Rural Physician Associate Program Research Articles

Impact of the Rural Physician Associate Program on Workforce Outcomes.

The Rural Physician Associate Program (RPAP) at the University of Minnesota Medical School (UMMS) is a 9-month rural longitudinal integrated clerkship (LIC) for third-year medical students built on a foundation of family medicine. The purpose of this study was to examine the relationships between participation in the RPAP program and the desired workforce outcomes of practice in Minnesota, primary care specialty (particularly family medicine), and rural practice. We analyzed workforce outcomes for UMMS graduates who completed postgraduate training between 1975 and 2017, comparing RPAP participants (n=1,217) to noparticipants (n=7,928). We identified graduates through internal UMMS databases linked to the American Medical Association (AMA) Physician Masterfile and the National Provider Identifier (NPI) registry. We identified workforce outcomes of rural practice, practice in Minnesota, primary care specialty, and family medicine specialty based on practice specialty and practice location data available through the AMA and NPI data sets. Proportionally, more RPAP graduates practice in state (65.7% vs 54.4%, P<.01), in primary care (69.0% vs 33.4%, P<.01), in family medicine (61.1% vs 17.3%, P<.01), and rurally (41.2% vs 13.9%, P<.01) than non-RPAP graduates. We demonstrate a significant association between participation in RPAP and a career in family medicine, rural practice, and primary care, all outcomes that promote meeting urgent rural workforce needs.

Perceived Influence of Medical Students' Community Health Assessment Projects.

To achieve overall health, physicians must understand how community and population health impacts individual health. Although several US medical schools have incorporated community health assessment project requirements into traditional curricula, examples in longitudinal integrated clerkships are unknown. This study was designed to assess alumni perceptions of the influence of community health assessment projects, a core component of the University of Minnesota Rural and Metropolitan Physician Associate Program's (RPAP/MetroPAP) 9-month longitudinal integrated curriculum. This 2018 study consisted of a descriptive cross-sectional survey of 480 RPAP/MetroPAP alumni who completed 457 community health assessment projects between 2004/2005 and 2016/2017. The authors administered a 14-item survey requesting date and location of RPAP/MetroPAP 9-month placement, name of project, source of project idea, and perception of project influence on professional activities. Quantitative data were collected using 4-point Likert scales. We collected qualitative data with open text boxes. The survey response rate was 42.29% (203/480). A key finding was alumni perceived project ideas arising from community partners had greater impact on their acquisition of several community engagement skills. One-half reported projects influenced their professional activities, evidenced by ongoing community engagement, interest and participation in public health and preventive health initiatives, efforts to learn about specific health issues, social determinants of health and patient advocacy. This exploratory study suggests medical student community health assessment projects enhance community engagement and soliciting project ideas from community partners increases student acquisition of community engagement skills.

University of Minnesota Medical School.

University of Minnesota Medical School.

The personalities of most medical students are suited to rural practice: Implications for rural education program recruitment

Introduction: The success of rural longitudinal integrated clerkship (LIC) programs has contributed to our understanding of selecting and training students for rural practice. Studies have explored the personality traits of students who participate in rural LICs although few have compared them with classmates who have not. The purpose is to compare personalities of four successive cohorts of students in the LIC Rural Physician Associate Program (RPAP) with their non-RPAP classmates.Methods: In a longitudinal cross-sectional design, medical students RPAP and non-RPAP, from 2013 to 2017 completed identical questionnaires comprising measures of personality, perfectionism, ambiguity tolerance, and resilience. T-tests, ANOVA, and post-hoc tests compared groups. K-means cluster analysis identified profiles of traits.Results: Total sample 286; RPAP = 128; non-RPAP = 158. Gender and age proportions were not different between groups. RPAP students were significantly lower in levels of perfectionism and higher in cooperativeness compared to non-RPAP classmates. Similar proportions of both groups were distributed across three personality profiles detected.Conclusions: Lower perfectionism implies advantages for rural practice. Nevertheless, similarities between groups suggest that most students would be successful in rural practice. More encouragement to all students may improve uptake of rural LICs. Greater attention to issues that affect decisions to explore rural medical education, particularly for our next generation of students, is required.

