Becoming a Rural Doctor, Part 3: Medical School

In the last two posts in this series on education and training for potential rural doctors, I have emphasized generalist education and presented a basic socioeconomic portrait of rural versus urban practice. Today's post will take a look at applying to, financing and attending medical school for the potential rural doctor.

1. Selecting a Medical School

I shouldn't be too cute here--the important thing to becoming a rural doctor is to go to medical school, period. Both allopathic and osteopathic medical schools will provide a solid grounding in basic sciences, although there may be some critical differences in the quality of training during the 3rd and 4th years between allopathic and osteopathic schools, depending on the strength of the network of affiliated hospitals.

Applying to medical school is a competitive process, and most of us do not have more than a few choices of schools to attend by the time the acceptances have been announced. A few things for the prospective rural doctor to keep in mind:

• There are a number of medical schools with a rural training pathways. These are programs within the medical school that are designed to give students who opt in to the program more exposure to rural medicine during their clinical years. Formal rural programs exist at the University of Minnesota, Michigan State University, the Jefferson Medical College, and the State University of New York Upstate campus.
• Even if there is no formal rural training track, medical school applicants may investigate the opportunity for rural rotations. This is one of those great questions to ask on interview day, when you will be asked repeatedly if you have any questions and don't want to be caught without any.
• Look for a medical school that has a Department of Family and Community Medicine. Do not assume that every school has a FCM department; some of the elite schools (Stanford, Harvard) do not. The presence of an FCM will help you set up rural clinical experiences if there is no formal training track.

In the end, I do not believe that attending a medical school with a rural training track is necessary for preparing for rural practice. The choice of a rural residency is probably more important, and will be the subject of another post. When it comes to medical school, I think there are some benefits to attending a large metropolitan school if you want to. It will give you the chance to experience an urban setting, and you will probably get to rotate through some of the major tertiary care centers in the area, which provides a rigorous foundation to your clinical experience.

2. Financing Medical School

In a previous post I discussed the true cost of medical school. I am not going to cover the same ground here, although I encourage prospective medical students to consider the opportunity cost of medical school before they commit to medical training. Once you have made the commitment, I recommend beginning the financial aid process as soon as you have accepted admittance to a school. The financial aid landscape is always changing, so I won't get too specific here. However, there are a number of scholarship opportunities for potential rural doctors who are fairly certain they plan to practice rural medicine:

• Primary Care Loans: These are low-interest loans given to applicants who are committed to practicing primary care in any demographic setting, and so are not limited to doctors in rural practice. They require the applicant to work in a primary care setting (i.e. not hospitalist) until the loans are repaid in full. Early termination of primary care service carries a heavy penalty in the form of an 18% interest rate.
• National Health Service Corps Scholarship Program: This is the same organization that funds a loan-repayment program for primary-care physicians. The scholarship program is more generous, providing "full tuition and fees, twelve monthly stipend payments, and other reasonable educational expenses" during medical school. The repayment period begins after completing residency and requires one year of service in a Health Professionals Shortage Area (HPSA) for every year of scholarship support, with a minimum service period of two years. The advantage of the scholarship program over the loan repayment program is immediate payment of tuition and fees, so the applicant does not accrue compounded interest on their loans during residency. The total amount awarded tends to be greater, because the one-to-one scholarship repayment period applies even if the program paid for higher private medical school tuition. Again, failure to enter an eligible HPSA position after residency carries heavy repayment penalties.
• State-specific scholarship programs: If you plan to work in the same state as your medical school, there may be smaller scholarship programs available to you in exchange for a period of service to the state after you complete residency. Consult your financial aid office for details on these types of programs.

I usually recommend loan repayment rather than scholarship programs for most applicants. The language of the scholarship program is fairly restrictive and you will be in a major bind if you decide against practicing in an HPSA area. However, if you choose to attend a high-tuition private medical school, an NHSC scholarship provides immediate funding and the best year-for-year repayment ratio.

3. Approach to Medical School

Once you're in medical school and have figured out a feasible way to finance it, it's time to get down to academics.

I don't have much to say about the basic science years. My school was pass/fail and I studied as much as I could stand to, and no more. I was a competent medical student, but not stellar; I think it is fair to say that I failed to live up to my potential, but I have no regrets. I had other personal goals to meet during the first two years of school, such as participating in a weekly writing workshop and volunteering at a residential hospice. I encourage all medical students to set some non-academic goals for their medical school years. I knew students who ran marathons, raised families, volunteered for their churches. Non-academic personal goals are important in medical school; they help keep you human.

