The STFM Working Group on Rural Health is presently surveying all predoctoral , residency, and rural fellowship programs regarding their rural curricula in hopes of developing a set of curriculum guidelines for rural training.

The purpose of the residency survey was to (a) better understand how FP residency programs in the U.S. are training residents for rural practice, and (b) to collate rural curricula and develop a workable template.

The survey included the following queries: type of program; number of residents declaring rural and ultimately going into rural practice; amount of time the resident spends in a rural community; the number of rural faculty; the methods of teaching (e.g. specific rural didactics, rural library, telemedicine, and computer interface); and coverage of specific rural topics. A copy of the program’s rural curriculum was also requested.

One hundred and fifty FP residency programs in the U.S. have been identified to have a partial or full mission to train their residents for rural practice (7). An additional 25 programs have been identified which do not have a rural mission but do have a rural training track (RTT), a rural satellite clinic, or a rural fellowship. One hundred of 150 programs have responded after two mailings for a response rate of 66%. Figure 1 depicts the location of all the FP residency programs in the U.S. with rural missions.

Figure 1

Proportionately, the regions with the most FP residency programs with rural missions are in the South (29 out of 43 programs located in Arizona, New Mexico, Texas, Oklahoma, Missouri, Louisiana), the upper/lower Southeast (42 out of 72 programs located in West Virginia, Virginia, Tennessee, Kentucky, North Carolina, South Carolina, Georgia, Alabama, Arkansas, Florida), and the West (30 out of 56 programs located in Washington, Oregon, California, Idaho, Montana, Wyoming, Colorado, Utah, Nevada).

The survey was sent to the program director or the rural liaison to complete. They were queried as to the specific methods of teaching utilized, such as whether or not they had dedicated didactics on selected rural topics. If they had didactics, they were asked what form was used the most for rural training (e.g. routine lectures, workshop format, syllabus of recommended readings). They were questioned if their medical library provided resources specifically on rural health and if so, what type of resources that these were, e.g. selected books, journal articles, monographs, audiocassettes, CD-ROM, videotapes. They were asked if the program exposed the residents to telemedicine conferencing or consultation, and whether the curriculum included computer skills development with training on the Internet.

Table 3 reveals the preliminary results of this study.

Rural Curricula Survey of FP Residency Programs in the U.S.

Results showed that 64% of residency programs with rural missions do have didactics on selected rural topics in addition to the usual Family Practice topics, and these were predominantly in the form of routine lectures. Over half of the programs provide the resident who is interested in rural practice with some exposure to telemedicine. Computer skills development, including Internet access, was included in almost all of the programs surveyed.

Less than half of the programs had resources in their medical library pertaining to rural health. Although most programs exposed their residents to learning computer skills and the Internet, surprisingly few had bookmarked any rural health information sites on the Web for the residents to explore.

The survey also focused questions on how programs dealt with specific rural health topics. The topic was considered to be "well covered" if the program provided dedicated didactics, workshops, or assigned specific readings for the resident. Table 4 depicts the rural health topics that were evaluated.

Rural Health Topics Considered

Results showed that most residency programs did not cover the following rural health topics well: rural health policy; rural hospital issues; networking and developing alliances; establishment of referrals; transition and adaptation to the rural community and lifestyle for both the provider and their significant other; unanticipated community roles that the provider assumes; and utilization of non-allopathic providers as support.

Summary

There are a total of 150 FP residency programs in the U.S. that have a partial or full mission to train residents for rural practice. The majority of these programs are located in the South, upper and lower Southeast, and the West.

Forty percent of rural physicians surveyed in the U.S. perceived that they were inadequately prepared for rural practice in certain medical areas. More training might be emphasized in the specialty areas of allergy, hematology, nephrology, and rheumatology. Specific areas include: newborn resuscitation and sick newborn care; advanced OB; geriatric home care and functional assessment; emergency surgery and pediatric trauma care; counseling; chronic childhood illnesses; pediatric behavioral, learning, and growth disorders; rehabilitation medicine; community health assessment; nutrition; practice management; quality assurance; and use of computers for practice.

The majority of residency programs that have a rural mission have specific didactics on rural topics. Topics that are not covered well include policy issues, hospital practice issues, personal issues, and utilization of non-allopathic providers as support.

Most of these residency programs have a well-defined curriculum on computer skills development and provide their residents with Internet access. However, many programs could improve on their medical library resources by including more rural health resources, and providing their residents with better recommendations for rural health bookmarks on the Internet.

Now that we have this information, the STFM Working Group on Rural Health has the intention of putting this data into context and developing a set of curriculum guidelines for rural training. This group has the hopes of also incorporating some of the more innovative strategies that other programs have already implemented into the guidelines. Once developed, it is envisioned that these curriculum guidelines and the samples of other rural curricula be posted on our web site "Rural Family Doc" (http://www.ruralfamilymedicine.org) and be used as a resource for all medical educators in rural health.

1. Rosenthal TC, Holmes McGuigan M, Osborne J, Holden DM, Parsons MA. One-two rural residency tracks in Family Practice: are they getting the job done?, Fam Med 1998; 30(2):90-93.

2. Norris TE, Acosta DA. A fellowship in rural family medicine: program development and outcome, Fam Med 29(6): 414-420.

3. Norris TE, Coombs JD, Carline J. An educational needs assessment of rural family physicians, J Am Board Fam Pract 1996; 9: 86-93

4. American Academy of Family Practice, Rural Family Practice: you can make a difference, second edition, 1997.

5. American Academy of Family Practice, Special Considerations in the preparation of Family Practice residents interested in rural practice, reprint #289-A; 1994.

6. Costa AJ, Labuda Schrop S, McCord G, Gillanders WR, To stay or not to stay: factors influencing Family Practice residents’ choice of initial practice location, Fam Med 1996; 28: 214-219.

7. Bowman RC, Penrod JD. Family Practice residency programs and the graduation of rural family physicians, Fam Med 1998; 30(4): 288-292.