Ensuring Successful Rural Medical Education Programs: Quality Improvement and Other Issues— A Symposium Society of Teachers of Family Medicine 32 nd Annual Predoctoral Education Conference February 2-5, 2006 Charleston, South Carolina

Presenters:  Drs. Bruce Bennard and Joe Florence – East Tennessee State University – James H. Quillen College of Medicine  Dr. Matthew Hunsaker - University of Illinois-College of Medicine at Rockford  Dr. James Leeper – University of Alabama, School of Medicine - Tuscaloosa

Session Goal: “Provide forum for individuals responsible for rural based medical education programs to share information that examines unique qualities of these programs, the factors that attract students to these programs, and the challenges that influence whether or not the programs are sustained.”

Session will examine two aspects of Quality Improvement: 1.Tensions that may arise among and between students and faculty around curriculum (clinical vs. non clinical training) 2.Need to ensure high quality training/education in rural settings distant from the academic center

Session Format: A.Overview of three established rural medical education programs (> 50 years) 1.scope and scale 2.tensions and challenges related to quality improvement issues 3.other issues of interest B.General discussion with input from audience

Community Partnerships Addressing Quality Improvement for Ensuring Successful Rural Medical Education Programs Rural Primary Care Track Quillen College of Medicine Joe Florence, M.D. Quillen College of Medicine East Tennessee State University Director of Rural Programs

Rural Primary Care Track Began 1992 in JohnsonBegan 1992 in Johnson and Hawkins counties and Hawkins counties Health science colleges (medical and undergraduateHealth science colleges (medical and undergraduate nursing, public health students) nursing, public health students) in interdisciplinary teams in interdisciplinary teams

Admission to RPCT (Quillen COM) Prior Acceptance to College of MedicinePrior Acceptance to College of Medicine Limited to 25% of Medical School ClassLimited to 25% of Medical School Class Application essay on “How your inclusion willApplication essay on “How your inclusion will benefit you as well as the program.” benefit you as well as the program.” Interview to make sure you understandInterview to make sure you understand /match the program. /match the program.

RPCT Goals (Quillen COM) Increase Rural Primary Care PhysiciansIncrease Rural Primary Care Physicians Train Physicians to Function in HealthTrain Physicians to Function in Health Care Teams Care Teams Equip Physicians To Become EffectiveEquip Physicians To Become Effective Agents (Leaders) of Community Change Agents (Leaders) of Community Change

Key Concepts of the RPCT Curriculum Early Community Based Clinical Training andEarly Community Based Clinical Training and Exposure to Rural Primary Care Exposure to Rural Primary Care Rural, Community Health and Leadership TrainingRural, Community Health and Leadership Training Emphasis on Self Directed, Experiential LearningEmphasis on Self Directed, Experiential Learning Emphasis on Health Promotion, Disease PreventionEmphasis on Health Promotion, Disease Prevention Emphasis on Community Based ParticipatoryEmphasis on Community Based Participatory Research for Health Research for Health Interdisciplinary Training (Medicine, Nursing,Interdisciplinary Training (Medicine, Nursing, Public Health) Public Health)

RPCT Curriculum st Year –Taught on Thursdays1st Year –Taught on Thursdays –Fall Communication for Health Professionals (Interdisciplinary) Rural Case Oriented Learning and Preceptorship 1 (Clinical) –Spring Rural Case Oriented Learning and Preceptorship 2 (Clinical) Rural Health Research and Practice (Interdisciplinary)

RPCT Curriculum nd Year -Taught on Tuesdays2nd Year -Taught on Tuesdays –Fall The Practice of Rural Medicine 1 (Clinical) Rural Community Based Health Projects (Interdisciplinary) –Spring The Practice of Rural Medicine 2 (Clinical)

RPCT 3rd Year Clerkship 2-8 week clinical clerkships focusing on2-8 week clinical clerkships focusing on Rural Continuity Experience Rural Continuity Experience –12 weeks – Primary Care at Rogersville or Mountain City –4 weeks – FP/OB – intensive primary care OB/women’s health experience at rural FP site

3rd Year Clerkships RPCT vs. Generalist RPCT Wks. –Internal Medicine 8 –OB/GYN 4 –Pediatrics 6 –RPCT Primary Care 16 –Psychiatry 6 –Surgery 8 Generalist Wks –Internal Medicine 8 –OB/GYN 8 –Pediatrics 8 –Family Medicine 8 –Psychiatry 8 –Surgery 8

RPCT 4th Year Clerkships RPCT Primary Care 8 wksRPCT Primary Care 8 wks –Must have Interdisciplinary Team –Must be Rural or Underserved –Must be Primary Care

