Under construction,
Using Your Residency - advice for student and residents about getting the most out of their training - a key preparation for rural practice
Dr. Bowman,
How are things for you? I'm on my psyc rotation at Richard Young. It's pretty interesting at times! I was mailing you to see if you could let me know who to get in touch with to find out about FP residencies around the nation who specialize in rural procedure based training. I appreciate your help.
Matt Summers
My response:
Procedurally oriented programs can
1. have an active indigent care component, county hospitals, etc - mostly large urban sites
2. have a VA that cooperates with FP residencies - like Johnson City FP residency
3. community based sites where FP is about the only residency in the hospital and they have procedural faculty and track record - Greeley CO, Waco TX, John Peter Smith in Fort Worth, Ventura Calif, many rural training track programs, such as North Platte
4. program with a focus on procedures and fellowship - UNMC accelerated rural training program
The AAFP student resident meeting in late July in KC is a good place to scope it out by talking to the residents there and comparing numbers.
Other suggestions for matt?
Bob: I know that way up here in Alaska gets missed because we are so far away, but don't forget about our pride and joy, the Alaska FP program, which has an active indigent population, VA contract, Sole Residency for the entire state, Community based program, supervised Rural training site for 6 weeks for each individual, and required 3 1/2 months of rural rotations, not to mention procedure clinics within our clinic and am FP faculty who has full credentials for EGD/Colonoscopy at our parent hospital ( over 1000 scopes at time of application 4 years ago). We are placing over 50% of our grads in Alaska, and 75% go to work with community health centers, IHS type sites, or rural practice.
Just thought you might like an update! Barb Doty M.D.
The approach needs to be much more outcome oriented with OB capable FP and colonoscopy capable faculty as the quickest and most reliable method of identifying truth in advertising among the many many wannabes. In the 1980's I started an Oscar nomination list to help students identify those programs most likelyh to help students with this interest. Over the year some programs came and went. John Peter Smith and Ventura are perennial favorites, but even Fort Worth Texas became saturated with many more hands than there were procedures. The "Oscar nomination List" is still fairly up to date, but contains the disclaimer that that the acquisition or departure of just one faculty can dramatically change the procedural training environment for some programs.
The start of list contains some general principles which have stood the test of time. The leadin to this email is one of them. People who are interested can email me and I'll send them the list. I'd prefer not to broadcast the list universally, because I'm sure there are some good programs I've left out. On the other hand the list does encompass my 7 years of experience on the RRC. 1994-2000 I reviewed almost all of the programs in the US twice each.
Also, procedural training is not just about numbers. The cognitive side , ie the preload and postgame managemnt dimensions are equally, if not more, important than the psychomotor act of the procedure. I will be in Kansas City with the Meharry/Vanderbilt exhibit. I'll bring a CDE burner for those who copies of the Oscar nomination list or the FP/OB fellowship curriculum which is becoming more universal as these special needs are recognized.
Bill Rodney Wmrodney@aol.com
Bob,
I am sure that someone else from the BRazos Valley program will answer this but
we have 9 faculty (or more) with full section/delivery privileges. We turn out
an average of one grad a year with section privileges (an advanced OB track
gives them greater than average experience); we have two who do colonoscopy; we
do office ultrasound - full OB reading. All of this is taught by FP faculty.
Nancy Dickey (Brazos Valley is College Station, Texas affiliated with Texas A&M
University)
Nancy W. Dickey, MD
President and Vice Chancellor for Health Affairs
A&M System Health Science Center
Phone: 979-458-0800
FAX: 979-458-0813
"Nancy W. Dickey" <dickey@medicine.tamu.edu>
Bob: All but one of our 8 faculty at the Alaska FP Residency are OB
trained and qualified. In addition, our rural immersion site in Bethel
has an OB-trained community faculty member. I am OB trained part-time
but do my deliveries in my home base community hospital in Palmer an
hour north. Our program director Harold Johnston continues to do OB.
Our graduates usually have at least 100 deliveries under their belt, and
the curriculum requires 3 months straight OB, 1 month GYN with OB call,
1 1/2 month of R3 high risk OB with OB call. A majority of our
graduates do OB upon completion, but rarely are c/section qualified as
politics in our Anchorage-based hospital limit access to training, and
the Alaska Native population aren't a training resource as they don't
usually need C-sections (they have "pelvises made for having babies" and
have a C-section rate of less than 10%). Does that answer your query?
Barb Doty
bdoty@alaska.net
Bob: I can only speak for our program, but often rural-based programs
afford residents the opportunity to gain procedural experience on a
near-daily basis for 2 years versus many urban programs that provide
experience during electives of a few weeks duration. For example our 2 RTTs
in WA (Colville and Goldendale) emphasize procedural training especially in
areas were residents want specific experience. Recent graduates have done
over 150 colonoscopies, over 120 EGDs, vast experience in colposcopies,
LEEP, dermatology experience, orthopedics/trauma and extensive OB and
C-section experience. Although the numbers are not as high in our
traditional urban-based Spokane residency, they are pretty good. Part of
this "success" is that family physicians are the primary care givers in our
part of the Country. Bob Maudlin
"Maudlin, Robert K." <MaudliR@fammedspokane.org>
Also consider the following links
Questions By Students and Other Info about Programs
Student Dreams and Rural Practice
Some Student Perceptions of Rural Practice
Physicians that stay in rural communities
Rural Student Interest Group Sites
1. Personal factors - I would add emphatically that whether a resident gets
procedural training is most dependent on how aggressive the resident is in
seeking out procedures. This is by far the most important aspect. If you are
more passive, the program design may be more critical in your ability to get
procedures. If you are more aggressive by nature, this may be less of a
determinant of your final numbers and privileges. Regardless of your aggression,
knowing your limits is important to quality of care in residency or practice.
Pushing these limits out further and further (in residency or practice) is a
function of experience volume, experience intensity (shoulder dystocias
managed), and self determination.
2. Tradition - Other factors that are key are the tradition of past residents
and their relationship with attendings and residents so that they have built a
good case for FP residents doing such procedures. One or two aggressive
residents can turn an entire program around in a year or two.
3. Volume - Residencies with a larger volume of patients allow residents to
access more patients in need of procedures. These are often more stressful in
terms of call and clinic, but you get to do more and decide more, critical to
becoming a rural physician.
4. Faculty and leadership of program - Faculty training and comfort with
procedures is a key. Program directors can really set the tone in this area.
Some Family Practice programs hire specialists on a part time or full time basis
or have them come volunteer at the residency clinic so that more procedures can
be done, this may include OB-Gyn, Surgery, etc. Ideally you can approach such
physicians and refer you patients to them as a resident and get to do the
procedure with the consultant (again dependent on the aggressiveness of the
resident and the relatationships and efforts of the program).
5. Access to indigent patients or indigent facilities (Veterans, County
Hospitals) with a tradition of residents making decisions is helpful in volume
and variety of procedures.
6. Training with attendings or faculty who know their patients well enables them
to let you do procedures. When faculty or attendings do not know patients, they
are not likely to allow residents much latitude. Faculty who have been there
longer can be a great help in this.
7. Competition - Whether there are competing residencies of other types is
important. Growth in other residencies can inhibit the procedures of the FP
folks. Obviously there can be some residencies that are sole community
residencies.
8. Communication - Finally, if you make it known regularly that you are heading
into rural and underserved practice, you can encourage attendings, faculty, and
other residents to let you make decisions and do procedures.
Robert C. Bowman, M.D.
rcbowman@atsu.edu