I. Selection
Successful programs that produce physicians for underserved areas must attract residents who are considering a career in this area. These residents will in turn attract residents with similar interests.
II. Curriculum
A curriculum that prepares residents for practice in underserved clinics must include exposure to these areas as well as training in the type of organizations who deliver this care and the management techniques unique to this area. Residents preparing for situations where trauma, procedures, or administrative needs will be great need special training in these areas to be more comfortable and therefore more likely to choose and stay in such areas.
Trainees must understand the living environments of patients in underserved areas. The world of poverty, lack of education, abuse, and crime is not as easily understood by those not exposed to it and it is too often taken for granted by those raised in it. The cultural and spiritual aspects of patients and communities is a major resource for improving the quality of health.
III. Faculty
Faculty for such training must have experience in this type of practice. They need to be enthusiastic about this type of practice. They should balance their experience and enthusiasm with the realistic demands of serving others. Faculty involved in these programs should continue this type of practice during their academic careers.
IV. Advisement
Residents considering such careers need advisement to be able to make maximal use of their training and to facilitate their development and maturation as physicians and whole persons. Faculty and staff providing the advisement should have personal experience in the potential problems and rewards of serving the underserved. Programs with Balint groups, support groups, or those with established quarterly reviews with residents are more likely to assist residents with this interest.
Examples of successful advisement include pushing residents to do moonlighting or take ATLS or PALS to build confidence and experience in dealing with uncertainty. Other residents have needed interventions to deal with the multiple demands of rotations and family responsibilities and their own driving force for excellence. Those who choose family medicine, rural medicine, or service to the underserved often decided early to be physicians and are driven to succeed in medicine. Many had to work long and hard just to get into medicine. Workaholism can be a real problem for them and some of their colleagues. Early recognition and intervention can save much pain. Those who plan to stay in careers of serving need to establish patterns of prayer, meditation, or other means of releasing and renewing personal resources.
V. Recruitment efforts
Programs preparing trainees for serving the underserved must prioritize the recruitment efforts of potential employers. This includes ongoing relationships with the federal, state, and local programs for the underserved. Those programs with needs for physicians should have early and frequent access to the residents during rotations, at meetings, and during noon conferences. The end of the second year and the beginning of the final year are particularly crucial times as residents actively examine their potential and possibilities. Increasing Recruitment Contact with Residents
These efforts must include the spouse of the resident. Residents and their spouses need to see the range of practice possibilities and lifestyle arrangements as well as successful and fulfilled practitioners. Devoted practitioners from underserved communities often make the best discussants. Faculty and staff must meet regularly with these practitioners and understand the needs of nearby underserved clinics. This involves shared responsibilities, meetings, grants, and communications. An exchange of board or committee members is often very useful. Faculty can help with recruitment, service, and advice. Community Board members or staff can provide management insight, can help fine tune training, and can assist in program development.
VI. Potential problems
One of the major difficulties of all who deal with the problem of underservice is burnout. It is critical that the training emphasizes means of dealing with burnout and the restoration of personal and family life as priorities during training. Dealing with difficult patients, staff, relationships, and personal problems is important. Regular habits of taking stock of one's self with and without the help of others is critical to recruitment and retention.
Another problem is lack of a track record. Successful programs build on relationships with physicians, clinics, and others who serve the underserved. Out of these contacts, the opportunities of training arise.
Politics is often a driving force. Family practice programs receive state and federal funding. Much of this funding comes with strings attached or expectations. Sometimes programs can be forced to provide more service than they are capable of. They can be forced to choose sites that are not conducive to education or likely recruitment of trainees. All programs for the underserved suffer from a lack of steady income. This may impact on mutual programs, the quality of programs, or personnel for the programs. It is helpful to understand the politics of any program. It is imperative to have contact with political officials who are currently or potentially involved in any developments.
Family practice received two mandates at its creation. People wanted a personal physician and governments expected family practice to produce physicians who would serve where few physicians served before. The support for our efforts is related to our ability to meet these needs.