RPAP Is SMART and Has Been for Forty Years

Academics love innovation, new grants, and change. A weakness of academic focus is doing what works -  practical and relevant. Academics often have to be forced to do the practical and relevant. Such is the case with RPAP. The Rural Physician Associates Program has been practical and relevant for 40 years and has facilitated increased primary care and rural services where needed since the first 3rd year medical student began.

RPAP is well known to the people at HRSA. During this past two years at least three times I have reminded them about RPAP as a very inexpensive way to increase health services for those in most need - in rural underserved areas. Given the serious problem facing HRSA with designs that would increase primary care demand in the face of failing primary care supply, worse in underserved areas, one would think HRSA would do more.

HRSA has been busy elsewhere on reports and programs that are not SMART - specific, measurable, achievable, realistic, and timely. RPAP is SMART and has been for 40 years since the Minnesota legislature forced it on the University of Minnesota.


RPAP involves 60 medical students in their first and most important clinical year of training. RPAP students initially spent an entire year, receiving a small stipend to do so. Rather than typical rural rotations where students play at rural health for a few weeks or months, RPAP students become rural health care. It takes them a few months to orient, but they become efficient and effective members of the health care team. Verby noted $40,000 to $70,000 more in revenue generated during a year with an RPAP student as compared to a year without. This is a substantial increase in services delivered in a most needed location - exactly what areas lacking in primary care and rural health services need.

RPAP is essentially a successful public-private partnership between the state and the people of Greater Minnesota. It is not really much help to the University of MN as the funds go to students. RPAP costs about $800,000 a year but has so far returned over 3 billion in services just for the graduates that have practiced in rural MN. About 10% of RPAP graduates are found in practice in the sites where they trained - they save hundreds of thousands in orientation and initiation costs as this 10% hit the practice with previous experience and have had 4 years since their RPAP rotation to prepare specifically for their practice settings. RPAP is one of few mechanisms to build health access leadership - as with Jay Erickson and others who are holding medical education accountable to state needs. RPAP is also a reason why Duluth has retained 50% entering family medicine - a SMART design resulting in SMART primary care choice.

RPAP is too valuable not to replicate far beyond MN and far beyond MD training. Thousands of RN, MD, DO, NP, and PA students should spend their final year or two in continuity primary care setting, in a rural setting, or in an underserved practice. RPAP generally accomplishes all three at once as rural areas are primary care, rural, and underserved intensive care.

Once again I implore HRSA to lead the nation toward public private partnerships with rural communities and away from short term rural rotations that actually result in less rural health care delivered. Community Friendly focus has been noted long before my publication in the Journal of Rural Health summarized at http://www.ruralmedicaleducation.org/community_friendly_aspects.htm

Short term rotations cost workforce. The cost of nurse and preceptor time is too great. It takes 4 months length to break even (RRH), 6 months for students not to be overwhelmed, 9 months to not want to leave (Verby), but they get it and help provide effective team care. We are supposed to be pushing this by the way and dysfunctional primary care in academic settings has been highly unsuccessful in much other than driving medical students and residents away from primary care careers (Keirns). The opposite of dysfunctional and the opposite of too many learner in one place is a good thing for learning, integration, and maturation.

RPAP need not cost much to states or to academic institutions, because it gives rural communities what they want and need - future young professionals and their families - before, during, and after graduation. Rural nursing is in short supply - RPAP works. Family practice employed NP and PA are the most important non-physician clinician component - RPAP works. Initial nurse practitioner training designs did involve some that required 9 months spent with rural physicians in the field - essentially the RPAP design. MD and DO students need much better primary care, rural, and underserved training - RPAP works.

State and federal government will need to see accountable health professional education - Specific, Measurable, Achievable, Realistic, and Timely   RPAP has been SMART since its start.

10,000 students helping to deliver $30,000 more care each with little additional cost is a really good win-win-win - for the students, for the communities, and for the nation. Preceptor satisfaction, continuing education, doctor-patient relationship training, enhanced primary care training measures, and improved focus on competency are just a few benefits - by design. You want to stimulate youth interest in health careers - here is a vehicle that works inside of communities in need - by design.

It is not time for innovation and change. It is time to replicate what works and has worked for 40 years - RPAP is just one that should be replicated.

If you like this, tell HRSA over and over, tell your state, tell those who train students, but don't shorten RPAP or make it convenient. Make it work for those in need of basic health access - by design.


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