Getting To Rural Practice and Getting Rural Practice

Getting to rural practice is often about a calling and a response, as it was in my case. Sometimes the career is thrust upon us. Taking a cue from Shakespeare,

Some are born rural, some achieve ruralness, and some have rural thrust upon them.
Regardless of the route to rural practice, the journey is often neglected. The need for a journey or path has long been marginalized as in paths to rural practice, to primary care, or to care where needed.

The emails awaiting me this morning back to back were about rural training and apprenticeship -  coincidence?
"People who commit themselves for a cause have a right to expect training in the job for which they have been selected. In some of the trades, this is called “apprenticeship.” In medicine, it is known as “internship.” In the military, it is referred to as “basic training.” In scripture, it is referred to as “discipleship.” However, in our modern day, training is often by-passed due to the pressures of time, need and a low value placed upon the office to be filled. This was not the case with Jesus in His selection and training of His disciples." - Standing Strong Through The Storm (SSTS), Paul Estabrooks, Training in Righteousness July 10, 2014

Rural medicine is indeed a way of life with rural living a key component. One of the best rural practice speakers by far was Bob Boyer MD - longterm rural doc in Kingman KS. His talk was about the barriers to rural practice and how those barriers were overcome using rural site and rural preceptorship examples. (See The Blizzard) His final story was about a complicated delivery resulting in a prolapsed inverted uterus. This rare and life-threatening event occurred during a blizzard with just he, the nurse, the patient, her husband, some Penthrane (like ether), and a phone call connection to his OB mentor at a hotel in Omaha far away from Kingman. The connections that we make shape our lives and the lives of others - especially in health care.

We followed Bob's great stories in Kansas City with small groups to address 4 levels from early student interest to senior FM resident info.
1. Bob talked about rural practice and rural living and he always had a good draw of those in the room (puzzling to me until I understood more about the importance of rural life and living)
2. Setting up rural experiences (for medical students)
3. Choosing a rural residency (for students)
4. Choosing a rural practice (for residents)
Sometimes we combined choosing with using your rural residency, emphasizing the procedural component. Program directors and recruiters from not for profits contributed to this event.

My favorite feedback comments came from senior residents or sometimes their spouses - who said that they now remembered why they got into a medical career in the first place. 
There was one (of about 12) session that I experienced that was the best session by far. I talked to Bob after this one. He noted that the best storytellers tell their story to a person in the audience. In this case, the person that he told his stories to was the spouse of a second year family medicine resident sitting in the middle of the room. She was about 8 months pregnant. The connection was electric.
Connections are the key

We ignore connections and many of the most important areas - such as "the why." Motivation, morale, commitment, and much of life meaning is about connection.
When we cannot get students before, during, or after medical school to experience rural life, rural practice, rural communities, and what we all value - we will remain limited and often so will they.
Now that we know long term rural continuity training can be the best medical education, there is no reason not to do so.
It is my opinion that traditional medical education is deteriorating with overall health education in worse shape. Twenty years ago we could demonstrate equivalency between rural training and typical training. In the past decades marginalization has taken a toll. Getting away from marginalization is important.

We were always limited as rural medical educators because we were forced to apply traditional measures rather than measures that were more about primary care, health access, and practice, especially rural practice. 

Academic experiences are limiting. This is why it took rural physicians moving into academics to connect what is most important.

Jack Verby was a rural doc for 20 years and RPAP MN director for 20years. He learned about the limitations of academic measurements and developed measures specific to rural practice - areas such as confidence, competence, and comfort levels. For example studies demonstrated students overwhelmed at 3 months of rural experience, neutral at 6, and did not want to leave at 9 months (particularly when sent back to the academic center for year 4). 

The RPAP experience was about becoming a part of the care delivery team, the practice, the community, and a part of other people's lives. RPAP students also contribute to local care delivery because they are connected as a part of the team - about $40,000 to $70,000 more care as estimated by Verby. This is different compared to short term rural exposures that can take more than giving because of time spent in orientation and other prep for an experience that never connects.

So much of the time primary care or rural experiences are just exposures - a rotating series of events to pass through on the way to graduation. Primary care and health access careers deserve much more as do half of Americans left behind by this training design.
Simplified training for medical students, nurse practitioners, or physician assistants might address cost factors, but not the most important factors. The pressures of time or "too much to learn" result in a loss of what to learn and why. Few are preceptorships or internships or involve relationships of any kind.

Without relationship there is not perspective - to your supervising preceptor, the practice, the community, various people in the community - not only for the student or resident but also for their family. As we know, the family may be more important than the physician.

This is also why it is difficult to leave rural practice for full time academics. Those of us who have attempt to do rural training - because the training is back in rural practice.

Taking training away from rural sites has been a 100 years mistake, with only some recent recovery and in small scale.

Moving away from broadest generalist family practice has been a 100 years mistake, as yet without recovery as we still do not have 3 years prep, 3 years med school, 3 years FM - all specific to rural family practice and all taught at a rural family practice site.

Hopefully we will one day lament this past time period - Why would learning ever be suppressed, and in so many dimensions?

A nice article appeared in Rural and Remote Health regarding Geographical and seasonal barriers to mammography services and breast cancer stage at diagnosis Time, distance, and other barriers are important to understand and the designers of health care often fail to understand the consequences of their designs. 

Thanks to RuralMed and rural colleagues for the multiple perspectives that tuned this piece and brought back so many pleasant memories and hopes of more to come. One other contributor to this has been some recent correspondence with Homer Flora, DO. He reached out from retirement at age 93 to reflect back on 1980s rural practice in the town we shared for 4 years - Nowata OK. He was gracious to note how the hospital should have adopted some of my proposals (senior living, community health activities). 
It was also good for me to acknowledge his contributions to me as a rural mentor. He was a GP and was by far the best anesthesiologist I have seen, impeccable charting and an efficient practice and use of personnel such that nearly all his time was face to face with lots of faces seen per day from 1954 to 1993. He was the primary supporter of 2 hospitals and was by far the most important individual local economic contributor. I still use his techniques with consultants. He would listen to a talk and then had specific questions about patients he had seen. You could see him learning more about what he could do (expand his cutting edge) and about how to best refer and when). I heard from his daughter also and was glad to hear that the town honored him in a mile long parade when he retired, but then he delivered care at a reservation practice and did locus. 
From my first rural research effort that reached publication - One rural doc was advised by his rural doc father not to practice in the same town. He was told to "go somewhere else and make your own enemies." Only those who experience rural understand such relationship - love, competition, conflict, belonging, and often in the same people - real life worth living. 
Will Teaching Community Health Centers "Get It?" - May take some time.

Best of Basic Health Access

Robert C. Bowman, M.D. 
 SMART Basic Health Access


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