Associate Director, Tacoma Family Practice Residency Program

Director, Rural Family Medicine Fellowship Program

Clinical Associate Professor, Department of Family Medicine

University of Washington, Tacoma

The piece I am going to address today is the next step up: What happens when I get all these folks? And there are actually two things you need to know when you basically get to a residency program, there are many of us that say you have to declare a rural mission so that we can take you. So what happens when 100% of them declare-- "Sure, I want to get into your program; it’s a good program to go to," but then what happens over those three years you have them in family practice training, and suddenly, they are not going rural. That is where we need a lot of your help, and that is what actually stimulated a lot of us to put a lot of this work together, to try to decide the big question

I want to do a couple things with you today. I want to give you the present status of where we are as far as residency programs across the United States, and, specifically, I am looking at family practice only. I am not looking at internal medicine, pediatrics, unfortunately, I am also not talking about osteopaths, and I am not going to be talking about mid-level practitioners. I am going to focus on physicians. How do we get physicians to go rural once we get them and we think that they have already been through this whole pipeline, and they are convinced, and they are going to go.

I want to talk about:

How many programs offer rural training?

Who chooses to go rural?

What does that profile, that particular physician that does choose to do?

How many residency graduates are truly going rural?

I want to show you some of the models of training that are in the United States because I am not sure that many of you may be aware of that. And also the success rate in rural placement. I also want to eventually go into the curriculum and answer maybe that question, or pose that question, "How well are we preparing these guys?"

And last but not least, this is where we need your input, and my hope in coming to the National Rural Health Association Meeting is to get your input because you get them after they leave me. Anybody that is in residency training, we don’t know, we don’t get a lot of feedback about how these folks are going. So I want to show you some of the data that we have out there, but more importantly what I want to find out from you all is basically how well prepared do you really think that the rural physicians that we are producing are? How good are they? Can we, as medical training institutions, do a better job? And are there other issues that we are totally unaware of? A lot of times those of us in the ivory towers in academia may not hear from you, so we might be totally unaware, so I think that might be fruitful for us.

As I told you I hail from Susanville, CA, in the northeastern part of CA, where I was in practice for about eight years. So everybody came through Susanville to get gas, eat something, or stay in our hotels overnight because it was cheap rates, but they were on their way to Reno in order to gamble away their money and their health. So what we found out was the following: Right now, to date, there are 488 family practice residencies in the United States, that includes both military and non-military. Bob Bouman out of the University of Nebraska Medical Center recently published a nice article for all of us, answering a lot of questions, out of a survey that they did in 1994 - 1996. They essentially surveyed all the residencies in the United States, and they had a pretty good response rate of about 96 percent. Simply, they wanted to find out from the program directors there how many of your grads who graduated went into rural practice. What we found was a couple of things: Out of all the residency programs in the United States, there are only 150 family practice residencies who actually said that they had a full or a partial rural mission. There are an additional 25 of the programs that do not have a rural mission, but they say they have a rural training track, or they have a satellite rural clinic, or they have what is now known as a newer program--a rural health fellowship program. So where are they all located?

Basically, the biggest places that have most of the residencies that train for rural training are in two places, in the Midwest, where out of the 118 residency programs that are there, 46 programs are rural; on the upper lower Southeast area, meaning area of Florida, Georgia, Alabama, North Carolina, South Carolina, 42 out of the 72 family practice residency programs do have rural missions. The third, basically, is in the West, including both mountain district and the pacific, and we are looking at 56 total family practice residencies and 30 out of those will claim rural.

So who chooses rural? If we look at the rural profile, what have we learned so far? Of the many studies on this, I want to highlight five of them for you. Basically, we looked at Dr. Pathman and also the North Carolina Rural Health Research, looked at all the primary care physicians in the United States. Pathman looked at all the National Health Service Corps folks that were out there, and if we look at the rural physician profile, predominantly they are all male. If we look at family physicians that are in rural areas again, that really only between 12 percent and 22 percent of physicians that are out in rural areas are female; the majority are male. Norris went on to identify that 90 percent of the folks that choose rural basically are married. In addition, Norris and his colleagues also did another study recently that was published in March of 1996, in the Journal of the American Board of Family Practice, and they found a couple other demographic findings that were important; basically they looked at rural physicians, via the American Academy of Family Physician profile, to identify those rural physicians and surveyed them. They had a pretty good response rate and they found the following in the folks that were already rural physicians: 56% of them graduated from a high school in a rural area defined as less than 25,000; they also found that those physicians who were in rural and still stayed in rural after four years basically 60% participated in a rural rotation while they were in medical school; an additional 50% participated in a rural rotation while they were in residency.