Surgical Skills Acquisition: Performance of Students Trained in a Rural Longitudinal Integrated Clerkship and Those From a Traditional Block Clerkship on a Standardized Examination Using Simulated Patients

ObjectivesRural longitudinal integrated clerkship (LIC) programs for third-year medical students provide strong educational curricula and can nurture interest in rural surgical practice. Students learn technical skills in an apprenticeship model. Variability in instruction and patient experiences across sites, coupled with a lack of simulation facilities, raise some concerns about technical skill development. To explore the adequacy of skills acquisition for students in the University of Minnesota Rural Physician Associate Program (RPAP), this study compared RPAP students’ performance on a scenario-based Objective Structured Assessment of Technical Skills (OSATS) with that of traditional surgery block clerkship students (Course 7500). Design, Setting, and ParticipantsThis is a nonexperimental post-only study. All enrolled students (n = 254) completed the OSATS examination. Students in the Course 7500 (n = 222) completed 15 hours of simulation skills training and supervised practice during their 6-week clerkship. RPAP students (n = 32) completed 3 hours of skills training before their 9-month rural assignment. Both groups had access to comprehensive online materials. Mean OSATS checklist, global rating, and total scores were compared at the end of training using t tests (p < 0.05). Self-reported OR and clinical experiences were explored. ResultsBoth groups did well on the OSATS. There were no statistical differences in completion time, checklist scores, mean global ratings, or total scores. RPAP students reported significantly more days in the OR, surgery cases, and first assists. Experience with OSATS tasks reported by RPAP students during clinical rotations correlated with their OSATS performance. ConclusionThis study supports the viability of the LIC model for fundamental skills acquisition when augmented with introductory simulation skills training and online resources. It also suggests that simulation fills a training gap for students in a traditional surgery block clerkship program. It opens a dialog about the potential partnership of surgery departments with rural LICs to address rural general surgery shortages. Further research in this aspect is needed.

Longitudinal integrated clerkships: transforming medical education worldwide?

In the 60 years following the Flexner Report of 1910, little changed in undergraduate clinical education until the model of a longitudinal integrated clerkship (LIC) evolved as an alternative to specialty-based block rotations. The first LIC, the Rural Physician Associate Program (RPAP) was introduced by the University of Minnesota in 1971 as a rural workforce initiative. Despite the success of the RPAP, it took 20 years for other institutions to develop the next generation of LICs in the 1990s. These initiatives have been shown to be successful in terms of recruitment into primary care and rural practice. The reliance of LICs on educational continuity appears to provide many advantages. Research over the last decade has shown the potential educational advantages of LICs undertaken in both rural and urban clinical settings. Compared with students who undertake teaching hospital clerkship blocks, students who complete some LICs have improved academic results, enhanced patient-centredness, greater exposure to common conditions and more meaningful learning relationships with patients and academic mentors. In this edition of Medical Education, two papers report other potential benefits for student feedback and for general practitioners as educators.

ミネソタ大学 Rural Physician Associate Program から学ぶ地域医療臨床実習

ミネソタ大学 Rural Physician Associate Program から学ぶ地域医療臨床実習

Efforts to Graduate More Primary Care Physicians and Physicians Who Will Practice in Rural Areas: Examining Outcomes From the University of Minnesota–Duluth and the Rural Physician Associate Program

To compare practice choices (primary care or specialty) and practice locations (rural or metropolitan) of medical students at the Duluth and Twin Cities (Minneapolis and St. Paul; TC) campuses of the University of Minnesota (UMN). In the early 1970s, Minnesota created two medical education programs at UMN to increase the number of rural and primary care physicians: the first two years of medical school at UMN-Duluth, where the program focuses on recruiting students who will be rural family physicians, and the Rural Physician Associate Program (RPAP) elective, a nine-month, longitudinal immersion experience with a preceptor in a rural community. In 2008, the authors analyzed outcomes for four student groups: (1) UMN-Duluth and (2) UMN-TC medical students who participated in RPAP and (3) UMN-Duluth and (4) UMN-TC students who did not participate in RPAP. UMN medical students complete their first two years on either campus; they can apply to RPAP for their third year. Non-RPAP students spend most of their third- and fourth-year rotations in the Twin Cities metropolitan area. The UMN-Duluth and RPAP students were most likely to select a rural location and primary care practice. UMN-TC, non-RPAP students followed national trends, choosing predominantly metropolitan and specialty practices. RPAP and UMN-Duluth provide significant, complementary educational programs that lead more graduates to choose rural and primary care practices. Efforts across the nation to address the crisis in rural primary care should build on these successful efforts.

