The CRIB: Cradle to Grave Involvement in Rural Communities

Local Faculty Development that Matters

Robert C. Bowman, M.D., 1999, update 2002

Thanks to Oklahoma State Osteopathic for the consult at Bristow OK that led to this development.

One of the most difficult parts of rural training is maintaining consistency. The quality of rural training is equal to or better than typical training. See Quality in Rural Medical Education. There are two approaches to developing sites and preceptors. One assumes that the knowledge and experience arises from academic centers. The other approach utilizes the organizational aspects of the academic center and uses the resources and knowledge and experience of the preceptors and their community. The approach involves a meeting of preceptors and key office and hospital people at the rural site. Academic faculty or coordinators are there to moderate and probe. If at all possible, some learners at various levels should also be present. Moderators should encourage them to participate and ask some challenging questions during the session. One particular intern at Bristow challenged some of the scut-work situations that occurred at the site, noting that although histories and physicals were helpful for preceptors, they were 1. time consuming for students and residents as compared to the preceptors who knew much of the H and P by heart, 2. often kept students and residents out of the office or from doing procedures available at the same time. The discussion that resulted was priceless and improved communications, priorities, and learning.

The community-driven process involves asking 3 questions with group responses recorded. 1. What do you wish you had learned in medical school (or residency) that would have prepared you better for rural practice? 2. What are the best learning resources that we have in this town for these learners? 3. How can we best get the learners to utilize these resources?

Academic folks then review the items and discuss how the players plan to use the information. Hopefully this includes a sit-down discussion at the beginning and mid-points of the learner's rotation, using the resource guide prepared for the site by this effort. Academics help prepare concise summaries and can usually integrate rotation learning points as well.


Experts point the way to involvement as a key factor. This is not a surprise to those in and from rural communities because being in a rural community is involvement. Mercer students rate the preceptor as an influence much more important than the rural preceptorship. You can educate students anywhere, but if you want to influence them, you need to involve them.

Involvement is a rather profound and nebulous term. Some students naturally pursue involvement. Others need help in the first steps. Others need some prodding. The heart of a good family physician is involvement and family medicine is the specialty that took on the task of getting involved in patient care in a new way. This involvement fueled the growth of the specialty and helped it gain support, even in the face of great great resistance from medical education. Family medicine continues to sponsor significant student involvement efforts, from official student interest groups, to involvement groups such as DOC that target alcohol and tobacco abuse, to other types of volunteer efforts.

The typical medical trainee is trained and socialized out of involvement. See Impact of Academic Distancing. Most patients, colleagues, and faculty are only 2-4 week relationships. One potential impact of this declining involvement may be the declining interest in rural and underserved practices over the past 20 years. Twenty years ago 20-30% of medical students were interested in rural practice, now 3% are interested. New studies show a slight improvement in the past two years. With so little involvement in training, it is likely that the consideration of a rural practice, where involvement is expected, would be made more difficult. 

One of the great assets of rural communities is the emphasis on involvement.

Without some special effort, few students will ever experience the real difference in rural practice, that special relationship between a family physician and a rural community, unless they take advantage of a rural training opportunity. This opportunity has to be more than just time spent in a rural doctor’s office, however. 

Rural preceptorships, using the traditional measures, may not be any better than other preceptorships, but there is little doubt that they are perceived to be the best clinical experiences by 3rd and 4th year medical students at Nebraska and other locations (See Gjerde). Perhaps this is due to the amount of involvement that students are allowed, as opposed to other rotations where they are spectators. When doctors know their patients, they are comfortable letting students take more initiative. This means that they can learn more in several dimensions, rather than just disease and treatment. Quality in Rural Medical Education

New studies connect rural interest with involvement. Students interested in practicing in towns of less than 10000 were compared with their peers in the 1995 Graduation Questionnaire that is sent to all senior medical students. When students with rural interest are compared with their classmates as a whole, there are some interesting differences. Click here for details. About half (47.6%) came from small towns of less than 10,000. The others had a wide range of urban backgrounds. Over 30% of these students had already decided to become family doctors before matriculation. Rural-interested students exhibit some desired characteristics for future physicians. Rural-interested senior medical students participated in twice as much volunteer service for the underserved both locally and internationally when compared with peers. This involvement may certainly have some influence on career plans. Over 60% of rural-interested students planned to locate their practices in a socioeconomically deprived area as compared with only 11.5% of other medical students.

These are the same curricular areas recently noted as inadequate by various interests such as the Pew Charitable Trust, the Kellogg Foundation, and the Council on Graduate Medical Education. This awareness seems to continue out into rural practice as new rural family physicians studied by Tom Norris listed many of these same inadequacies. Medical school admissions committees would do well to correctly identify and prioritize rural-interested students, not just because of their rural interest and their potential for longer retention, but because of their involvement and awareness. Or perhaps they should choose students first for their willingness to get involved, then on academic ability. Physicians who want to "make a difference" would certainly need to get involved and this involvement may be essential to both recruitment and retention for rural and underserved areas.

So the question is, how can we involve our students in rural communities and how will we support these activities. It is our hope as rural faculty that communities and practices develop the following information for use by preceptors and preceptees, or others who hope to learn about rural health and rural communities. 

CRIB Summary

Competence  What do you do well in your practice, what do others in the community such as physicians, other providers, local leaders, do well? Consider the usual practice stuff  (procedures, obstetrics, office management, organize local physicians, counsel patients) but also look beyond (public health, work with the schools, participate in local organizations)?

Rural Living  What are the best parts of your community (schools, churches, organizations, public health, community-minded people or projects, community events or celebrations)?

Involvement   How can I involve students with the above? Best done in a group session with many of these people in the community coming together.

Best of your community  Do those around you have some special skills or talents that students could learn about (skills of other doctors, office manager, nurses, hospital administrator, community leaders, ministers, senior citizens)?

Another way is to get students involved during a rural preceptorship. 

There are special opportunities that rural physicians have - check out these sites:

Why does rural fit in with medical education.  Why Rural Emphasis. Rural preceptor development sites

Articles by Joe Hobbs on the Invisible Faculty and Decentralized Clerkships are important to review. The Invisible Faculty by Joseph Hobbs, M.D.

Studies from Mercer in Georgia asked about the preceptor instead of the preceptorship, an important distinction. When asked in this fashion and when the preceptorship is placed in the critical time between the second and third years of medical school, preceptors are the most significant impact at the school. Although the preceptors grumble occasionally about breaking in green troops, they cannot deny the satisfaction they feel in helping students to learn about medicine the right way from the start. We all know that some teachers seem to do a better job of attracting students to similar careers.

Even experienced workforce researchers admit that there is something about involvement. Involvement may be a key factor in retention in rural practice. One of the major workforce questions of our time is how changes in involvement may impact rural practice. These include:

Getting students involved may be even more critical than ever before.