Medical RPCT graduates residency selection Of the 98 graduates, 78% have chosen primary careOf the 98 graduates, 78% have chosen primary care residency training: residency training: –44 Family Medicine –19 Internal Medicine –13Pediatrics or Internal Medicine-Pediatrics – 2Obstetrics-Gynecology – Other Specialties: Psychiatry (5), Surgery (8), Emergency Medicine (3), Ophthalmology (1), Radiology (1), Internal Medicine-Transition (2)

Graduates selecting Tennessee residencies Of the graduates, 48% chose to stay inOf the graduates, 48% chose to stay in Tennessee for residency training: Tennessee for residency training: –39ETSU 20 family medicine, 12 internal medicine, 1 pediatrics, 1 IM/PEDS, 2 Surgery, OB-GYN 1, Psychiatry 1 – 8 Other Tennessee programs –51Out-of-state

Of the first 25 graduates who have completed residencies Twenty (80%) are now in practice inTwenty (80%) are now in practice in towns of less than 25,000 persons towns of less than 25,000 persons Thirteen practice in TennesseeThirteen practice in Tennessee Five others in rural counties in Virginia,Five others in rural counties in Virginia, North Carolina, Kentucky and West North Carolina, Kentucky and West Virginia Virginia Two are members of the ETSU facultyTwo are members of the ETSU faculty

Pre and Post Program Objectives Interest Trend *Interest in: CPP † Graduates Traditional Graduates P= Upon Entering Upon Exiting Upon Entering Upon Exiting Upon Entering Upon Exiting Rural Practice <0.001 Primary Care or Community Health <0.001 Care for Underserved <0.001 Interdisciplinary Group Collaboration <0.001 *Rating based on 5 point Likert Scale (scale 1 least to 5 greatest) † CPP = Community Partnerships Program

Balancing Clinical vs. Community Emphasis on MISSION – Improving Rural HealthEmphasis on MISSION – Improving Rural Health –Units of Practice – patient, family, community –Public Health – population based approach –Iterative Continuous Quality Improvement Model –To improve health and to provide quality care especially with chronic disease management – “It takes a team”

Issues of conflict Comparability of generalist vs. rural curriculum –2 tracts vs. one - LCME Accreditation Differences inDifferences in –Goals and Objectives - Knowledge, skills and attitudes - Perceived and real –Faculty – Academic vs. real world Physician vs. Interdisciplinary –Location – college/urban/suburban vs. rural

Issues of conflict –Schedules –Experiences – Community, clinical vs. classroom Real patients vs. simulated patients –Discipline specific training vs. generalist –Evaluation

Issues of conflict Comparability of outcomesComparability of outcomes –Tests and Grades Internal – –Shared required course grades –OSCE’s External – USMLE, residency selection, location of practice –TIME Travel time Class time – clinic and community time

Improving Quality and Resolving Conflict Mission firmly believed by AdministrationMission firmly believed by Administration and University Leadership and University Leadership Clear Goals and ObjectivesClear Goals and Objectives Evaluation standards understoodEvaluation standards understood Quality Improvement CurriculumQuality Improvement Curriculum Management Management

Improving Quality and Resolving Conflict Plan-Do-Study-ActPlan-Do-Study-Act Constant evaluationConstant evaluation FeedbackFeedback COMMUNICATIONCOMMUNICATION –Among and between students and faculty, both formal and informal… –“Open channels” – Open door policy – Occasional get-togethers

Rural Medical Education Program RMED Matthew L. Hunsaker, M.D. University of Illinois College of Medicine at Rockford RMED was created to improve access to Primary Care Services in rural Illinois and reverse the maldistribution Of physicians existing in Illinois in the early 1990’s. It is the synthesis of directed, admissions, curriculum and Academic-Community partnerships to ensure rural physician workforce capacity in Illinois.

Admissions Process Rockford- RMED RMED Supplemental ApplicationRMED Supplemental Application RMED Application Pre-ScreeningRMED Application Pre-Screening Recruitment and Retention CommitteeRecruitment and Retention Committee –Composed of community members from around the state –Represent non-academic selection characteristics (suitability for rural practice) –15 Positions available per year in RMED Program + 5 Administrative Admissions

Applications Process Rockford- RMED Recruitment and Retention becomes the admissions committeeRecruitment and Retention becomes the admissions committee –Rank list is forwarded to College Admissions Committee for final admission approval –Competition exists for “top” students between RMED, regular admission, and the four campuses –Students may have additional requirements to fulfill prior to enrollment date (conditional acceptance) –If admission is via other pathway, student may compete for an “Administrative Position” (Maximum 5 Students)

Curricular Approach RMED- Rockford 4 Year Curriculum4 Year Curriculum –Foundations in Rural Family and Community Medicine I & II (M1 & M2) –The Interface Between Family Medicine and the Community (M3) –Rural Family Medicine Preceptorship (M4)

