A Health Equity Fellowship Based in Experiential Learning Through a Rural Academic-Community Partnership

Abstract

While rural communities continue to experience significant health disparities, investment in graduate medical education (GME) focused on rural health remains uneven.1 Investing in rural GME could allow early-career physicians to address health disparities by providing leadership training and mentored experience generating systems change. Leadership skills and systems change are especially important when physicians work in communities they are not from. There is a steep learning curve to understanding a community's priorities, governance structures, and building their trust. Despite best intentions, unprepared physicians may fail to make lasting beneficial change for the community, and communities risk losing physicians to burnout and turnover.The Massachusetts General Hospital Fellowship Program in Rural Health Leadership teaches skills in leadership and health systems change to early-career primary care physicians through a rural-based experiential learning model based on Kolb's Learning Styles Inventory.2 Fellows develop attitudes, knowledge, and skills in leadership and health equity by moving through 4 stages of learning: (1) experiencing and reflecting on the rural experience; (2) acquiring new knowledge and concepts; (3) practicing new ideas through discussion; and (4) taking action and learning from the result.Fellows spend a quarter per year of the 2-year program at the rural community partner site in Rosebud, South Dakota, working clinically as independent attending-level physicians. Rosebud is the home of the Sicangu Lakota Oyate and Indian Health Service Rosebud Service Unit and has long experienced some of the worst health outcomes in the country due to sustained historical, systemic, and infrastructure challenges. As the Rosebud community experiences many of the same challenges facing rural communities across the United States, fellows learn skills in leadership and health equity that can be translated in their future careers to other sites with challenged infrastructure.Faculty support is provided by a network of academic teaching physicians experienced in rural health through a combination of asynchronous/synchronous and remote/on-site forums, including weekly meetings where difficult clinical cases and systems improvement work is discussed, a de-identified encrypted group chat, monthly discussion exchanges with other global and rural fellowships, weekly fellow seminars, and shared reading lists. These teaching interactions provide fellows with new concepts to apply to their experiences, as well as opportunities to articulate their reflections and test their new ideas through discussion.A key aspect of the fellowship is the completion of a mentored capstone project in any aspect of systems change—research, policy, advocacy, quality improvement, or education are a few examples. Focused mentorship and a program-funded Master of Public Health are pillars of the capstone project support. These capstone projects allow fellows to apply their lessons learned to new practice and to observe the results.The key values of the program are imbued in the structure of experiential learning and are seen in the fellows' activities during the program and beyond (Table).In a 2021 GME survey of fellows, the clinical breadth and intense experiential learning in clinical and leadership roles was consistently named as a major strength of the program.Successful graduates from the program should be prepared to move directly into a leadership position in rural and community health. Since the first fellowship class graduated in 2017, the fellowship has produced 7 graduates. Since graduation, fellows have gone on to positions in medical education leadership, policy, and leading innovative clinical programs with rural and underserved populations.