Innovative generalist programs: academic health care centers respond to the shortage of generalist physicians

International approaches to rural generalist medicine: a scoping review

BACKGROUND

Contemporary approaches to rural generalist medicine training and models of care are developing internationally as part of an integrated response to common challenges faced by rural and remote health services and policymakers (addressing health inequities, workforce shortages, service sustainability concerns). The aim of this study was to review the literature relevant to rural generalist medicine.

METHODS

A scoping review was undertaken to answer the broad question 'What is documented on rural generalist medicine?' Literature from January 1988 to April 2017 was searched and, after final eligibility filtering (according to established inclusion and exclusion criteria), 102 articles in English language were included for final analysis.

RESULTS

Included papers were analysed and categorised by geographic region, study design and subject themes. The majority of articles (80%) came from Australia/New Zealand and North America, reflecting the relative maturity of programmes supporting rural generalist medicine in those countries. The most common publication type was descriptive opinion pieces (37%), highlighting both a need and an opportunity to undertake and publish more systematic research in this area. Important themes emerging from the review were: Definition Existing pathways and programmes Scope of practice and service models Enablers and barriers to recruitment and retention Reform recommendations There were some variations to, or criticisms of, the definition of rural generalist medicine as applied to this review, although this was only true of a small number of included articles. Across remaining themes, there were many similarities and consistent approaches to rural generalist medicine between countries, with some variations reflecting environmental context and programme maturity. This review identified recent literature from countries with emerging interest in rural generalist medicine in response to problematic rural health service delivery.

CONCLUSIONS

Supported, coordinated rural generalist medicine programmes are being established or developed in a number of countries as part of an integrated response to rural health and workforce concerns. Findings of this review highlight an opportunity to better share the development and evaluation of best practice models in rural generalist medicine.

The residency program in social medicine of Montefiore Medical Center: 37 years of mission-driven, interdisciplinary training in primary care, population health, and social medicine

Founded in 1970 to train physicians to practice in community health centers and underserved areas, the Residency Program in Social Medicine (RPSM) of Montefiore Medical Center, Bronx, New York, has graduated 562 board-eligible family physicians, general internists, and pediatricians whose careers fulfill this mission. The RPSM was a model for federal funding for primary care residency programs and has received Title VII grants during most of its history. The RPSM has tailored its mission and structured its curriculum to promote a community and population orientation and to provide the requisite knowledge and skills for integrating social medicine into clinical practice. Six unique hallmarks of RPSM training are (1) mission-oriented resident recruitment/selection and self-management, (2) interdisciplinary collaborative training among primary care professionals, (3) community-health-center-based and community-oriented primary care education, (4) biopsychosocial and ecological family systems curriculum, (5) the social medicine core curriculum and projects, and (6) grant support through Title VII. These hallmark curricular, training, and funding elements, in which population health is deeply embedded, have been carefully evaluated, regularly revised, and empirically validated since the program's inception. Practice outcomes for RPSM graduates as leaders in and advocates for population health and the care of underserved communities are described and discussed in this case study.

Rural Medical School Applicants: Do Their Academic Credentials and Admission Decisions Differ From Those of Nonrural Applicants?

CONTEXT AND PURPOSE

Medical schools located in states with sizable rural areas are concerned about preparing physicians for practice in these areas; this is of particular concern for medical schools that are part of a state-owned university with a responsibility to educate physicians for rural areas. Because individuals from rural areas are most likely to return to practice medicine in rural areas at the conclusion of their training, it is important to recruit these individuals to medical schools to educate them for rural practice.

METHODS

This study examines 7 years of admission data for students who applied and were accepted to the University of Missouri-Columbia School of Medicine, which has as a specific mandate to prepare physicians for rural practice.

FINDINGS

The study indicates that rural applicants are more likely to be admitted to the medical school, and based on admissions criteria they are at least as academically qualified as nonrural applicants.

CONCLUSIONS

The study demonstrates that a medical school can maintain competitive admission criteria while at the same time accepting those students more likely to enter rural practice. This is valuable information that medical schools with a similar mission to prepare physicians for rural practice might consider in their admissions decision-making process.

Structuring student learning in the primary care setting: where is the evidence?

Over the past two decades, the majority of medical schools in the USA have embarked upon curricular initiatives to enhance the teaching of ambulatory or office-based primary care. Identifying characteristics of these primary care experiences that make for the most effective learning is a top priority in medical education research. In this paper we examine what is known about the influence of variability in the structure of primary care experiences on student learning outcomes. We examine the questions of how rotations are scheduled, who does the teaching and where the teaching takes place. Given the variability in curricula across the 125 accredited medical schools in the USA and the absence of agreed-upon objectives, outcomes or assessment measures for primary care education, it is not surprising that the current literature has fallen short in providing definitive answers. There is much debate about the benefits of community vs. campus sites, longitudinal vs. block experiences, and the influence of specialty training of the preceptor, but little in the current literature to guide and substantiate a programme's choice. What can be concluded with relative confidence is that clinics currently offer more active student experiences than do private offices, that students may be more satisfied with rural experiences than with urban or suburban experiences, and that longitudinal and block experiences have different learning advantages. Research in primary care medical education will benefit from the current movement towards a cross-institutional consensus on educational objectives and outcome measures and on the general application of a more rigorous research methodology.

Interdisciplinary student health teams: combining medical education and service in a rural community-based experience

Several initiatives have been introduced over the years to address the maldistribution of health care professionals and to improve access to care for underserved rural populations. One of these is the sponsorship of community-based, service-oriented teams comprised of students from various health disciplines. This study investigated extramural training as a complement to traditional hospital-based experiences. The specific objective of the study was to determine the extent to which the nation's medical schools combine training with a rural community-based experience in the form of an interdisciplinary student health team program. In the fall of 1994, a 32-item questionnaire was mailed to the chief academic or clinical affairs administrators of the nation's 126 allopathic medical schools. A total of 104 (82.5%) medical schools responded to the survey. Eighty-six of the respondents (82.7%) reported some type of rural training or public service activity; 22 (21.2%) acknowledged the sponsorship of an interdisciplinary student health team program. Small rural communities, those with populations of 5,000 or fewer, were the focus of 76 percent of the reporting programs. Nearly two-thirds of the reporting programs were located in the South, the region with the nation's lowest physician-to-population ratio. The nursing and medical professions were most frequently represented, although a wide range of disciplines were identified as participating on the student health teams. Activities of the teams included both ambulatory care and community outreach services. The majority of the programs used team-building exercises to enhance team effectiveness. Extramural training programs offer students a realistic examination of the social, cultural, economic, and political forces that influence both individual and community health. Rural community-based programs, such as interdisciplinary student health teams, should be valued because they can strengthen the link between the sponsoring institution's educational mission and its public service obligation.

[Basic medical competence: a neglected educational goal in medical education?]

This paper analyses some recent proposals of how to change undergraduate medical education in Germany and in other countries. This leads to the formulation of a set of fundamental clinical competencies, which are defined as skills that enable physicians to react to challenges pertaining to their work in a professional way. These fundamental clinical competencies comprise knowledge, skills and attitudes. With regard to the actual performance of the German system of undergraduate medical education, deficits are depicted in the following areas: psychosocial and communicative competencies including advice and provision of information to patients, primary care, public health, ethics and clinical epidemiology/evidence-based medicine. For each of these areas, a proposal for change is provided.