Foundations in Rural Family and Community Medicine I and II (M1 & M2 years) (M1 & M2 years) –Delivered at Urbana-Champaign Campus during the 1 st year –Core concepts of Family Medicine including comprehensive patient care, continuity of care, patient education, and doctor-patient relationship in rural communities explored –Summer internship between 1 st and 2 nd year encouraged

The Interface Between Family Medicine and Community (M3 Year) Community-Oriented Primary Care (COPC)Community-Oriented Primary Care (COPC) –Define characteristics of the Community –Identify the Community’s Health Issues –Modifying or Designing Health Programs –Evaluating Effectiveness of New Programs –Student selects 4 th -year Preceptorship location, performs a site visit, and completes a community structure project

Rural Family Medicine Preceptorship (M4 Year ) RMED Capstone 16- week Preceptorship in Small Rural Community with a Family Physician Student lives and works in the community Clinical Skills Development and Mentorship 25 Sites Statewide - Geographically and Culturally Diverse Faculty Site Visits, Faculty Development and Telecommunications used to monitor and develop this experience Student Designed and Implemented COPC Project

RMED OUTCOMES Graduates In practice (residency complete)= 65In practice (residency complete)= 65 In primary care = 5584%In primary care = 5584% (Family Medicine, Gen. Medicine, Pediatrics)(Family Medicine, Gen. Medicine, Pediatrics) In Illinois (All Specialties)= 4874%In Illinois (All Specialties)= 4874% In Illinois In Primary Care= 4468%In Illinois In Primary Care= 4468% (N=118) (N=118)

RMED- Outcomes Community Population for Grads in Illinois (N=48) 13 in Smallest Rural (less than 5,000)13 in Smallest Rural (less than 5,000) 26 in Small Towns(5,001-20,000)26 in Small Towns(5,001-20,000) 5 in Mid-Sized City (20,001-75,000) 5 in Mid-Sized City (20,001-75,000) 4 in Large City (>75,000) 4 in Large City (>75,000) in Primary Care in Illinois Border States (WI & IL) “HALO Effect” 5 in Primary Care in Illinois Border States (WI & IL) “HALO Effect”

RMED Future NCRHP- Expanding Program to Academic Primary Care CultureNCRHP- Expanding Program to Academic Primary Care Culture –Interdisciplinary (Medicine, Pharmacy, Nursing, Public Health, Social Work, Dentistry) –Model RURAL Health Center Interdisciplinary Integration Patient and Community Centered –Earlier Recruitment Focus Junior High and High School Health Science Learning Projects (Project in a box)

RMED Challenges (conflicts)- 1. “16-weeks is too long” - Family Obligations (non-traditional students) -Often feel isolated from non-RMED M-4 cohort - social - “peer groups” -Immersion Experience - student lives in community 2. “Non-primary care Student” - student that does not choose Primary Care often feels pressure to take non-generalist curriculum (Why can’t I take 16 weeks of Anesthesia, Surgery, etc. ) (Why do I have to do rural 16-weeks…”I” don’t want too!!!!) - program enrollment stipulates RMED curriculum is not flexible student may not dis-enroll

RMED Ensuring Quality Faculty Development Seminar Site Visits (planning visit & during preceptorship) Program Evaluation--- By everyone!!!! Preceptor During 16-weeks & Final Evaluation of Student Student Self-evaluation (Pre & Post) Preceptor (During & Post) 2 nd survey Post-graduation to ensure anonymity Including “Anything else we should know about the program from a students point of view.”

University of Alabama School of Medicine Tuscaloosa Campus College of Community Health Sciences James Leeper, PhD Professor, Community and Rural Medicine Rural Programs Director of Education and Evaluation Rural Medicine Clerkship Director

Tuscaloosa Birmingham Huntsville

Current Structure Birmingham: All students (currently 160 per year) take 2 years of basic science courses on the Birmingham campus. One hundred remain in Birmingham for their clinical training.Birmingham: All students (currently 160 per year) take 2 years of basic science courses on the Birmingham campus. One hundred remain in Birmingham for their clinical training.

Current Structure Huntsville: Thirty third-year and 30 fourth- year students transfer from Birmingham for clinical training. This program began in 1972 and is 95 miles north of Birmingham, has a Family Medicine residency programHuntsville: Thirty third-year and 30 fourth- year students transfer from Birmingham for clinical training. This program began in 1972 and is 95 miles north of Birmingham, has a Family Medicine residency program

Current Structure Tuscaloosa: Thirty third-year and 30 fourth- year students transfer from Birmingham for clinical training. This program, began in 1972 and is 60 miles southwest of Birmingham, has a Family Medicine residency programTuscaloosa: Thirty third-year and 30 fourth- year students transfer from Birmingham for clinical training. This program, began in 1972 and is 60 miles southwest of Birmingham, has a Family Medicine residency program

UASOM History of Community/ Rural Medicine Rotation Tuscaloosa was unique among the three- campus UASOM until 1993 in terms of having a required Community Medicine rotation in a rural community for all medical students.

