Background and Objectives: Rural health disparities are growing, and medical schools and residency programs need new approaches to encourage learners to enter and stay in rural practice. Top correlates of rural practice are rural upbringing and rurally located training, yet preparation for rural practice plays a role. The authors sought to explore how selected programs develop learners’ competencies associated with rural placement and retention: rural life, community engagement, and community leadership. Methods: Qualitative, semistructured phone interviews (n=20) were conducted with faculty of medical schools or family medicine residencies across the United States, Canada, Australia, and South Africa in which success in training rural practitioners was identified in the literature or by leaders of the National Rural Health Association’s Rural Medical Educators Group. Participants included 18 physician program directors, one nonphysician program administrator, and one PhD researcher who had studied rural preparation. Interview transcripts were read twice using an inductive process: first to identify themes, and then to identify specific strategies and quotes to exemplify each theme. Results: Participants’ recommendations for rural preparation were: (1) Be intentional about strategies to prepare learners for rural practice; (2) Identify and cultivate rural interest; (3) Develop confidence and competence to meet rural community needs; (4) Teach skills in negotiating dual relationships, leading, and improving community health; and (5) Fully engage rural host communities throughout the training process. Conclusions: Medical schools and residencies may increase the likelihood of producing rural physicians by implementing these experts’ strategies. Educators may select strategies that mesh with the structure and location of their training program.
Introduction Few US studies have examined the usefulness of participatory surveillance during the coronavirus disease 2019 (COVID-19) pandemic for enhancing local health response efforts, particularly in rural settings. We report on the development and implementation of an internet-based COVID-19 participatory surveillance tool in rural Appalachia. Methods A regional collaboration among public health partners culminated in the design and implementation of the COVID-19 Self-Checker, a local online symptom tracker. The tool collected data on participant demographic characteristics and health history. County residents were then invited to take part in an automated daily electronic follow-up to monitor symptom progression, assess barriers to care and testing, and collect data on COVID-19 test results and symptom resolution. Results Nearly 6500 county residents visited and 1755 residents completed the COVID-19 Self-Checker from April 30 through June 9, 2020. Of the 579 residents who reported severe or mild COVID-19 symptoms, COVID-19 symptoms were primarily reported among women (n = 408, 70.5%), adults with preexisting health conditions (n = 246, 70.5%), adults aged 18-44 (n = 301, 52.0%), and users who reported not having a health care provider (n = 131, 22.6%). Initial findings showed underrepresentation of some racial/ethnic and non–English-speaking groups. Practical Implications This low-cost internet-based platform provided a flexible means to collect participatory surveillance data on local changes in COVID-19 symptoms and adapt to guidance. Data from this tool can be used to monitor the efficacy of public health response measures at the local level in rural Appalachia.
The training family medicine residents receive will have a lasting impact on how they deliver care in the future. Evidence demonstrates an imprinting effect based on the training environment itself. Thus, residency training represents a critical time for establishing clinical experiences that embody core primary care principles and ensure excellent care delivery. This paper focuses on the clinical experience in the family medicine practice setting. We have used Starfield’s four C’s of primary care and added two more: cost and community, as the tools to achieve the triple aim. In reviewing the current state of residency programs across the country, we noted that there was a lack of measurement on how programs were performing when it came to the six C’s. We will briefly describe some recent innovative collaboratives among residencies. Next, we examine the six C’s of primary care in context of current care. These six C’s inform our recommendations for residency training standards to create the family physicians of the future. The overarching theme of these recommendations is the need to measure and report on what we want to ultimately improve.
Traditional primary care is not designed to engage and support patients with complex social, behavioral health, and medical needs. Our Bridges to Health program offers drop-in group medical appointments (DIGMAs) that include a physician, a nurse care manager, a behavioral health counselor, peer support, a consulting occupational therapist, and a clinical pharmacist to provide a safe, accessible environment for such patients. Other services include care management; medication assistance; and transportation, nutrition, and social support.Over 6 years we have enrolled more than 500 patients, reduced their hospital utilization about 50%, and improved functional scores in over 2/3 of them. Once stabilized, most are able to transition to traditional primary care. WHO AND WHERE
are fictional family physicians who portray qualities that fit the current role definition 1 of the family physician while providing care in different practice settings. In the October 2018 article "Cultivating Country Doctors: Preparing Learners for Rural Life and Community Leadership," Thach, et al discuss five strategies that training programs can adopt to help them recruit, train, and retain family physicians in rural medicine. 2 These are all practical strategies that can be adapted to fit many types of training programs.I believe two of the strategies described should be implemented for the training of all family physicians regardless of the type of practice setting they intend to work in after graduation. All programs should work to "develop confidence and competence to meet … community needs" and "to teach skills in negotiating dual relationships, leading and improving community health" 2 to all their residents. As core faculty in an urban-based community family medicine residency it is clear to me that all residents benefit from these skills. It seems that as family medicine evolves, it is also falling victim to the lure of subspecialization. When family physicians work to their full scope of practice, they tend to experience lower rates of burnout 3 and I believe there is an equal benefit to well-being by being integrated into the community. 4 These two strategies can be accomplished through modeling how we practice the full scope of family medicine. We can share our joy and struggles with "cradle to grave" knowledge and procedural skills in the outpatient, inpatient, community and wilderness settings. We can illustrate how we deal with community patient encounters through sharing stories of the patients we see while running errands. We can teach residents to lead by including them in our institutional meetings and community projects.In addition to the five training strategies mentioned in this article, graduates entering any practice setting benefit from strong social support. A study of resilience strategies of physicians experiencing low levels of burnout revealed that they participated in leisure-time activity, desired and sought interaction with colleagues, and developed relationships with friends and family. 4 We should be helping every graduate create a plan to cultivate a strong social network both long-distance and within their new community. We can also schedule time for them to share their thoughts with us at least once a month, more if needed. Those of us who have experienced this type of mentoring can testify to its value. 5 We should absolutely focus attention on getting more graduates to fill the health care gap in rural America and provide them the mentoring to succeed. Even better, for all family medicine graduates: guide them to develop competence in practicing the full scope of family medicine, help them cultivate a heart for their own community, and show them how to lead.
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