Longitudinal Integrated Clerkships

In Reply: We certainly agree with Dwyer Brooks and her colleagues about the importance of longitudinal clerkships and applaud the long history of longitudinal clinical education of the Minnesota Rural Physician Associate Program (RPAP). There are several questions, however, that are interesting to consider. First, why do the RPAP students not talk about feeling challenged by issues of professional boundaries, while the students in our longitudinal clerkship definitely do? Do they not have the challenges because of differences in patient selection or because of different faculty expectations of students' involvement? Our students' patients are selected from among the most ill and complex in their preceptors' panels, and preceptors expect students to develop strong therapeutic alliances with their patients over time. Second, and perhaps even more interesting, is the question: Is it better for students to feel challenged or not? If these challenges represent the development of a sense of responsibility toward the patient, is it better for them to be postponed until residency or to remain under the surface during student clinical rotations? We believe it is critical, as the literature suggests, to “unmask” the hidden curriculum and make it explicit. To address this need, over the past six years, we have developed orientation and reflective exercises specifically designed to prepare our students for boundary and role challenges,1 and we have measured students' perceptions by surveys. Over this time, our students report decreased perceptions of “having more responsibility than they can comfortably handle,” without leaving them, as many traditional students report, “having less responsibility than they feel they can handle.” We believe these boundary challenges, along with other challenges to their understanding of their emerging roles as physicians, provide students much-needed opportunities for professional and moral development and are best addressed under the supervision of experienced preceptors. Clearly, more research needs to be done to find what is the best educational mix of students' genuine responsibility for patients with supervisors' guidance. Barbara Ogur, MD Cofounder and codirector, Harvard Medical School–Cambridge Integrated Clerkship, and associate professor of medicine, Harvard Medical School, Boston, Massachusetts; [email protected]. David Hirsh, MD Cofounder and codirector, Harvard Medical School–Cambridge Integrated Clerkship, and instructor in medicine, Harvard Medical School, Boston, Massachusetts.

Learning professionalism during the third year of medical school in a 9-month-clinical rotation in rural Minnesota

Background: Professionalism is now an explicit part of the medical school curricula.Aim: To examine the components that are part of developing professionalism during the Rural Physician Associate Program (RPAP) experience, a 9-month rotation in a rural community during the third year of medical school.Methods: Two researchers analysed 3 years of essays for themes. IRB approval was obtained.Results: Themes were organized using Van de Camp's model of professionalism. Students described how patients taught them about illnesses, the affects on their lives and the lives of their families. Preceptors role-modelled how to relate to patients with compassion and respect (Professionalism Towards the Patient). As a member of the health care team, clinic and hospital staff taught students how to be a good team member (Towards Other Health Care Professionals). Shadowing preceptors in their roles as physicians and community members, students learned about their responsibilities to the community (Towards the Public). Multiple opportunities for self-evaluation and reflection taught students to know themselves and find balance between work responsibilities and their personal lives (Towards Oneself).Conclusion: The RPAP appears to create a supportive learning environment that incorporates psychological safety, appreciation of differences, openness to new ideas and time for reflection – an ideal environment for developing professionalism.

Recruitment and Retention of Rural Physicians: Outcomes From the Rural Physician Associate Program of Minnesota

Founded in 1971 with state funding to increase the number of primary care physicians in rural Minnesota, the Rural Physician Associate Program (RPAP) has graduated 1,175 students. Third-year medical students are assigned to primary care physicians in rural communities for 9 months where they experience the realities of rural practice with hands-on participation, mentoring, and one-to-one teaching. Students complete an online curriculum, participate in online discussion with fellow students, and meet face-to-face with RPAP faculty 6 times during the 9-month rotation. Projects designed to bring value to the community, including an evidence-based practice and community health assessment, are completed. To examine RPAP outcomes in recruiting and retaining rural primary care physicians. The RPAP database, including moves and current practice settings, was examined using descriptive statistics. On average, 82% of RPAP graduates have chosen primary care, and 68% family medicine. Of those currently in practice, 44% have practiced in a rural setting all of the time, 42% in a metropolitan setting and 14% have chosen both, with more than 50% of their time in rural practice. Rural origin has only a small association with choosing rural practice. RPAP data suggest that the 9-month longitudinal experience in a rural community increases the number of students choosing primary care practice, especially family medicine, in a rural setting.

