Journal Club: July 2013

journal club

By Shana F. Sandberg, PhD, Research Writer, Association of American Medical Colleges Center for Workforce Studies

Comparison of Academic and Practice Outcomes of Rural and Traditional Track Graduates of a Family Medicine Residency Program
Stephen M. Petrany, MD, and Todd Gress, MD, MPH

Rural Track Training Based at a Small Regional Campus: Equivalency of Training, Residency Choice, and Practice Location of Graduates
William J. Crump, MD, R. Steve Fricker, MPA, Craig Ziegler, MA, David L. Wiegman, PhD, and Michael L. Rowland, PhD

Summer in the Country: Changes in Medical Students’ Perceptions Following an Innovative Rural Community Experience
Kevin Y. Kane, MD, MSPH, Kathleen J. Quinn, PhD, James J. Stevermer, MD, MSPH, Jana L. Porter, MS, Weldon D. Webb, MA, Harold A. Williamson, Jr., MD, MSPH, and Julie Burdin, MD

About Rural Training and Practice

Rural areas of the United States face difficulties recruiting and retaining physicians, compromising access to health care. Only about 10% of U.S. physicians currently practice in rural areas, and AAMC data show that less than 3% of students entering medical school today indicate plans to practice in a small town or rural area after graduating. Over the past two decades, medical schools have addressed rural physician shortages by establishing rural training tracks designed to encourage student interest and opening regional campuses where students may undergo some or all of their training in a rural setting, learning first-hand what it means to practice rural medicine. However, questions have been raised about whether these programs have been successful in producing students who will practice in rural areas and about whether students in rural training tracks are academically on par with their counterparts in more traditional medical training programs.

Article Summaries

The Marshall University Family Medicine Residency implemented a rural track (RT) in 1994 in which residents spend part of their training at a community health center in rural Lincoln County, WV. Petrany and Gress compared practice outcomes of graduates of the RT with those of the traditional track (TT) and found that RT graduates were more than twice as likely as TT graduates to practice in a rural location upon graduation (83.3% versus 40.4%; P < .01).  They also found that academic outcomes (including median PGY 1 and PGY 3 ITE scores and percentage of ABFM certification) were similar between the two groups, indicating that RT graduates do as well academically as TT graduates.

Crump and colleagues compared University of Louisville School of Medicine students who are enrolled in a program to complete their third and fourth years of medical school at the rural Trover Campus (ULTC)—which is 150 miles from Louisville in Madisonville, KY—with students who spend all four years at the main campus. They found that ULTC graduates were 6 times more likely than main campus graduates to choose a non-metropolitan area as a practice site (55% versus 9%; P = .001). While ULTC students did score lower on the MCAT, USMLE Step 1, and USMLE Clinical Knowledge (CK) scores, the mean differences between the two campuses actually decreased between Step 1 and Step 2 CK, indicating that the ULTC students tended to close some of the gap after their clinical training. In addition, after controlling for USMLE Step 1 scores, a non-inferiority analysis demonstrated that shelf exam scores in obstetrics, surgery, and pediatrics and USMLE Step 2 scores, ULTC scores achieved equivalence with those at the main campus.

Kane and colleagues compared students at the University of Missouri School of Medicine who completed the Summer Community Program—in which medical students spend 4-8 weeks during the summer after their first year working alongside rural, community-based physicians—with students who did not participate in the summer program. Students who participated in the rural summer program were more likely than students who did not to enter a primary care residency after completing medical school (RR=1.31; 95% CI: 1.12-1.50), and twice as likely to choose family medicine specifically (RR=2.21; 95% CI: 1.68-2.88).  Overall, 72% of the students who participated in the summer program indicated increased interest in rural practice, and 46% did go on to choose a rural location for their first practice site.

Questions

  1. What kinds of barriers do you think exist to encouraging more students to practice in rural locations after medical school and residency?
  2. Each of the programs described focuses on a different stage in medical training and requires a different time commitment from students. What difference, if any, do you think it makes when in their education students are exposed to rural training and how long their rural training lasts?
  3. Special programs designed to increase training in rural medicine—such as the ones reported in these articles—while achieving impressive results, are often small programs (for example, the University of Louisville program provides the opportunity to train at the Trover campus to 6-10 students per year, the University of Missouri School of Medicine summer program trains 10-20 students per year, and 12 residents graduated from the Marshall University Family Medicine Residency rural track between 1994-2006).  How might these programs be increased in scale or spread to other schools?  What do you think it would take to achieve results on a larger scale?
  4. One critique that has been raised about this type of study is that it is not always possible to determine whether it was the curriculum itself or the types of students selected into these programs (who may have already been predisposed to rural practice) that account for the outcomes. What additional information would you want to know to better understand the reasons for the outcomes? If you were able to design a study, what factors would you take into account?

Further Reading

Brooks RG, Walsh M, Mardon RE, Lewis M, Clawson A. The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of the literature. Acad Med. 2002;77:790-798.

Rabinowitz HK, Diamond JJ, Markham FW, Wortman JR. Medical school programs to increase the rural physician supply: a systematic review and projected impact of widespread replication. Acad Med. 2008;83:235-243.

Chen F, Fordyce M, Andes S, et al. Which medical schools produce rural physicians? A 15-year update. Acad Med. 2010;85(4):594-598. 

Barrett FA, Lipsky MS, Lutfiyya MN. The impact of rural training experiences on medical students: a critical review. Acad Med. 2011;86(2):259-263. 

