Rural Health Opportunities Program

UNMC student touts advantages of RHOP program

RHOP Program Details

RHOP addresses the special needs of rural Nebraska by encouraging rural residents to pursue health care careers. RHOP students obtain early admission into participating University of Nebraska Medical Center colleges upon completion of studies at Chadron State College (CSC) or Wayne State College (WSC).   See Web site at for further info. A total of 374 Nebraskans have participated in RHOP (Rural Health Opportunities Program) in a variety of health professions since it began in 1992, and more than 70 percent of graduates from the program have returned to rural areas to practice.

Other Special small college programs at Rural Community College Initiative 

Impact of the RHOP Program

When I visited Wayne State I talked to a professor who taught microbiology. She mentioned that during the seven years of RHOP, the number of A grades in her Microbiology class had gone from just 2 to 14 well-deserved ones per semester. She noted that the quality of the students, both RHOP and non-RHOP, continued to improve. She attributed this to increased competitiveness between the students. Other science and math professors echoed this viewpoint. Enrollment at both schools had increased at a time when other small colleges were losing ground. This sounded like a fairly good benefit for little cost and the extra efforts of a few faculty, but I began to wonder....

What was it about this insignificant program that made such a difference in the college?

It dawned on me that RHOP was one of the few factors that leveled the playing field between a choice of rural and urban colleges. For once, these small colleges had an advantage over the large urban colleges as far as admissions. Because of the program, the students attracted more competitive students, this resulted in improved education at the college. This was a positive feedback loop because as the students got better, more were admitted to further professional training. This was quite a change from the past. I asked myself how things had been deteriorating for so many years?

Challenges Remain

In the first few years, students had some academic difficulties in the first years of medical school. Later RHOP students have had less problems. The academics at Chadron and Wayne have improved greatly. Both colleges have increased the numbers of students and the competitive level of students. Other Chadron and Wayne students routinely apply for health professions positions and are accepted. Perhaps the greatest benefits are yet to be realized. Students in RHOP are able to attend a small college rather than being forced into larger urban colleges to improve their chances of being admitted. Students going to urban locations are more likely to meet urban spouses and spouses with more specialized careers, making it difficult or impossible to return to small towns to practice. RHOP lengthened the college stay for medical students from 3 to 4 years. This was done to improve academics (which took care of itself), but this decision may be a good one for location reasons. Another year in the small location will encourage more rural marriages. The RHOP program has also had impact on other young professionals who have benefited from changes at Chadron and Wayne. It is hoped that they will also be more likely to chose rural locations because of these effects.

Comparisons and Companions

Some feel that the small college health advisors, who have regular contact with Jefferson admissions in the PSAP program Physician Shortage Area Program Links and Info, play a special role in connecting rural and academic communities. Small college advisors and faculty given this opportunity have done well in other states. Area Health Education Centers have also worked to feed the proper students in to admissions (PEPP program KY).

Matchmaking is not an uncommon practice in traditional communities. The late Robert Waldman, M.D., Chancellor at the University of Nebraska Medical Center, initiated a hub and spoke approach known as the Rural Health Education Network. This led to the Rural Health Opportunities Program (RHOP) which admits rural high school students into a variety of health professions schools. In the medical school component, 4 – 6 medical school students from the smallest towns are admitted to medical school after graduation from high school. They attend one of two small rural colleges at either end of the state. These two colleges have used the program to improve their admissions and academics, making them more attractive to students interested in a variety of professions. The strategy of selecting and training students in more rural locations has been successful at WWAMI, Duluth, the Upper Peninsula program, Alabama, East Tennessee, Mercer, East Carolina, and many if not most osteopathic medical schools.

Programs like RHOP may lead the way to more than a cure for physician maldistribution. Small towns also need other young professionals to provide leadership, economic impact, and jobs. Young professionals also support and encourage and retain one another. Efforts to improve small colleges may restore the breeding grounds for these young professionals. Students doing pre-professional preparation in a rural college location are likely to marry a spouse that is more likely to want to return to small towns. The RPAP program Duluth Plus RPAP in Minnesota gives just a hint of the economic impact of programs that work to restore young professionals to rural areas. RPAP has graduated over 900 physicians since 1971 and most have gone into rural areas. RPAP costs about $800,000 a year, but the RPAP graduates that have chosen rural Minnesota have generated over a billion dollars of economic activity in their practices alone, seven billion dollars if their hospital impact is added!