The Rural Physician Associate Program: The Value of Immersion Learning for Third‐Year Medical Students

Changes in health care and new theories of learning have prompted significant changes in medical education. Some US medical schools employ immersion learning in rural communities to increase the number of physicians who choose to practice in these areas. Founded in 1971, the rural physician associate program (RPAP) is a longitudinal immersion learning experience for students during their third year of medical school. Students are assigned to a primary care preceptor(s) in a rural community ranging in population from 1,000 to 30,000 for 36 weeks. To describe students' perceived value of this immersion learning experience. Data from 3 classes (2004, 2005, 2006) of students (n = 95) were analyzed, including final essays that reflect on their experiences and logs of their patient encounters and procedures. Themes from students' essays related to the hands-on learning experience are presented. Frequencies of ambulatory encounters and procedures were calculated and compared with those of metropolitan area colleagues where possible. The continuity experience allows for one-to-one mentoring and long-term relationships. Students see physicians, clinic/hospital staff, and patients as their teachers. The environment is nurturing, but nudges them outside their comfort zone. Students gain increasing competence with their skills and do best if they are independent and seek out learning opportunities. They report more hands-on experience, more confidence and autonomy than their peers in the metropolitan area. The RPAP experience provides a nurturing, longitudinal, immersion learning experience that facilitates the gradual but steady development of clinical skills alongside a personal and professional mentor.

Clinical skills day: preparing third year medical students for their rural rotation

In order to prepare third year medical students in the Rural Physician Associate Program for a nine-month community-based continuity care experience in rural Minnesota, USA, a clinical skills day that featured human patient simulators and standardized patients was developed. Patients presenting with common urgent and routine primary-care problems were developed and presented using the objective structured clinical examination for teaching. The goals of the day were to: (1) distinguish urgent from non-urgent clinical presentation; (2) use clinical guidelines for making decisions; (3) communicate effectively in stressful situations; and (4) uncover a significant clinical issue with a different presenting complaint. Case scenarios were written for a variety of diagnoses in patients with differing ages. Scenarios were both urgent and non-urgent and typical of what might be encountered in primary care. They included: chest pain with bradycardia and pulseless electrical activity; major trauma from an all-terrain vehicle; labor and delivery; acute abdomen (acute appendicitis in a 20 year old and diverticulitis in a 70 year old); anaphylaxis after an influenza vaccination; pediatric upper respiratory infection in which the mother demanded antibiotics; knee injury in a middle-aged man after a weekend of football; heartburn with an underlying significant depression; and X-ray review. The experience occurred in the Interprofessional Education and Resource Center (IERC), where each room was a fully equipped ambulatory examination room with a computer for accessing data and a video camera for central monitoring. Faculty were recruited from the College of Medicine and received an on-line presentation orienting them to the IERC, the teaching model and the scenario assigned to them with supporting evidence-based guidelines. Students reviewed an on-line audio-visual presentation orienting them to the IERC and outlining the learning expectations for the day. Otherwise, students were not expected to prepare for the day because this was an immersion learning experience. Faculty were present in each room as observers, facilitators and educators. Their roles were active or passive, depending on the case scenario and the presence of a simulator or standardized patient. Each station, except the radiology station, involved a debriefing at the end for final questions, and distribution of educational resources or summary teaching points. Standardized patients also gave the students feedback. Students were randomly assigned to small groups of three to four students and rotated through the stations as a unit. To date two classes of students (n = 77) have participated. Evaluations were completed by both students and faculty and included both qualitative and quantitative data immediately after the event and 9 months later (n = 59). Evaluations were overwhelmingly positive with means well above four on a five-point Likert scale. Feedback from both immediate and delayed evaluations were and continue to be used to improve the session for the following year. Both students and faculty were enthusiastic about this 'hands on' team learning format, which provided students with opportunities to begin to understand the complex skills that they will need before they learn them step-by-step.

Comparing Rural-Trained Medical Students With Their Peers: Performance in a Primary Care OSCE

Background: Although it is well-established and considered successful, there is limited data on how the graduates of a Minnesota rural medical education program (Rural Physician Associate Program [RPAP]) compare with their peers.Purpose: To compare the performance of RPAP students with their peers on a primary care observed structured clinical examination (OSCE).Methods: The performances of RPAP students and a group of non-RPAP Year 4 medical students were compared on the same OSCE.Results: RPAP students performed at least as well as their peers on stations assessing performance on common primary care clinical scenarios but not as well on a small number of stations that assessed applied knowledge of specific content taught in the traditional clerkship curriculum.Conclusions: We provide evidence that rurally trained students at this institution performed at least as well as their peers on OSCE stations testing performance in common primary care scenarios. The broader implications of this study are that medical students may receive high-quality training in rural communities, as documented by their performance on an objective structured clinical examination.