Rabinowitz HK, Diamond JJ. Markham FW, Santana AJ. Increasing the supply of rural family physicians: recent outcomes from Jefferson Medical College’s Physician Shortage Area Program (PSAP). Acad Med. 2011;86(2):264-269.

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One Comment

  1. Kemi Tomobi
    July 31, 2013 at 4:37 PM

    The rural community is an underserved population, and the current set up in graduate medical education makes it hard to meet the healthcare needs of this population.  One thing to consider is that practicing rural medicine is not just primary care medicine, but involves all specialties, because the rural population needs the same health services, including special surgeries that those in more urban, surburban, and metropolitan populations do. That said, I attempt to answer these questions:

    1. What kinds of barriers do you think exist to encouraging more students to practice in rural locations after medical school and residency? One barrier is the shift in interest from primary care to specialization, and the perception that the rural population does not need specialized services.  I used to think that all that was missing from rural medicine was the people needed to practice primary care. I had this perception while speaking to a cardiologist who initially trained as an internist, and through the obligations of his scholarship, he worked in an underserved, rural community after completing internal medicine residency.  He later went back for cardiology fellowship and is now a cardiologist through a major academic teaching hospital.  He cited money as one of the reasons he chose to further specialize.

    My perception then changed upon speaking with the administration staff of a hospital in a rural, underserved setting. The staff sought more orthopedic surgeons for this rural community.  I was surprised that the community would need someone so specialized. If specialty care was needed, I assumed that patients traveled several hours to get such care, after being referred by primary care physicians.  Apparently, this was not the case, and I learned that rural populations have a need for specialist care that is still not fulfilled.  The orthopedic surgeon’s services was never enough. There needed to be more orthopedic surgeons.  Therefore, the attractiveness of specialization is a barrier, but also the perception that primary care is all that is needed in rural populations is also a barrier.

    Also, physicians and physicians in training have to consider family when choosing a location to work, and that could affect the decision to practice rural medicine.  

    Finally, lack of exposure to rural medicine in medical education may be a barrier to increasing interest in serving rural populations.

    2.   Each of the programs described focuses on a different stage in medical training and requires a different time commitment from students. What difference, if any, do you think it makes when in their education students are exposed to rural training and how long their rural training lasts?

    This is a great question. People change career direction at any stage in the hierarchy of training and practice. There are people who grew up in a rural population or have otherwise developed an interest in rural medicine before starting medical school.  If students are seeking exposure to the filed, the preclinical years may be best, as this offers flexible time, and allows students to build in this preclinical exposure before the formal clinical clerkship years, when they may not get as much exposure to rural medicine.  Such exposure can vary in length, and may occur abroad, or more locally. 

    Another reason the preclinical years are a great time for exposure is because of the tendency of trainees to lose empathy as they go on in training.  This loss of empathy may occur most during third year, and may be be a reason that some medical students choose to specialize instead of choosing primary care medicine.  Some student interest groups in the preclinical years may further aid with exposure to rural medicine.

    The length of training for rural medicine may vary.  Some people make a year out fellowship opportunity and gain exposure to rural healthcare, or they may pursue summer international or other community opportunities that increase opportunities for rural medicine.  For someone considering rural medicine or otherwise undecided, a 2 week elective on a third year rotation may not be enough.

    3. Special programs designed to increase training in rural medicine—such as the ones reported in these articles—while achieving impressive results, are often small programs (for example, the University of Louisville program provides the opportunity to train at the Trover campus to 6-10 students per year, the University of Missouri School of Medicine summer program trains 10-20 students per year, and 12 residents graduated from the Marshall University Family Medicine Residency rural track between 1994-2006).  How might these programs be increased in scale or spread to other schools?  What do you think it would take to achieve results on a larger scale?

    These programs may increase with more recruitment of rural physicians into the program.  The more rural preceptors that become available, the more positions available for students to pursue.  Again – rural medicine is more than just primary care medicine, and if you can recruit specialized physicians to practice in rural areas, that may even attract medical students who are undecided about specialty choice but may want exposure to rural medicine.  Also – assuming that some medical students have the option for rural vs. academic clerkships for some rotations – if students become more aware of their learning style and environment practice preferences, they may decide early on if training in a large academic practice environment vs. training at a smaller community hospital is right for them.

    Other schools can reach out to smaller community hospitals for preceptors willing to train medical students.  More exposure to the truths about rural medicine for both students and physicians – will help on a larger scale.

    4.  One critique that has been raised about this type of study is that it is not always possible to determine whether it was the curriculum itself or the types of students selected into these programs (who may have already been predisposed to rural practice) that account for the outcomes. What additional information would you want to know to better understand the reasons for the outcomes? If you were able to design a study, what factors would you take into account?

    Additional information:  – how student got interested in medicine.  Family member in medicine, exposure to illness in family, intellectual challenge, love of science – are all factors that may affect future specialty choice.  All this information would be in the primary and secondary applications for medical school, and is already available with the AAMC.  – where student grew up – background, socioeconomic status, etc.  While the AAMC has figures for this information already, wit would be great to see a retrospective study of other medical students, residencts or practicing physicians that identifies the above qualities that predispose to a career in rural medicine.  The medical student and resident study should be regional or institution-specific, as with the above journal articles, so that one can also assess the influence of curriculum and exposure during medical school and residency.

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