Medical Students’ Reflections of Rural Training Experiences Carrie A. Roseamelia, PhD Emily M. Mader, MPH MPP Cinthia Elkins, MD PhD

Disclosures Authors have no conflicts of interest or other disclosures Nothing to disclose

Recruiting Primary Care: Why is this important? Patient Protection and Affordable Care Act, 2010 Primary care Ambulatory and outpatient teaching Increased demand for care outpaces growth in physician supply Underserved communities The PPACA has a targeted focus on expanding primary care, which requires a renewed focus on ambulatory and outpatient teaching The demand for PCPs has already outpaced growth/supply, and this is especially true for underserved communities (rural, inner-city urban, select demographics)

Recruiting Primary Care: RMED Approach RMED was established in 1989 to address the needs of the medically underserved communities by attracting young doctors to rural practice. RMED students live and learn in small communities in New York State, working side-by-side with local providers. RMED students develop mentorship relationships with small town physicians who are enthusiastic teachers. Students complete FM, Surgery and EM along with 4-19 weeks of elective time at their RMED site. Many students spend elective time with FM preceptors.

Methods Purpose: To explore the experiences of RMED students with respect to their training and learning environment 2014 RMED Cohort 15 students Students submit monthly reflections 94 reflections Qualitative thematic analysis Purpose of Study: The purpose of the study is to explore the experiences of RMED students with respect to their training and learning environment at their respective sites. This study will analyze students’ journals to explore the benefits and challenges of participating in a rural training program. Results from the study may provide recommendations for program improvement. IRB exempt Directions for students: The goal of the RMED Monthly Reflection is to promote your growth as a professional through creative writing. For this requirement, you should prepare a monthly written statement that conveys the nature of your experience on the RMED Program and both personal and professional insights gained from your stay in the community. This should be a reflective piece. Creativity and self-reflection are strongly encouraged, as are photos Monthly reflections were collected Jan-May (Prime) and through to Oct (Trad); Writings were typically 2 paragraphs long;

Impact on Student Learning Results Impact on Student Learning Program Setting Mentors Setting Sub themes included: student-patient positive bond (36), student-patient access (25), feels like ‘home’ (11), connection to community (34), positive bond with patients outside of clinical setting (20), rural access to care (22) Main Theme for Mentors Sub themes included: Community of clinicians (46), preceptor as a positive colleague (68), preceptor with positive patient rapport (26), connection to community (34) Program Sub themes included: learning objectives (100), hands on opportunities (65), continuity of care (63), cross discipline exposure (19), cross specialty exposure (49), program comparison with Upstate experience (64)

Mentors: More than just a preceptor Commitment Relationships Clinical Skills Mentors include all members of the care teams on which students work and learn Foundation: clinical community has a broad range of clinical skills Relationships: The core group of mentors working with the student can quickly learn their unique strengths and weaknesses and continually challenge students to increase their clinical responsibilities. Commitment: preceptors are committed to their communities, patients and students Exemplar Quotes “It was powerful to work with someone who has a strong background and knowledge base because it let me see the type of person I could aspire to become.” “It is clear that the local physicians have established strong ties to the local community that extend beyond the medical realm.”

Training Setting Community Needs Local Providers Community needs for providers are high and resources/pipeline opportunities are low. Program is seen as a recruitment ground for future providers. Exemplar Quotes “While so many physicians seem increasingly cynical in this era of rapid changes in medicine, it was refreshing to see doctors who were truly committed to work that they loved.” “It is a difficult decision since I have great role models in each specialty.“ “They have all been welcoming and are always willing to involve me in thought provoking cases.” “Even the patients I interacted with were very happy about a student being in the hospital and learning from them.” “There were all eager to share their story with me and gave me permission to help with their cases.”

RMED Program – Providing the Building Blocks Structure Students/Site Student-driven approach Reception Host community Clinical community Exposure Multiple specialties Interdisciplinary work environment Continuity of care Structure: Only 1-2 students at each site, student opt in and are “selected” into the program Reception: Open arms, students are valued and expected to actively participate/engage with patients, treated as intern by preceptors and doctor by patients. Exposure: … Exemplar Quote “On top of seeing upwards of 50 patients a day, he went out of his way to teach me as much as he could in a week.”

Student Learning Outcomes: Technical Skills …from presugerical interviewing to intubating and pushing meds…. Helped me hone my physical exam skills I perform a history and physical, look up labs and imaging on the EMR Challenged me to formulate, defend, and commit to plans of care for my patients Trained me in appropriate scrub technique, Foley catheter insertion, and instrument identification Exemplar Quotes

Student Learning Outcomes: Interpersonal Skills It is important to listen to my patients and to be a source of comfort and understanding for them One of the most fundamental tasks of a physician is to gather relevant information and convey it to other members of the medical team in a concise and clear manner I learned so much about how to ask both open-ended and focused questions to get an accurate and useful history to guide treatment Exemplar Quotes We should explain why we are ordering images so that the technicians and radiologists know where to focus their attention

Student Learning Outcomes: Professional Development …having the ability to do entire visits made me feel as if I was truly coming closer to being a doctor rather than just being a better medical student I feel like I am gaining a practical knowledge of patient management that is difficult to teach and can only be acquired through firsthand experience My preceptors expect me to code my own patient visits for billing purposes and to justify diagnostic tests I propose Exemplar Quotes Advice from RMED grad to incoming RMED students, “Throughout the course of your experience, you will be working very closely with a core group of preceptors. In my case, they have become trusted advisers who have given me excellent advice and offered to help me with any concerns as I transition into residency. I find myself constantly being challenged to function at the level of a first year intern

Student Learning Outcomes: Personal Growth Most times I was very confident in my assessment and I could sense that the patients had confidence in me too. I have learned the importance of taking responsibility for my own learning. These skills will serve me well not only as a resident but also as an attending physician I finally realized that I am ready for residency and it is thank to RMED that I have not just the knowledge, but the confidence, to take care of my patients as best I can I have learned that to best care for a patient, a physician must have a detailed understanding of him or her as a person Exemplar Quotes

Program Impact on Primary Care Of 15 RMED students in the 2014 cohort: 11 Family Medicine (20 in COM), 1 Internal Med, 1 OB/GYN, 1 Psychiatry, 1 Neurological Surgery

Real time evaluation of memos Inform student hangout group discussions Limitations Self selected process One student cohort Graded assignment Next Steps Real time evaluation of memos Inform student hangout group discussions Analyze with next cohort (n=23) Self Select: Students self select into the program during MS2; we do not allow students with major deficiencies into the program. One cohort: Pilot project, focusing on student growth over time Graded assignment: Students are aware that the assignment is viewed by a program staff member and may feel apprehensive about speaking negatively about the program and their preceptors. Some students provided negative feedback – one wrote about their difficulty working with their FM preceptor and his high expectations , and many felt that scheduling and coordinating with their preceptors was time consuming and difficult.

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