Dr. Robert Bowman, in his study of residency programs, also showed the following: what about the programs that graduate more rural physicians? What is characteristic about them? What we found is the following: Those programs that require more rural training months, those that require more OB training months, had a full or partial rural mission, had a procedural emphasis, they were located in rural states, had fewer residents that were female, and the program director was a rural contact for the residents, more of those folks graduated rural physicians than not.  See table of changes in FP Graduate Locations over the years.  See table of characteristics of FP programs with rural components. 

What about how many finally get placed in the United States of all the family practice residents that graduate? Only about 30% of all family practice graduates who are trained in the United States finally go rural. (22% of graduating residents in their first year choose rural). Dr. Rosenthal also published a study looking at the residents that basically left their program. They found about 30% of the physicians relocate every two years, which is another thing to put in the back of your brain when you are recruiting some of these folks. They also found that 33% of rural physicians eventually move to urban. Dr. Peter West out of the University of Washington has a family practice residency network that is made up now of 16 family practice residencies, but at the time when he did this, there were about 13, and basically surveyed 358 grads over those who practiced four years or more and asked, What did you choose initially when you left and now where were you four years after? And this is what they found: 38% of male physicians initially chose rural practice who graduated from the family practice residency programs that were affiliated with the University of Washington. After four years, 18% of them decided to change to urban. So this is a little bit different than Tom’s studies. Twenty-one percent of the female physicians initially chose rural practice when they graduated, and after four years, 27% changed to urban.

So what are some of the models we are seeing out there so that you do know in residency, and there are many of them. There is not one particular one. We don’t have a standardized training institution that we think is best because we simply don’t know; there is not a lot of data out there yet to see Is my product better than yours? Is my model going to graduate more than not? So the four models that you will see is mostly the primary location is in a metropolitan area, not unlike mine. Mine is a town of 175,000 people, but I have a "rural" residency program in mine. A lot of people question if that is an oxymoron. Again, those people who are located in metropolitan areas, the models that you will see is that they will have rural rotations at distant sites, but not everybody requires them; a lot of them have just put it as optional or as an elective. The other models of primary locations in metropolitan areas, but they also have a satellite rural clinic, or their primary rotation is in a metropolitan area, but they have a rural training track in which they spend one year in the metropolitan area and then two years in a rural practice somewhere close by. The fourth models of primary location is located in a rural area. And, last by not least, some programs just have a rural fellowship program along with the primary location being in a metropolitan area.

So what are some of the issues that we see with the models? Basically, as I said, there is limited data available on which models are most successful in terms of attracting and recruiting the most applicants, who best prepares, what model best prepares the rural physician, and, last but not least, who graduates the most? Who is successful enough with that particular model that graduates the most? There is a new study that just came out that Tom will go through, so I don’t want to burn his bridges, but he will talk a little bit about what he found with the rural training tracks that are out there. What about a rural curriculum? We know that most programs that have a rural mission do have and have developed their own rural curriculum. But the problem with it right now is that we really do not have a standardization across the board as much as you’d think we have as far as talking about the curriculum, what’s important, are there templates that we can basically look at, and have we collaborated all of our rural curriculum together, and that is one of the things we are expecting to do now with our new project.

Secondly, most rural curricula that is out there is based on anecdotal experiences of rural physicians that have been out there that now have become teachers, much like myself. The issue basically is now there is a little bit of data coming out that is beginning the surface regarding the needs assessment of the rural physician and truly asking those questions as opposed to relying on anecdotal experiences. But also important with that, there is also some data beginning to surface of how well prepared rural physicians are and how they perceive themselves for rural practice based on their cognitive and procedural needs. But the problem that we have is we don’t have much data at all whether these providers feel adequately prepared for other important tenets, and we’re talking about things such as my own transition to a rural community, my significant other’s transition to a rural community, their belief system, their values, do we teach them that, should we teach them that, should the community teach them that, should medical school do that, who should do something in order to, hopefully, improve retention with these folks?

