Rural physicians need to acquire many different skills during the years of training and practice. Rural medical education is a series of steps progressing in multiple, overlapping dimensions. The following outline is adapted from Mengel's article in Family Medicine about Generalist Courses in US Medical Schools. The curriculum is specific for rural family physicians. Those who hope to prioritize rural training may use the outline. The reference point is admittedly personal at the present. The intent of distribution is to invite examples, clarification, and suggestion of areas for study and survey.
Each subject or area has two designations in parentheses (M-1/M-4). The first designation is an estimation of the level of training when this subject is addressed: NA means not currently taught at all, M-2 means medical school year 2, PGY-2, means residency year 2, RFP-2 means practice year 2. All of these are guestimates.
The second designation is a suggestion as to when it should occur for proper training for a rural primary care physician. A designation of M-1 does not preclude the need to teach this prior to entering medical school or as a criteria for admission. Those with an asterix (*) are from Mengel's table.
*Purposes Medical school applicants should already understand the history of medicine. Schools of primary care should only accept candidates who demonstrate this understanding. The following represents necessary remedial work:
*General medical history (NA/M-1), I would add the development of medical education from 1850 (AMA, public health, Flexner, subspecialization, reimbursement, the changing rural to urban demographics, and the finance of medical education)
The need for rural physicians (NA/M-1), including the physician role in access and quality of care and the economic and leadership role
*Philosophical and ethical foundations of medicine (NA/M-2), illustrating the societal obligations of physicians and medicine and the need to balancing personal and physician needs with those of individual patients and society in general
This is the area of medical education that is most emphasized and most well- defined. It also appears to be a much smaller part of the whole curriculum. The evaluation process for medical schools and students is almost completely based on this small area.
Biomedical (M-2/M-2)
Psychological (M-3/M-3)
Procedural (PGY-3/PGY-3)
Medico-legal (M-4/M-4)
Public health (NA/M-4)
Rural community structure and function (RFP-2/M-2) Government, Education, Economics
Rural modes of practice (RFP-2/M-3) Public health service Rural health clinics Hospital-sponsored practices Solo, group, satellite
Duties of other health providers (RFP-2/M-2) Extenders, mental health and social workers
After the development of each area of knowledge, application begins. Learning in this area depends on personal application, synthesis, instruction, environment, and challenge. Curriculum can impact on the selection of types of training and ultimately career decisions. Who (whether generalist or not) teaches each of these areas may have an impact as well.
*Interviewing and history taking (M-2/M-1)
*Physical examination (M-2/M-1)
*Clinical decision making (M-4/PGY-1)
*Clinical management (PGY-2/PGY-2)
*Health maintenance (PGY-2/PGY-2)
Lifelong learning (NA/PGY-2)
Career choice and development (NA/PGY-3)
Practice management (NA/PGY-3) - necessary if private practice is to remain an option or leader/administrators who have the physician perspective are considered important
Negotiation (NA/RFP-3) - a part of working with people on a daily basis Leadership (NA/RFP-3) - physicians are always in leadership roles, but do not always have leadership skills
Those without the ability to develop and understand relationships should not enter the medical profession. Physicians work with a variety of people daily. The role of a physician is constantly changing. Physicians obtain the ability to establish effective relationships through application, teaching/counseling, and role modeling.
*Doctor-patient (M-2/M-2)
Interdisciplinary (NA/M-2) - physicians must work in teams
*Family system (NA/M-3)
*Cultural issues (M-3/M-3)
*Community-oriented care (NA/M-4)
*Health care systems (NA/M-4) Private or Public; Federal, State, and Local
Values are set by individuals and groups. Values are interpreted by institutions and governments. Physicians are often caught in the middle. The most difficult thing about being a physician professional is being able to render service to patients without regard to the material needs of the physician. Objectivity is necessary, but difficult. Physicians must understand their own views and needs as well as those of patients and others. These include cultural and religious sensitivity. Physicians also have an advocacy duty to inform the public and help change rules, policies, or laws which conflict with the values of society.
*Ethics (M-4/M-4)
*Malpractice (M-4/M-4)
*Economics (NA/PGY-3) Reimbursement, quality and availability of services Personal balance issues (NA/PGY-3) - rural physicians must deal with conflicting practice vs personal needs, time management issues, and family needs. It is impossible to completely separate the personal, family, practice, and community roles of rural physicians.
* those from Mengel, Davis, Barton. Generalist Courses in US Medical Schools and Their Relationship to Career Choice, Family Medicine 1992; 24: 234-7 The rest of the subjects and all of the text is added by Robert Bowman, M.D.