Timeline : 2 months in 4 th year (During this time there was no Family Medicine rotation. The students were placed with rural primary care physicians and split their time between clinical practice and community medicine.) : 2 months in 4 th year (During this time there was no Family Medicine rotation. The students were placed with rural primary care physicians and split their time between clinical practice and community medicine.)

Timeline : 1 month in 4 th year (primarily community medicine) : 1 month in 4 th year (primarily community medicine) : 5 weeks in 3 rd year (allowed some clinical exposure) : 5 weeks in 3 rd year (allowed some clinical exposure) : 6 weeks in 3 rd year integrated with Family Medicine : 6 weeks in 3 rd year integrated with Family Medicine

Timeline : 4 weeks FM followed by 2 weeks CM in 3 rd year : 4 weeks FM followed by 2 weeks CM in 3 rd year 1993-present: In 1993 the UASOM decided to have a required rural medicine experience on all three campuses1993-present: In 1993 the UASOM decided to have a required rural medicine experience on all three campuses

Present Tuscaloosa: 4 weeks FM followed by 4 weeks RM in 3 rd year (both in same rural community) (1 week of FM in Tuscaloosa)Tuscaloosa: 4 weeks FM followed by 4 weeks RM in 3 rd year (both in same rural community) (1 week of FM in Tuscaloosa) Huntsville: 4 weeks of primary care in rural community in 3 rd yearHuntsville: 4 weeks of primary care in rural community in 3 rd year Birmingham: 4 weeks of primary care in rural community in 3 rd year (recently made a selective and available in 3 rd or 4 th year)Birmingham: 4 weeks of primary care in rural community in 3 rd year (recently made a selective and available in 3 rd or 4 th year)

Rural Medicine Content Two-week Community Health Assessment (review of community systems) –Agency visits/interviews –Leader interviews –Common citizen interviews –Farm visit

Content Two-week Special Project (investigation of specific health-related issue and recommendations to community)Two-week Special Project (investigation of specific health-related issue and recommendations to community) Pass/Fail grade based on two oral/written reports. Students keep daily log and log of interviews. Graded by Community and Rural Medicine faculty and community preceptor.Pass/Fail grade based on two oral/written reports. Students keep daily log and log of interviews. Graded by Community and Rural Medicine faculty and community preceptor.

Quality Improvement Issues Clinical vs. Non-Clinical Tensions –Prior to 1993 Problem: Tuscaloosa campus different from other two Solution: Integration of clinical with non- clinical activities. Better selection of students

Quality Improvement Issues Clinical vs. Non-Clinical Tensions –1993-present UASOM commitment to rural medicine on all three campuses plus better selection of students for branch campuses solved the problem. The beginning of the Rural Medical Scholars program in 1996 also helped (10 rural students per year specially recruited). The recent change in Birmingham has not made things worse in Tuscaloosa.

Quality Improvement Issues Equivalent Quality of Medical Education Across SitesEquivalent Quality of Medical Education Across Sites –This has been a concern, but not a problem. Preceptors are board-certified family physicians. Students are supervised by Family Medicine and Community/Rural Medicine faculty.

Outcomes UASOM Data for Matriculants Campus%FM%Rural AL Practice Birmingham Huntsville Tuscaloosa

Medical Student Comments “My preceptor was excellent, not only for his medical expertise, but also in his willingness to expose me to the entire rural medicine experience from the business aspects to the interactions with the community, including sampling of local culinary specialties. I appreciate the fact that one could experience a great deal of satisfaction from taking care of an individual in all aspects of his/her life. My experience in Carrollton made me consider primary care as an option when once it was not even in the running....I also recommend doing both Family Medicine and Community/ Rural Medicine at one site because it allows one to develop a rapport with the community and the health care system so that he/she is better able to analyze the needs and concerns of the community and how they relate to patient care.”

Medical Student Comments “I learned how it takes a community and everyone contributing in their own way to provide for a healthy environment to live in medically, politically, and socially. I encourage other students to participate in the community as much as possible, to get to know people and to become a part of that community.... I found that after being here I was more of a member of the community after my rural medicine rotation because of my community involvement than I did after a month of seeing patients in the clinic or the hospital. I’m actually a little disappointed that I have to leave, which I would have never dreamed of a month ago.”

New Developments Tuscaloosa Experience in Rural Medicine (TERM)Tuscaloosa Experience in Rural Medicine (TERM) –Third Year: 4 months at rural site (FM, RM, IM, OB/GYN, PEDS, Surgery) –Fourth Year: 2 months of acting internships plus up to 4 months of electives at rural site