The rural physician associate program: new directions in eduction for competency

The Rural Physician Associate Program (RPAP) has 34 years experience in training 1097 medical students as independent distance learners in a 36 week, community-based continuity primary care experience. This program has been successful in preparing competitive students who select primary care residencies and return to rural practice. The RPAP program has been based on traditional apprentice-style clinical teaching with the support of computer-based resources to enhance distance learning. However while the clinical exposure and development of medical skills was strong, there were weaknesses in evidence-based medicine and managing healthcare, and inconsistencies in community or population health learning. New directions in the educational program for RPAP are described that have been or are being developed to address the competencies as outlined by the Accreditation Council on Graduate Medical Education. They include online and other resources, preceptor education and support, interactive journaling and cases, electronic portfolios, community projects, observed structured clinical exams and examinations. Ongoing challenges to competency-based education include developing meaningful measures and tools to assess competence for areas such as professionalism or systems-based practice; providing faculty development toward being able to practice, teach and evaluate students with an understanding of the competencies; and to build in ways of practicing, learning and improving care that involve effective teams of health-care professionals.

The rural physician associate program: New directions in education for competency

The Rural Physician Associate Program (RPAP) has 34 years experience in training 1097 medical students as independent distance learners in a 36-week, community-based continuity primary care experience. This program has been successful in preparing competitive students who select primary care residencies and return to rural practice. The RPAP program has been based on traditional apprentice-style clinical teaching with the support of computer-based resources to enhance distance learning. However while the clinical exposure and development of medical skills was strong, there were weaknesses in evidence-based medicine and managing healthcare, and inconsistencies in community or population health learning. New directions in the educational program for RPAP are described that have been or are being developed to address the competencies as outlined by the Accreditation Council on Graduate Medical Education. They include online and other resources, preceptor education and support, interactive journaling and cases, electronic portfolios, community projects, observed structured clinical exams and examinations. Ongoing challenges to competency-based education include developing meaningful measures and tools to assess competence for areas such as professionalism or systems-based practice; providing faculty development toward being able to practice, teach and evaluate students with an understanding of the competencies; and to build in ways of practicing, learning and improving care that involve effective teams of health-care professionals.

The Rural Physician Associate Program: successful outcomes in primary care and rural practice&#x0D;

The Rural Physician Associate Program (RPAP) has trained 1063 medical students in rural communities for the past 34 years and produced 658 primary care physicians and 521 physicians who currently practice in rural communities. While the students' experience in this nine-month clerkship is primarily clinic-based, they see patients in the emergency room, assist in surgery, deliver babies, attend physician meetings and participate in community health education. They experience real continuity of care by following a patient from the clinic or emergency room to the operating room and throughout their recovery. They diagnose a pregnancy, deliver the baby and then do the well-child examination in the clinic. The students recognize the value of this experience, as expressed in their final essays. They value the mentoring of the physicians, the relationship with the patients and the experiences in health care in which they play integral part. While the trend toward primary care in medical education is decreasing, the outcome of the RPAP program is holding steady at approximately 80%. Selection is certainly a factor, because many of the students who apply for RPAP have already expressed an interest in primary care. Additionally, the mentoring relationship with their preceptor, professionally and personally, and the ability to observe the lives of other practising physicians provides a reality check that may guide decisions. The enthusiasm for teaching, and the significant engagement with and impact on the community of the physicians may be another factor in deciding on primary care. Practising alongside physicians who find intellectual challenge and rewarding relationships in primary care is essential in continuing to produce primary care physicians of future.

The Rural Physician Associate Program: New Directions in Education for Competency

The Rural Physician Associate Program: New Directions in Education for Competency

University of Minnesota Medical School - Minneapolis.

University of Minnesota Medical School - Minneapolis.

Improving the Supply of Physicians in Rural Areas

Pathman et al¹are to be congratulated on their research of the comparative rural retention of National Health Service Corps (NHSC) physicians compared to non-NHSC physicians. There is a curious absence of significant documentation by the NHSC concerning retention of NHSC physicians compared to other rural physician programs and their success in retaining rural physicians.^2-4 See also pp 1552 and 1559. While I was director of the Rural Physician Associate Program (RPAP) for 20 years in Minnesota, I studied and experienced the reasons why medical students and physicians remain in or leave a rural community. The RPAP is a clinical clerkship during which third- and fourth-year medical students spend 9 to 12 months with a seasoned preceptor in a rural community.³They return to the medical school for their senior year with a host of attitudes, behaviors, and skills unobtainable by their non-RPAP classmates in the urban