Small college advisors and rural medical educators working together can spread the good news of rural careers to high school students, teachers, counselors, and parents through rural high school career fairs. Special admissions programs guarantee an attentive audience. When the Flexner reforms impacted medical education a century ago, they stimulated high school and college education to make great strides. Unfortunately these reforms made it more difficult to train doctors for underserved areas and minority populations (Ludmerer Time to Heal). Medical education could reverse these unanticipated effects by working more closely with small colleges.

At the other end of medical education, there is also great potential. Robert Maudlin tied small rural communities in Washington State such as Colville and Goldendale to graduate training in Family Medicine to create the first rural training track at the Spokane Family Medicine residency. Maudlin demonstrated efficient program costs, excellent training, and superb location outcomes. RTT programs continue to graduate 75% into rural practices (Rosenthal). Rural workforce experts such as Pathman believe that specialized graduate training may also hold the potential to improve rural retention.

The latest addition to rural graduate training is the Accelerated Rural Training Program (ARTP)Meeting the Needs of Underserved Rural and Inner City Areas with Accelerated Graduate Training. Jim Stageman used his experiences as a rural physician and preceptor in the Colville site (prior to Maudlin's RTT program in Spokane) and as a program director in Nebraska to develop a 7 year comprehensive rural medical education program. Accelerated rural trainees do a special training year that combines the last year of medical school with the first year of residency. They do a fourth year rural fellowship that emphasizes procedures. They commit to a rural practice location. A key part of the program is accelerated learning. Rather than wander through a fourth year that is often less than challenging, accelerated rural training program residents experience a year with constantly increasing responsibilities, an optimal learning situation. ARTP residents also moonlight in rural hospitals and emergency rooms a year earlier.

It makes no sense for educators to create rural graduate programs if there are few or no students interested in taking advantage of them. The ARTP program does not stand alone. A former rural physician guides admissions at Nebraska. All Nebraska students do rural experiences in the first and third years. In Minnesota, the RPAP success would be much more limited without the Duluth selections process.

West Virginia may have worked out the ultimate community-driven approach. Threatened with the closure of one of the three medical schools, leaders decided that they could indeed work closely with rural communities and facilities. Health professions education has moved out into rural West Virginia in a variety of disciplines and locations. Rural students introduced into the pipeline as early as middle school also enjoy tuition free college and health professions training. Perhaps they will reward the West Virginia’s underserved communities with service instead of chafing at crippling debts.

Making the Marriage Work: Community-Friendly Experiences and Sustainability

Many times academicians have expected rural communities to provide experiences for students and residents with little notice or preparation or support. Others have taken a different approach. The The CORE Program Combined Outstate Residency Experience (CORE) is a two month rural preceptorship. Three residency programs in Nebraska have combined their efforts to insure that there is a constant stream of family practice residents going to 4 small towns for up to a 3 year period. Towns are selected based on the need for physicians, the willingness of the hospital to support the program, and the ability of preceptors to teach.

CORE residents have stood in the gap to assist rural practitioners and health systems with much needed FTE in exchange for hands-on learning experiences. As much as possible within billing and training guidelines, residents function as rural physicians. Rural communities also learn using hands-on techniques, in this case by practicing recruitment on CORE residents. In the past decade, only one CORE site has failed to recruit a practitioner. Over 60 of the graduates of the RPAP long term preceptorship have returned to the community where they did their rural experience. The savings in recruitment and orientation costs are enormous in such situations.

Rural medical education also can add to workforce far more than the education of students costs. CORE is just one example where residents share call, see patients, and help satisfy community expectations. This may stabilize the most vulnerable systems and preserve access. Such medical education programs also help rural health systems in need to sustain or even build market share. Medical education also works directly to serve rural communities. Rural residency programs, rural training tracks, and rural satellite sites serve over a hundred rural communities across the nation, but there is even more potential. Some 800 of 2500 family practice faculty have been rural physicians. Many of these might have been able to stay in their rural practices if the training had moved to their location rather than vice versa. Trainees experiencing the bond between rural practitioners and communities firsthand might well value this long after graduation.

Getting Rural Doctors to the Smallest Towns