Kathleen D. Brooks

Efforts to graduate more primary care physicians and physicians who will practice in rural areas: Examining outcomes from the university of Minnesota-Duluth and the rural physician associate program

Purpose To compare practice choices (primary care or specialty) and practice locations (rural or metropolitan) of medical students at the Duluth and Twin Cities (Minneapolis and St. Paul; TC) campuses of the University of Minnesota (UMN). In the early 1970s, Minnesota created two medical education programs at UMN to increase the number of rural and primary care physicians: the first two years of medical school at UMN–Duluth, where the program focuses on recruiting students who will be rural family physicians, and the Rural Physician Associate Program (RPAP) elective, a nine-month, longitudinal immersion experience with a preceptor in a rural community. Method In 2008, the authors analyzed outcomes for four student groups: (1) UMN–Duluth and (2) UMN–TC medical students who participated in RPAP and (3) UMN–Duluth and (4) UMN–TC students who did not participate in RPAP. UMN medical students complete their first two years on either campus; they can apply to RPAP for their third year. Non-RPAP students spend most of their third- and fourth-year rotations in the Twin Cities metropolitan area. Results The UMN–Duluth and RPAP students were most likely to select a rural location and primary care practice. UMN–TC, non-RPAP students followed national trends, choosing predominantly metropolitan and specialty practices. Conclusions RPAP and UMN–Duluth provide significant, complementary educational programs that lead more graduates to choose rural and primary care practices. Efforts across the nation to address the crisis in rural primary care should build on these successful efforts.

Learning professionalism during the third year of medical school in a 9-month-clinical rotation in rural Minnesota

Background: Professionalism is now an explicit part of the medical school curricula. Aim: To examine the components that are part of developing professionalism during the Rural Physician Associate Program (RPAP) experience, a 9-month rotation in a rural community during the third year of medical school. Methods: Two researchers analysed 3 years of essays for themes. IRB approval was obtained. Results: Themes were organized using Van de Camps model of professionalism. Students described how patients taught them about illnesses, the affects on their lives and the lives of their families. Preceptors role-modelled how to relate to patients with compassion and respect (Professionalism Towards the Patient). As a member of the health care team, clinic and hospital staff taught students how to be a good team member (Towards Other Health Care Professionals). Shadowing preceptors in their roles as physicians and community members, students learned about their responsibilities to the community (Towards the Public). Multiple opportunities for self-evaluation and reflection taught students to know themselves and find balance between work responsibilities and their personal lives (Towards Oneself). Conclusion: The RPAP appears to create a supportive learning environment that incorporates psychological safety, appreciation of differences, openness to new ideas and time for reflection – an ideal environment for developing professionalism.

Management of professional boundaries in rural practice

Purpose Rural physicians wrestle with professional boundary issues routinely in everyday interactions, and their situation differs from the experience of their urban colleagues. Medical students receive limited exposure to professional boundary management in preclinical training. Increasingly, schools are implementing rural longitudinal clinical clerkships which expose students to rural boundary setting. This qualitative study explored the management of professional boundaries integral to rural practice and how this management may differ from their urban colleagues. Method Semistructured interviews were conducted in 2010 with 12 rural physicians across Minnesota exploring their perceptions of professionalism in rural practice. A social constructivist approach to grounded theory was used to analyze the data. Results Five primary themes regarding rural professionalism emerged from the data: centrality of care, rural influences on choice, individualization of boundary setting, advantages of dual relationships, and disadvantages of them. These themes served to illustrate rural boundary management. Conclusions This study’s findings indicate that rural physicians are routinely confronted with professional boundary issues in everyday situations, and these circumstances do not always reflect those of their urban colleagues. Given the increase in longitudinal immersion clinical clerkship programs to nurture student interest in future rural practice, acknowledgment and acceptance of the nuances of dual relationships and boundary setting in different clinical learning contexts are vital to help students identify their personal needs for privacy and be better prepared to negotiate the realities of rural practice. These findings may inform future medical education initiatives on professional boundary setting as an aspect of professionalism.

Profiles of rural longitudinal integrated clerkship students: A descriptive study of six consecutive student cohorts

Background: Medical schools worldwide are challenged to address the rural primary care workforce shortage by creating community-engaged curricula to nurture student interest in rural practice. Aim: To examine the personal characteristics of six consecutive rural longitudinal integrated clerkship student cohorts to understand whom the programs attract and select and thus inform the development of such programs. Method: A cross-sectional cohort design was used. Six cohorts (2007–2012) completed a survey on demographics and factors that influenced their choice of rural primary care. The Temperament and Character Inventory was used to measure personality. Analysis was mainly descriptive. Where appropriate univariate analysis compared variables between groups. Results: Sample size was 205 with the majority female (61%), between 25 and 29 years (64%), single (60%) and lived longest in rural communities with populations less than 20,000 (60%). Rural lifestyle, background and desire to work in underserved areas were noted to impact rural medicine interest. Professional satisfaction, personal and professional goals and family needs had the highest impact on career decisions, and financial concerns lowest. Conclusion: The stability of students’ personal characteristics across cohorts and the workforce outcomes of this program suggest the recruitment process successfully nurtures students who will fit well into future rural practice.

Longitudinal Integrated Clerkships

To the Editor: We wish to share our responses to three recent articles1–3 in Academic Medicine that discussed longitudinal clerkships in light of our own experience with such a clerkship. Each year since 1971, the University of Minnesota’s Rural Physician Associate Program (RPAP) has educated 35 to 40 third-year students in a nine-month longitudinal rural clerkship. They experience continuity with a primary preceptor, health care team, and patient population. An organizing principle is to follow the course of a patient’s care in his or her primary care physician’s panel, learning from primary and specialty clinicians.