Byron J. Crouse, MD Lisa Grill Dodson, MD Taihung Duong, PhD Byron will do introductions and depending on number of attendees, will have attendees introduce themselves and provide overview of goals for the session noting we will limit our discussion to medical school innovations as one piece in the rural health pipeline – 5 minutes Part 1: 25 minutes presentation Overview of three generations of rural health educational programs  Intro and overview of early rural programs Description of three new rural health programs

History of Rural Health Programs First Generation Jefferson University of Minnesota-Duluth and RPAP WAMI Second Generation Illinois – RMED Alabama Byron – background of rural health programs - 5 minutes

Oregon 1992: Required Rural and Community Health (RCHC) clerkship rotation for all MS3 students 50% frontier sites 10% urban underserved 80% FM, 10-15% Peds, 5-10% IM Originally called Primary Care Clerkship because of faculty resistance to rural label Lisa – overview of program development in Oregon – 5 minutes

Oregon successes One of the most common reasons for applying to OHSU cited by applicants Consistently the highest rated clerkship Overcame faculty resistance to educational quality issues and rural label Maintained interest among OHSU students in FM as a specialty in the face of declining national interest

Oregon failures Decline in # OHSU students matching to FM No increase in number of students from rural backgrounds No increase minority students (esp. Native American and Hispanic) Decreasing # of Oregon(instate) students Class admitted in 2004, 43% Oregonians No increase in OR applicants (max 450) Decreasing percentage of students from rural bkgd

Needs assessment OHSU needs: More Oregon students (legislature and Dean) More diverse students (faculty, AC, legislature, Dean) Expansion of class size (Dean, +/-faculty, legislature) More community based rotations (Dean, legislature, health systems, +/- faculty) Better relationship with community docs, hospitals Better relationship with legislature and governor More state support ($ and other)

Figuring it out Champion: Oregon AHEC Consultants: Local foundation grants funded Howard Rabinowitz (Jefferson Medical College) Bob Bowman (University of Nebraska) Tom Norris and John Coombs (University of Washington) Joe Ichter (University of New Mexico) Rural Medical Educators External partners/beneficiaries Internal partners/beneficiaries Make yourself visible, helpful and indispensible!

Oregon Rural Scholars Program (ORSP) Admissions based track (SOM) 5-10 students per year with high likelihood of return to rural practice Enhanced learning opportunties for rurally interested students (Scholars and others) Increased support for community preceptors to enhance retention (fac. dev, library, on campus learning, consultation) Rural recruitment support (locum tenens)

Indiana University School of Medicine (IUSM) Rural Medical Education Program IUSM has one 4-year campus (Indianapolis) and eight 2-year satellite campuses (entering class total of 294). The new 4-year rural program is based in Terre Haute in West Central Indiana (entering class of 24). The program is available only to Indiana residents from rural counties. A rural medicine admissions committee composed of rural community leaders and school of medicine faculty interviews the applicants. 8 students accepted to the first rural medicine class in 2008-2009 Students are assigned to rural physician preceptors and rural patients for all 4 years. Peter will give overview of Indiana program – 5 minutes

University of Wisconsin: Wisconsin Academy for Rural Medicine Expanding class size from 150 to 175 with 25 new positions for WARM Need for all specialties Admissions Established subcommittee of the SMPH Admissions Committee to address WARM Curriculum RHIG Rural Health Elective during year 2 Years three and four innovations Rural/Regional educational development Byron will review initiative in Wisconsin – 5 minutes

Rural Admissions Evidence: Features of medical schools that produce rural physicians (Rabinowitz) Strong institutional mission Targeted selection of students Focus on primary care (esp. FM) Lisa – 20 minutes - admissions

Strengths at OHSU Strong primary care presence FM dept has significant curriculum time and faculty leadership roles in all 4 years of curriculum US News and World Report ranking # 2 for OHSU, #3 for DFM (???meaning???) Rural and urban residency programs, both with rural exposure Required 3rd yr clerkships in Rural Community Health and Family Medicine Strong FMIG Strong AHEC presence around the state Lisa – 20 minutes - admissions

Institutional Commitment Strengths Only one med school Need Challenges Fractured relationship between OHSU and the legislature & governor Poor economy/bad tax structure Poor support for education, esp. higher ed New leadership, unknown bias Lisa – 20 minutes - admissions

OHSU SOM admissions Admissions: MPH, MD/PhD preference Rising MCAT and GPA scores, heavy “service” weighting No legislative mandate, declining state $, antagonistic relationship w/legislature Class of 2008 more than 50% non-Oregon students Financial implications for SOM (tuition differential) High quality applicant pool Strong resistance to “diluting” admissions process Lisa – 20 minutes - admissions

Curricular Innovations Classroom Experiences Medical education through a “rural lens” Rural elective Content Timing Rural Health Interest Group Byron – 20 minutes on curriculum Educational Content Context Continuity Another option to review curricular innovation is more chronologically: Years one and two Rural experiences Classroom experiences Rural Interest Groups Summer Clerkship Years Three and Four Clerkship location Electives

1)The Health of Rural People and the Communities 1)The Health of Rural People and the Communities and Environments where they live 2) Rural Health Care Team 3) Rural Links to Public and Population Health  4) Rural EMS Issues  5) Rural Obstetric Care  6) Rural Perinatal and Pediatric Care 7) Surgery - issues of trauma, anesthesia coverage 8) Home Care - patients sent home from tertiary centers with complex health care services

9) Rural Mental Health and substance abuse 10) Dental Care 11) Rural Hospitals and Networks - the rural health care 'system critical access hospitals rural health centers community health centers 12) The Economics of Rural Practice -optimizing utilization of resources - when/ how to refer/ consult/ communicate with secondary and tertiary centers - clinicians. 13) Community-Oriented Primary 14) Farm health & safety

Curricular Innovations Rural Clinical experiences MS I and MS II Rural clinical experiences Summer experience between MS I and II Externship Community/Public Health projects Research MS III and MS IV Geographic innovations Longitudinal experiences Rural enrichment opportunities Byron – 20 minutes on curriculum Educational Content Context Continuity

Faculty Development or From community physician to clerkship faculty Taihung Peter Duong, Ph.D. Peter – 20 minutes on faculty development

Identifying clerkship faculty or You are “It” Clinical faculty for first and second years: continuity into third and fourth years? Physician preceptors during first and second years: an expanding role in third and fourth years? Determining common interests/anxieties. Time management Linkage with medical school resources Linkage with medical school faculty Peter– 20 minutes on faculty development

Academics or what do I teach and how? Expectations of the clerkship director Understanding the clerkship syllabus What is the core curriculum? What is the competency curriculum? Evaluation tools Grading practices Objective Structured Clinical Examination (OSCE) National Board of Examiners (NBME) Subject Examination Peter– 20 minutes on faculty development

Academics or what do I teach and how? The didactic material or “do I need to lecture”? Information technology to the rescue Polycom to the rescue What do my students know? The electronic academic record Logging patient encounter Listing clinical skills Peter– 20 minutes on faculty development

Rural Health Programs: The next generation Innovations in rural health education continuing to evolve Existing shortages in rural physician workforce significant today and projected to worsen Summary of key comments from Session Group thoughts on next steps Byron will wrap up session, comment on key concepts from presentations and discussion, facilitate brief discussion on needed next steps… 5 minutes