Rural Physician Associate Program (RPAP) University of Minnesota STFM, Jan 29 2010 Therese Zink, MD, MPH David Power, MB, MPH Deb Finstad, BS Kathleen.

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Presentation transcript:

Rural Physician Associate Program (RPAP) University of Minnesota STFM, Jan Therese Zink, MD, MPH David Power, MB, MPH Deb Finstad, BS Kathleen Brooks MD MBA MPA

RPAP program 39 year old longitudinal (9-months), immersion learning, with primary care (usually family medicine) preceptor in rural MN during the 3 rd year of medical school Twin Cities 4 to 8 week clerkships in Twin Cities metro area

Power (2006, TLM) compared USMLE and OSCE scores of 33 RPAP and 35 TC students: similar Minnesota Lacy (2007, FM) shelf exams rural clerkship and urban: similar Nebraska Schauer (2006 Acad Med) compared USMLE and preceptor scores 296 traditional 3 rd yr. and 29 ROME (rural): similar, but Internal Medicine preceptor assessment higher North Dakota

Notion that RPAP students ‘handle themselves better in the clinic exam room with patients’/ ‘more comfortable clinically’ not confirmed with prior largely quantitative comparison

To provide a comparative assessment between conventional training in a structured clerkship that is based in urban / suburban areas vs. rural longitudinal preceptorship (RPAP) 10 years of data using both quantitative and qualitative data

Obtaining data from various sources: challenges Descriptive statistics of test scores (quantitative) OSCE review of high and low scorers on primary care OSCE (qualitative) Here, look at 2009 graduating class

Non-RPAP (n = 171) RPAP (n = 35) Sig Gender Multicultural 47.4% Female 22% 56% Female 11% NS MCAT Mean/STD BI: 10.5 (1.3) PH: 10.2 (1.5) VR: 10.0 (1.4) Writing: P Mean/STD BI: 10.1 (1.3) PH: 9.6 (1.7) VR: 9.5 (1.7) Writing: P NS.05 NS College GPA Mean/STD 3.7 (.24) Mean/STD 3.7 (.21) NS

Non-RPAP (n = 171) RPAP (n = 35)Sig. Step 1 (Pass Rate 185) 1 st time takers Median: 226 Range: 178– % pass Median: 219 Range: % pass NS Shelf – Peds (Pass Rate 60%) Median: 76 Range: Median: 72 Range: Shelf – OBGYN (Pass Rate 60%) Median: 73 Range: Median: 72 Range: NS

Non-RPAP (n = 171) RPAP (n = 35)Sig. Shelf – Surgery (95 th centile) Median: 71 Range: Median: 71 Range: NS Step 2 CK (Pass Rate 184) 1 st time takers Median: 236 Range: 174 – % pass Median: 232 Range: % pass NS Step 2 CS98.3% pass100% passNS

Non-RPAP (n = 171) RPAP (n = 35) Sig. OSCE--Overall (Pass Rate 65%) 1 st time takers Median: 75% Range: 62% – 85.6% 93.4% pass Median: 73.4% Range:67.7%-84.6% 97.1% pass NS OSCE—Patient Communication 86.9%.06 (SD) 86.1%.06 (SD) NS OSCE—Clinical Decision Making 73%.08 (SD) 72%.06 (SD) NS

OSCE station videotape reviews: High and low scorers in 4 representative OSCE scenarios: 1) chronic cough: -patient interview -SOAP note & presentation to faculty 2) dysuria in female adolescent, 3) Health Care Maintenance in middle age male, 4) Medication reconciliation

Three family physician faculty (including Power and Zink); all experienced OSCE evaluators Each reviewed tapes independently One fully and one partly blinded to student group Small group process: Discussed their observations of each scenario Agreed upon emerging general themes Guided by a qualitative expert providing process advice

RPAP students generally had more established routines in patient interactions RPAP students (both high and low scorers) integrated conversation and rapport building into beginning of interview, identified self and used patient’s name more consistently TC low scorers less effective at promoting flow in patient encounter

RPAP students (high and low scorers) well rehearsed and effective at explaining preventive care issues: colonoscopy dilemma related to PSA testing, value of preventive care—’like an oil change’ One low scorer ALL relational, little content In comparison, low scoring TC students less comfortable

Non-RPAP students (high and low scorer) more complete interview with teens More complete w/ teen risk assessment, (but top RPAP student covered many essential areas without using the HEADDSSS mnemonic) Had had a formal presentation from the “best and brightest” on adolescent care RPAP students had access to online video of presentation

RPAP students generally more consistently good performers; non-RPAP students higher variability (more highs, more lows) One RPAP student ‘beautiful’ interpersonal skills / counseling but content deficits with osteoporosis medications and diabetes goals identified by skilled SP, not necessarily by an ‘average’ patient

UM-Duluth preferentially recruits on interest in primary care and rural practice, larger % of Duluth students in RPAP Non-blinded investigators Some missing data Larger ‘picture’ to come

RPAP scores generally comparable to non-RPAP students: UMN Scores rank well nationally In general, all RPAP students (high and low scorers) demonstrate comfort with the patient encounter Contributes to literature on the effects of rural longitudinal curricula