So what do we already have? Basically, as Jeff alluded to earlier, we are trying to get together now all the rural curriculums, and that is what we are trying to collect to see if there is some common boundary, and if we can come up with some standardized template in order to help improve what may be lacking.

The American Academy has published two things that you may or may not know about. You can order them through the American Academy of Family Physicians. One is called "Special Considerations in the Preparation of Family Practice Residents Interested in Family Practice." This was first published after a survey of all the program directors in family practice to find out What do you think residents really need to be successfully trained to go into rural practice? It was first published in 1990, and there was a recent update in 1994. The important things that are there are broken down into four components: They basically say that first-hand rural training experience is important, so they recommend at least a two-month rotation in rural practice; an ongoing integrated curriculum, bringing in such important aspects of practice such as consultation availability, health care access, learning how to network, learning how to obtain tertiary care support; they also bring up important aspects such as discussion of physician, spouse, and family issues. Also important are things about fostering sensitivity to the unique social issues of rural practice, etc. The other two components are certainly practice management, understanding how to work with an interdisciplinary team, you cannot do it all yourself. Thirdly, specific clinical areas that they recommend, such as how much OB should you have, how much surgery should you have, those sorts of things, and last but not least they also mention their fourth component, something known as community-oriented primary care. It expels the important part of personal clinical information systems such as computers and using that as well.

The other thing that you may or may not have seen as well is also a monograph that has come out entitled A Rural Family Practice, You Can Make A Difference. This is a workbook designed to interest both medical student and the residents, talking about every aspect about rural practice they need to know. Chapter four especially talks about rural practice issues and transition, things you need to know before you make that major decision. So it is very helpful monograph that we include usually in our teachings as well.

Publications that you need to know about that are important that are out there that may help you are the following: this is from Dr. Costa and his colleagues out of Northeastern Ohio University College of Medicine, and a couple things are important here; they surveyed all PGY-third-year residents, and there were 64% who responded to a survey asking a couple of things. They wanted to find out what were the critical, influential factors that made you choose rural versus urban. They identified 24 influential factors from about 12 published studies, and they found that 63% of their respondents were male, 72% were married, and this is what they found: the number one rank on the list of the most influential factor was the significant other’s wishes; a lot of us already know that in the community. So, again, how do you address that from a teaching institution? But other things that are very important to them such as recreation and culture, proximity to family and friends, significant other’s employments, schools for kids, etc.

Another study by Laura May Baldwin out the University of Washington also surveyed graduates from the University of Washington’s Family Medicine Residency Network, the one that I alluded to before. Out of 553 civilian graduates, they were surveyed in 1982 with an 84% response rate, out of those 116 went rural. Their findings suggested the following: that rural physicians may experience high stress. Well, I think we know that, but there are a couple things that come from this as well if you are recruiting a rural doc, that where the stress comes from is that rural physicians may be a at a greater risk of being named in a malpractice suit, generally, we think that may reflect the greater range of OB, emergency medicine and surgery that they do and provide; they work longer hours; they took more call; there is a much broader scope of practice that they do than their other colleagues who are non-family physicians in urban areas; they saw more patients in a greater variety of settings, and they practice with a lot less support.

Finally, another important publication that you need to know about is one that recently came up by Tom Norris and John Kuhms entitled An Educational Needs Assessment of Rural Health. This was published in 1996, and this one surveyed over 1,000 U.S. rural family physicians practicing just under four years. They had a 57% response rate; the important point that they found was that 40% of their rural physicians basically indicated a perception that they had inadequate preparation for rural practice. He gives a major list of what these docs were talking about. A lot of them include a lot of these common factors that they felt they were unprepared for. So this is going to be new news for a lot of residency training institutions as far as are we paying enough attention because these physicians are saying, "You did not train me well enough; I could do a lot better." And that was newborn resuscitation and sick newborn care, OB/GYNs, complicated OB like gestational diabetes, to twins; medical specialties, especially nephrology, hematology, allergy, and rheumatology; geriatrics, home care, and functional assessment; and surgery, especially assisting in emergency surgery or pediatric trauma care.