When it came to clinical rotations, I was much more serious. I knew I was interested in Family Practice and I tested my commitment to the speciality in every rotation I did. My core rotations--Psychiatry, OB/GYN, Medicine, Surgery, Family Practice, Pediatrics, Neurology--occasionally tempted me in another direction. This is a good thing. I believe that being engaged in more than one specialty is a sign of an open mind. More than anything, I would recommend maintaining such a generalist's mind during your education. I knew a lot of people who were determined to go into OB/GYN, for example, and were crushed when they had a horrible experience during that rotation. I, on the other hand, never though OB/GYN would attract me, and I very nearly considered matching in it, but--kept the mind open and still went into family practice.

Students have no choice in the above core rotations. They are considered the foundation of clinical medicine and constitute the majority of the third year of med school. The real fun comes during the fourth year, when you can choose electives.

As I have discussed previously, I actually took an extra year of medical school in order to write a novel (currently sitting in a drawer somewhere, like a lot of first novels) and to explore my commitment to rural family practice by taking extra electives. Spread over two years, with chunks of non-rotation time for writing, I took:

• Inpatient Family Medicine (equivalent to an Internal Medicine Subinternship)
• Advanced Obstetrics
• Advanced Outpatient Pediatrics
• Two rotations in Rural Family Medicine
• Elective in STD Clinic
• Research elective

Now, this is a lot of electives and I probably would not have been able to squeeze them all into one year, although I suppose I could have if the scheduling gods had been on my side and I had limitless energy. The first three electives were considered subinternships and the hours were grueling. Thereafter, the electives were much more forgiving and helped me improve my skills while maintaining sanity.

For medical students interested in rural medicine, who do not plan to pursue a prolonged medical school pathway, I would recommend the following electives:

• Inpatient Medicine or Family Medicine: this is the classic "sub-I" and will help prepare you for internship more than anything else.
• Elective in Rural Family Medicine: again, if your school has an FCM department, they will help get you a placement. It is good to experience a setting completely different from your medical school in order to test your commitment to living and practicing rurally.
• Advanced Obstetrics: if you are interested in Family Practice, it's a good idea to see if you really like OB, because the volume of OB during residency is a major decision-point for most people.
• Ambulatory Pediatrics: again, this is a major portion of Family Practice and is great experience for the potential rural family doctor. I was much better prepared for my intern clinic thanks to this rotation. Prospective rural pediatricians would benefit from this rotation, too, as well as electives in Inpatient Pediatrics and Neonatology.
• Emergency Medicine: I chose not to take EM, but a lot of people did and I understand it helped them learn to triage patients based on severity of illness and improved their physical skills such as suturing and casting (still my weak spots to this day). If you are interested in rural medicine, you might choose a rural ER rotation.

These are just a set of guidelines for planning your medical school curriculum. There are a number of other approaches, including one in which you do electives in everything but the specialty you are interested in (apart from one subinternship, which is expected prior to entering the Match). This approach is usually motivated by the chance to try out a whole lot of bits and pieces of medicine that you will probably never get to experience ever again, and it makes a lot of sense. My approach was motivated by a desire to be sure about becoming a rural family physician. The electives I chose exposed me to rural medical settings, confirmed my commitment to practicing obstetrics within family practice, and helped me build important skills that helped me out during my residency years. These skills included coping with high patient volumes and acuity, multitasking, and competency in medical Spanish. I think I was particularly well-prepared for my rural residency as a consequence.

In the next post in this series, I'll go into the choice of residency in more depth, and argue that a rural residency is important to developing confidence for rural practice.

Comments

[Angela]

Thank you for posting invaluable information for someone that is passionate about becoming a rural doctor. I'm 31 trying to finace going back to school. I'm currently awaiting my fincial aid approval, but am unsure if I will be receiving any since I do work full time in ophthalmology as a COT and make pretty good money. My question is, do you know of any scholorships for a single woman going back to collage full time, not medical school yet I still have 2 years to finish in undergrad, that will be going into rural medical care? Any information would be greatly appreciated. Thank you. My e-mail address is astebbins77@yahoo.com

[Angeli]

Really helpful post. I've been looking forward to this series since you mentioned it, and have really enjoyed your insight in the education towards becoming a rural physician. There's not much information like this around, so thanks!