Cultivating Rural Doctors

The latest buzz at my hospital is the imminent arrival of a group of 3rd year osteopathic medical students (OMS) who will be doing their core rotations in Rural.  A number of medical schools are trying to encourage more young doctors to work in rural areas by having them rotate in rural hospitals and clinics, which is a good idea because these programs will give students an idea what life is like in a rural community so they can make informed choices about where they will practice.

I made a point of doing rural rotations when I was a fourth year medical student. First there was an OB elective in Fresno, at a regional medical center serving a large agricultural area, then a family medicine elective in Selma, CA., a few miles down the road. The hospital in Selma had a dozen med-surg rooms, two ICU beds, and two labor and delivery rooms. The residents' clinic was about 400 yards away across a well-groomed lawn, and I had to dodge water sprinkler arcs when I ran back and forth between the two buildings. Then there was another family medicine rotation in Salinas, CA., at the hospital where I would later do my residency. These rural experiences helped me understand what it was like to live in a small community and practice in settings where specialists are not immediately available, so when I returned to Salinas, I was committed to being in such a setting.

The OMS who are coming to Rural will be doing rotations in OB, Medicine, and Surgery. They will be following physicians who have volunteered to be preceptors, so they will get to see what goes on in clinic and at the hospital for each of these specialties. Will my hospitalist group be teaching Medicine clerks? No. Here's why:

1. My hospital has absolutely no facilities for medical students to assemble. The hospitalists have no place to put their things, and no call room, so there is certainly nowhere to stash a dozen students.

2. The osteopathic medical school sponsoring these students are sending them to Rural with absolutely no local administrative support. When I asked where they would be staying, I was told "oh, I think they're renting a house to share." Not only is there no one at the school helping them find safe housing, there will be no one in Rural to ensure their evaluations from precepting physicians are completed, communicate mid-point feedback to them so they can improve their performance, or obtain their feedback on the rotation sites and attendings. Wherever I did a rotation, there was a medical student coordinator who made sure I knew where to go, what time to be there, and shuttled the mutual feedback between student and attending physician that would ultimately go into my Dean's Letter at graduation. I suppose these OMS will have to figure out all of this on their own.

3. The osteopathic medical school also seems to be slapping this rural rotation program together at the last minute. One internist received information about the student who would be following him two weeks before the rotation is scheduled to begin--his first notification about the rotation at all. I was approached by one of the school's faculty, who used to work in Rural, in April with a similar request. She asked me to take on "four or five" medical students for an Internal Medicine rotation beginning at the end of June. Considering the more than full-time job I have providing clinical services and being the hospitalist group's CFO, I had to say no to the request. I was astonished that anyone would expect any group, even a well-staffed one, to be ready to take on four or five brand new third-year medical students with only a few months notice.

4. In my opinion, the school has also not provided adequate information about the student's preclinical curriculum or expectations of what they should be able to achieve during a rotation. For example, when I was approached by the faculty member in #3, I asked her to send me syllabi of the preclinical coursework I could expect a third-year student from her school to have passed. I never received it. Today, I read a flyer going around the hospital announcing the students' arrival next week, listing the expectations for their rotations in Medicine, OB and Surgery. The entire document is two pages long. Now, when I was a medical student, these curriculum outlines usually occupied a one-inch binder and included lists of disease entities I was expected to encounter, procedures I might perform, and a whole host of professional standards I was required to maintain. They also documented what I could expect from the attending physicians and residents who were teaching me. They were densely-written, highly specific, and soporifically boring documents I rarely bothered to read in full, but I felt reassured by their existence, because I knew someone had ideas about what I was supposed to learn and how I might go about learning it. I worry that the OMS do not have such an anonymous benefactor among their school's faculty.

5. I have serious misgivings regarding the quality of the program these OMS are coming from. The program is relatively new--I think their first class was in 1998 or 1999--and is rapidly expanding. It is associated with a number of other schools offering healthcare degrees around the country and overseas. I am suspicious of any phenomenon characterized by rapid growth (think: tumor), especially when there appears to be no standards of quality. The faculty member in #3, in an effort to persuade me to take on medical students on our hospitalist service, said: "Oh, it's really not that much work to teach them. Just have them do an H&P or two, and write some progress notes." Mind you, she is talking about THIRD YEAR INTERNAL MEDICINE here, which is usually one of the most demanding of all core rotations in med school. Medical students have been known to spontaneously combust while rotating through Medicine. When I was a third-year medicine clerk, I got to work at 6am to pre-round, and I usually didn't leave until after dark. I wrote many H&Ps during the rotation, and many more progress notes, and I was expected to run all over checking labs, looking at X-Rays, presenting cases, etc. etc. The work was so intellectually challenging and emotionally overwhelming (I met some of the saddest cases on Medicine) that on at least two occasions I burst out into tears at the nurse's station. Sad but true. Anyway, the idea that a core internal medicine rotation should be easy to teach is an affront to my respect for the profession AND to the students who have chosen to enter it, and I told this faculty member so.

I hate being such a Grinch about these OMS who will be arriving next week. I have always enjoyed teaching and have given some thought to returning to a residency setting one day, but I have a great deal of respect for the time and energy involved in being a good teacher. I'm worried that the OMS who will be arriving will have one of those fragmented, where-are-we-supposed-to-be experiences that I hated when I was a student. I'm even more worried they won't leave Rural with the hard-won sets of experiences that lay a good foundation for the rigors of residency and the challenges of real-life practice. I know we need more rural doctors, but not at the expense of excellence in medical education.

Comments

[armytomed]

Dr. Chan,

I appreciate your time to write the blog and your insights. It gives a great view into rural programs as that is what I am interested in.

I have recently been accepted to a DO program on the east coast. I can see how you would have misgivings about the med students considering what you wrote about the conversation with the school rep. Hopefully their education is a quality one even if the admistration is apparently insufficient.

What association does Touro have with European programs? I know that there are at least three Touro campuses...is that what you are referring to or about the growth of osteopathic medicine in general?

I want to make sure that I get the best education I can and be the best physician I can for the people I will help care for.

[Theresa]

Touro has a campus in Israel that does not offer advanced degrees. I shouldn't have written Europe and will correct the post. Given Touro's growth over the last decade, they might be planning to expand their Israeli program into medicine, but I don't have any inside info.

I think med students get the education they go after, but what they can attain depends a lot on what is put in front of them. My concern in this post is the louche attitude the school has towards their students' core (foundation) experiences, which should be rigorous and properly supported.

[Betty]

The osteopathic schools are famous for flooding the clinical preceptor market. Not only do they not have affiliated hospitals, many of them place their students all over the country so they cannot possibly keep track of them with their limited faculty. Same with most of the Caribbean schools. And they pay for clinical slots. There are a couple of good ones that I have been personally affiliated with, but the "expansion teams" are problematic. And, now, the new one in Colorado is actually "for profit", the first "for profit" medical school in the country.

Knowing (but not naming) the hospital where you practice, I can't imagine 5 students doing their core internal medicine rotation there. An elective in rural medicine, yes.....but not a core 12 week rotation.

[Dragonfly]

That is why a certain % of each class here has to go to a rural hospital (and gets well subsidised for it). It can be an awesome learning opportunity, but I feel sorry for those students who are about to come. It does sound like they will be guinea pigs as the program wasn't worked out in time.