In addition, what we are supposed to do best at as family physicians, we were supposed to counsel, but the majority of these folks say they were not prepared enough to deal with what they see, including things such as marital discord, abuse, domestic violence, etc. "I want more training with that." Plus, are the chronic conditions that they see, including chronic childhood illnesses, pediatric growth disorders, behavioral disorders as well, and rehabilitation medicine.

Finally, the other thing that stuck out for me is just community assessment. As community docs we should be doing that pretty well, but a lot of folks felt that they were not trained well enough in that as well. Computer use in practice more reflecting the changes today is also important to them.

So in our rural curricular survey of the residency programs, a couple things for our purpose is to understand what modalities other family practice residency programs were using, to understand what subject matter was taught, and also to look at the rural curriculum. So we did a survey questionnaire much like Jeff did, looking at the type of program but more specifically looking at their teaching modalities as well. Out of 151 who had rural missions, we had about 100 responses for about a 66% response rate.

This is what we have found so far: most programs do a pretty good job who do rural training, in providing selected didactics are important issues in rural practice. The majority tend to be rotating lectures. Their libraries suffered a little bit; they could use a little bit better resources. A lot of them had telemedicine training. A lot of them taught computer skills, unfortunately, while under recommended bookmarks. The question was how many rural bookmark Websites do you recommend for them to look at because there are a lot. If any of you are Web surfers, you will find that there are more and more everyday that are filled with wonderful information, and only about 20% of them said, "I guess we do it, it is a good idea, but I think that we do." These were the specific rural topics that we asked, and specifically we asked them, "Do you provide a didactic, a workshop format, or at least a syllabus?" That we declared as being something that a topic was covered fairly well.

As one would expect, these are important issues to talk about, we want to look at some of the other important issues out there for folks, and we found that they did teach people about leadership skills, hospital privileges, ethical dilemmas in rural practice; a lot of people taught a lot about practice management on managed care and how to finance your office and how to develop skills in doing that. A lot of folks talked about community-oriented primary care and how to use mid-level practitioners. Watch out for the recruitment and retention, understand how to get recruited, and how to prevent provider isolation. 

We don’t talk a lot about networking and developing alliances or establishing referrals. We don’t talk a lot about our significant other’s transition to rural areas or even my own transition to a rural area. We don’t talk a lot about the unanticipated community roles that are assumed by the rural provider outside of being just a physician, and we don’t talk a lot about homeopaths and naturopaths, people that you may have to work in conjunction with that is a pretty normal norm out there in the rural area.

So, in summary, the big question again is Are we training these guys right? What we found, what I tried to show you today is that there are only about 150 family practice residency programs in the United States with a rural mission. If you are a recruiter, or you are looking to get somebody in your clinic, you should basically know who they are because, again, that is where STFM (Society of Teachers of Family Medicine) can probably point you to as well. The majority are in the Midwest and in the upper lower Southeast area. The typical profile of a good program that you can count on, we talked about requiring rural and OB rotations and procedures, but they have to have a full and partial mission. The program director also should be the direct liaison for that rural area, and it should be located in a more rural state. The typical profile of the resident that is going to go to your rural community is going to be male, married, and they are going to have graduated from a rural high school. There are many areas that we need to pay attention as training institutions as far as what needs a little more emphasis as far as training goes, and we covered that.

All in all, we found that the majority of the residency programs provides specific didactics on rural topics that are pretty good for part of the training. A lot of them train folks on computers, which could be a future tool--Deborah Phillips will talk about that--but again they could improve some of their resources, such as libraries as well and the Internet, which they are not using at this point. They can improve their coverage on important tenets of rural practice that makes you survive, that we covered as well. Outside of the typical clinical topics that we talk about a lot, we need to pay more attention to those important tenets and hopes of getting more people out there and giving them ways of how to succeed as well. The questions I have for you are how can we do a better job than what we are doing? Would it be worthwhile to survey communities? And, if we do, who should we survey? Hopefully, we will get some answers on that. Is there anything else that we are not training our future rural providers? And, last but not least, what are some of the other issues that we may be totally unaware of as medical training institutions?