An Accelerated Rural Training Program
Background: Several authors have pointed out the need for enhanced training for those residents contemplating rural practices. Most students and policy makers are reluctant to commit to primary care training beyond the required 3 years.
Methods: The University of Nebraska Medical Center received approval for an accelerated family practice training program in 1993, and developed a 4-year program that requires a 1-year rural procedures fellowship and a commitment to practice in rural Nebraska.
Results: The Nebraska accelerated rural training program has recruited 10 classes to this program and has placed more than 50% of the graduates in communities with a population of less than 8,000.
Conclusion: The requirements of this program are unique. Special consideration must address the issues of recruitment of students, integration into the basic program, licensure issues, determination of fellowship training needs, and faculty recruitment.
Counties without a critical mass of at least 4 physicians face formidable challenges when attempting to maintain their rural health systems. They often have difficulty generating enough volume to maintain facilities and a sufficient number of physicians to share the call load. Nebraska ranks second in the nation with 47 of these counties.
Norris et al detailed some of the perceived impediments to attracting physicians to and retaining them in rural communities. In particular, there was a perception among potential candidates that their 3 years of residency training were not adequate to prepare them for the uncertainties of rural practice. Another concern was the perception that rural physicians were not reimbursed as well as were their urban counterparts and, as a result, recent graduates would have more difficulty paying off their ever-increasing student loans.
The College of Medicine at the University of Nebraska Medical Center (UNMC) has a history of developing numerous initiatives to help address the problem of physician shortages in rural Nebraska. The Department of Family Medicine has created four such programs at the graduate level:
Rural medical educators have long searched for an opportunity to change the usual process of medical education to help meet the needs of rural communities. An opportunity presented itself in 1991, when the American Board of Family Practice (ABFP) issued a request for proposals to replicate the success of the original University of Kentucky accelerated program. UNMC answered with a proposal that would adapt the 3-year medical school, 3-year residency model into a 3-year medical school, 4-year residency program that would also meet the needs of rural communities.
In designing the 3-year medical school, 4-year residency program, the authors theorized that, as small rural hospitals closed, the surviving hospitals would eventually achieve a critical mass of patients that would allow them to remain viable. The remaining hospitals would need a cadre of 3 to 5 well-trained family physicians who would (1) be comfortable practicing in a small rural community; (2) provide each other with moral support and a reasonable call schedule, thereby addressing one of the lifestyle issues particularly important to today's graduates; (3) have extra training in procedural medicine that would allow them to be more comfortable in managing a higher percentage of their cases in the local hospital, thereby insuring its continued viability; (4) be able to perform additional procedures, which would increase the financial viability of rural practices, including the ability to manage their substantial student loans more effectively; and (5) be comfortable providing consultant services to physician extenders who practice in surrounding communities that are too small to support their own family physician.
Background: Several authors have pointed out the need for enhanced training for those residents contemplating rural practices. Most students and policy makers are reluctant to commit to primary care training beyond the required 3 years.
Methods: The University of Nebraska Medical Center received approval for an accelerated family practice training program in 1993, and developed a 4-year program that requires a 1-year rural procedures fellowship and a commitment to practice in rural Nebraska.
Results: The Nebraska accelerated rural training program has recruited 10 classes to this program and has placed more than 50% of the graduates in communities with a population of less than 8,000.
Conclusion: The requirements of this program are unique. Special consideration must address the issues of recruitment of students, integration into the basic program, licensure issues, determination of fellowship training needs, and faculty recruitment.
Counties without a critical mass of at least 4 physicians face formidable challenges when attempting to maintain their rural health systems. They often have difficulty generating enough volume to maintain facilities and a sufficient number of physicians to share the call load. Nebraska ranks second in the nation with 47 of these counties.
Norris et al detailed some of the perceived impediments to attracting physicians to and retaining them in rural communities. In particular, there was a perception among potential candidates that their 3 years of residency training were not adequate to prepare them for the uncertainties of rural practice. Another concern was the perception that rural physicians were not reimbursed as well as were their urban counterparts and, as a result, recent graduates would have more difficulty paying off their ever-increasing student loans.
The College of Medicine at the University of Nebraska Medical Center (UNMC) has a history of developing numerous initiatives to help address the problem of physician shortages in rural Nebraska. The Department of Family Medicine has created four such programs at the graduate level:
The combined outstate residency experience (CORE) program, which is a joint program established in 1982 between the Department of Family Medicine and its affiliate program in Lincoln, Neb, and requires all residents to spend 2 months during either their second or third postgraduate years (PGY 2 or 3) in rural Nebraska. Four rural sites are selected for up to 3 years based on need for physicians and willingness to train residents. By having a constant stream of residents for a 3-year period, communities have been able to continue to maintain services and facilities.
The primary care program described below.
The University of Nebraska rural training track program, initiated in 1992, which is a separately accredited residency that consists of five rural training track sites spread across the state. Residents in the rural training track programs spend their first year in Omaha and their last 2 years in a rural site (2.1 format), with 2 residents per year level at each site (2-2-2).
Our accelerated 3-year medical school, 4-year residency track, the accelerated rural training program, which is the subject of this article and which began in 1993.
Rural medical educators have long searched for an opportunity to change the usual process of medical education to help meet the needs of rural communities. An opportunity presented itself in 1991, when the American Board of Family Practice (ABFP) issued a request for proposals to replicate the success of the original University of Kentucky accelerated program. UNMC answered with a proposal that would adapt the 3-year medical school, 3-year residency model into a 3-year medical school, 4-year residency program that would also meet the needs of rural communities.
In designing the 3-year medical school, 4-year residency program, the authors theorized that, as small rural hospitals closed, the surviving hospitals would eventually achieve a critical mass of patients that would allow them to remain viable. The remaining hospitals would need a cadre of 3 to 5 well-trained family physicians who would (1) be comfortable practicing in a small rural community; (2) provide each other with moral support and a reasonable call schedule, thereby addressing one of the lifestyle issues particularly important to today's graduates; (3) have extra training in procedural medicine that would allow them to be more comfortable in managing a higher percentage of their cases in the local hospital, thereby insuring its continued viability; (4) be able to perform additional procedures, which would increase the financial viability of rural practices, including the ability to manage their substantial student loans more effectively; and (5) be comfortable providing consultant services to physician extenders who practice in surrounding communities that are too small to support their own family physician.