Bypassing or Bridging Techniques

Rural medicine is every bit as complicated as any medical specialty. Before the era of subspecialization dominated medical education, most deans and experts including Flexner and Osler noted that small towns needed the best physicians. The real challenge to rural practice is not wasting your life, or being constantly bombarded with patient needs. The real challenge is pushing yourself to be the best physician you can be because you are caring for your friends, neighbors, and community. The rest of medicine may have not figured this out, but rural physicians have.

In order to prepare well for rural practice there are many obstacles to overcome. The chief ones are those that take students and residents away from active medical decision making. Over the years this has become so common as not to be noticed. Hope: Students From the Underserved, For the Underserved  The difference of rural training is that the right kind of medical education is a higher priority in rural areas, not so much because of rural, but because rural doctors and others serving the underserved over the long haul understand what it takes to become a rural physician.Why a Preceptorship Is Better

Another rationale for bridging is the waste that can result if the right students are admitted, but find no appropriate programs to facilitate their needs in later years. A total waste is to begin at the end of the pipeline without having the right students in place. Bridging keeps the flow of rural physicians coordinated and intact. Others strategies at Rural Curricula, Strategies, Guidelines

Bridging is a method of keeping potential rural physicians in the rural pipeline. It is also a method of providing a suitable alternative curriculum in a medical education system that no longer meets the needs of primary care training and preparation for rural practice. The transitions in medical education are many. These include determination to become a doctor, the admissions process, the move from basic science to clinical, graduation to residency, becoming physicians in attitude, graduation to rural practice, and determination to stay in rural practice.

Some of the most successful rural medical education (and medical education) programs use bridging techniques. Here are some examples of these transitions

  1. Determination to become a doctor and preparation - Combined bacc/MD programs, preadmission tracks, AHEC efforts, PEPP program, Rural High School Career Days  Rural Background
  2. Admissions process - preadmission tracks   Admissions Package
  3. Basic science to clinical - Mercer rural preceptorship, RPAP in MN, Rural Student Interest Groups, WVSOM 1st clinical http://www.wvsom.edu/clined/CourseOverview.htm
  4. Graduation to residency - Accelerated Programs, Residency Efforts to recruit students  Rural Contributions of the UNMC Department of Family Medicine
  5. Becoming a physician - CORE Program, 2 month rural preceptorship, Moonlighting Rural Contributions of the UNMC Department of Family Medicine
  6. Graduation to rural practice - Recruitment Fairs, Moonlighting, Fellowships, Ronnie Boyd in MS Recruiting New Rural Practitioners
  7. Determination to stay in rural practice - Training experiences helpful here, also availability of community facilitators such as Iowa Programs Roger Tracy or Office of Rural Health people in the state who actively seek out and help, also a better match through efforts such as Office of Rural Health in Wisconsin (Fred Moscol), better fit might just equal better retention. Retain Rural Doctors

This leaves many questions, including 

How much can we patch the existing system before total reform is necessary? too late

How much of a role can Family Medicine take on in medical schools?

Generalism, Generalists, Specialists, and Medical Education

How much can rural communities and practitioners do?

The Role of the Rural Community and Practitioner

How will licensure changes and restrictions impact medical training?

Accreditation and Demands of Rural Practice

Successful combinations of programs

Multilevel Examples, Statewide

Minnesota - Duluth - RPAP

Nebraska - RHOP, Rural Preceptorship, Accelerated or RTT programs

Of all the items mentioned above, the least understood is the determination to stay, retention area. This seems most related to the type of preparation for rural practice. This preparation shapes the confidence, competence, and attitudes of the students and residents. Better preparation may allow trainees to explore better how they fit with certain types of communities and practitioners, for a better long term relationship or even a lifetime spent in one community.

The reasons for attempting to have physicians stay longer include:

  1. Stability of the health care system (ability to recruit and retain other health practitioners)
  2. Efficiency of the physician with passing years (community and patient knowledge)
  3. Reduced cost of orientation and getting new physicians up to speed (estimated at $250,000 for each loss of physician)
  4. Less loss of market share during physician turnover

By the numbers: Rural Doctors and Rural Economies

Breeding Young Professionals and Healthier Rural Communities

Recruiting New Rural Practitioners

Self Assessment of Community Recruitment Effort

www.ruralmedicaleducation.org