1. Student Performance in a Rural Family Medicine Clerkship Experience: Are They Learning as Much as Their Peers?
Hannah Maxfield, MD
John Delzell Jr., MD, MSPH
Michael Kennedy, MD
Tony Paolo, PhD

2. Background
The availability of physicians in rural Kansas is below the national average.
Studies show that students are more likely to consider rural practice if the following is true:
They have frequent rural exposure in medical school
They have early exposures to rural locations during their medical education
They have long duration exposures

3. Based on this knowledge
In 1999 the University of Kansas School of Medicine established volunteer rural options for their third year required clinical clerkship in family medicine on the Kansas City campus to expose students to rural learning environments.
Students were given the option of completing 6 weeks of their clerkship in one rural site with one preceptor.
Ten possible rural practice locations were developed.
The emphasis at these sites was in experiential learning and the students did not have “live” didactic lectures during their time in the rural location.

4. Quality Assurance
In an effort to assure that students were not disadvantaged by opting for a rural clerkship experience, we measured rural student performance on standardized testing and compared their performance to that of their peers who remained urban.
This was part of QA for the clerkship.
We anticipated that rural students might not perform as well on the Family Medicine Shelf exam since they did not have “live” didactics offered in Kansas City during the clerkship.

5. Research question
Do students who choose a rural Family Medicine Clerkship option perform as well on their evaluations and knowledge acquisition as their peers who do not choose rural rotations?

6. Methods
A cohort matched study of urban versus rural clerkship was done
Data for the rural option from third year medical students from the years were examined and compared to urban.
1624 students stayed at the Kansas City urban campus and 79 went to a rural location.

7. Comparing the groups No Rural Rotation Rural Family Rotation
Significance
Measure N
Mean SD
P-value
Effect size
MCAT
Verbal reasoning
1624
9.09
1.80 79
9.14
1.75
.81
.03
Physical Science
8.92
1.41
9.10
1.65
.36
.13
Biological Science
9.36
1.51
9.16
1.42
.26
MCAT Sum
27.38
7.10
27.41
3.89
.94
.00
Undergraduate GPA
Science
1616
3.57
.37
3.58
.33
.75
Cumulative
3.64
.31
3.65
.29
.62
KU Basic Science GPA
3.19
.55
3.08
.54
.07
.20
Initial Step 1 score
214.19
21.73
213.57
18.83
.80
% passing Step 1
93%
95%
.58
.10
% Male
1623
56%
52%
.09
% Caucasian
1575
76%
87%
.01*
.35

8. Control group
The MCAT scores, undergraduate GPA, basic science GPA and USMLE Step 1 scores of these two groups were not statistically different.
There was also no significant difference in these two groups in regards to gender.
The only significant difference was that there was a higher percentage of Caucasians who completed the Rural Family Medicine rotation

9. Comparing performance
No Rural Rotation
Rural Family Rotation
Significance
Measure N
Mean SD
P-value
Effect size
FM grade
1624
3.29
0.58 79
3.48
0.60
.006
.33
FM shelf exam
73.44
7.17
74.20
6.50
.36
.11

10. Analysis
While there was no difference in previous standardized exam scores between these two groups of students…
Those who chose to complete their clerkship at a rural location had a significantly higher clerkship grade
Their subject exam scores were not significantly higher

11. Interesting!
Residency Match specialty
No Rural Rotation
Rural Family Rotation
Significance N %
P-value
Effect size
Family Medicine
275 18 22 29
0.02
0.28
While compiling the results we observed an additional finding
Students that did the rural option chose FM residency at a higher rate

12. About 1.6 times more likely!
Analysis
Students that completed a family medicine rural clerkship rotation were significantly (p-value = 0.02) more likely to enter a family medicine residency than students that did not do a rural family medicine rotation.
About 1.6 times more likely!

13. Conclusions More Caucasian students chose the rural clerkship option
Student clerkship grade from the preceptor was higher for rural option students
Student shelf exam scores did not vary with choice of site (urban versus rural)
Rural option FM clerkship students chose family medicine residency at a higher frequency than urban students

14. Discussion
While students are not at any disadvantage when it comes to knowledge acquisition, our data shows that they achieve a higher grade in their clerkship.
It seems likely that this is related to their clinical evaluations.
A natural next question would be whether this is a result of more developed clinical skills or whether rural physicians give higher grades.

15. Discussion
There are many possibilities for the increased interest in Family Medicine
Self-selection for a rural Clerkship
Influence of a GREAT experience
Continuity of care was appealing
Greater autonomy in rural practice was appealing

16. Future directions
We do have OSCE data for the last few years, would be interesting to see whether there is any correlation there.
Could be interesting to create a survey to examine reasons for choosing Family Medicine residency then compare rural versus urban.

17. References
Paolo, A. Performance of Students on Rural Clerkships: Graduating Classes of Shauer R, Schieve D. Performance of Medical Students in a Nontraditional Rural Clinical Program, throught Academic Medicine 2006; 81: Wilson M, Cleland J. Evidence for the acceptability and academic success of an innovative remote and rural extended placement. Rural and Remote Health 8:960. (Online), Zink T, Power D, Finstad D, Brooks K. Is There Equivalency Between Students in a Longitudinal, Rural Clerkship and a Traditional Urban-based Program? Family Medicine 2010; 42(10): Zink T, Power D, Olson K, Harris I, Brooks K. Qualitative Differences between Traditional and Rural-Longitudinal Medical Student OSCE Performance. Family Medicine 2010; 42 (10):