Developing Rural Health Training Programs to Support Quality Care

November 15, 2019 - Clinician shortage in rural areas is one of the leading drivers to poor health outcomes in rural areas. Patients in remote areas sometimes travel hours to receive specialized care. Access to care is frequently cited as one of the biggest drivers of health disparities in rural areas.

Increasing the number of physicians practicing in rural areas is a simple solution to this problem, but rural health training programs are not attracting as many medical students and trainees as needed.

These future providers feel like they have little incentive to practice in these locations. Rural hospitals typically have fewer bells and whistles, and students are less likely to see unique and complex cases compared to their urban counterparts. In addition, practicing in an urban location often brings the excitement of attractions outside of the hospital.

It is not surprising, then, that many students and young professionals want to train and practice in urban locations. The conundrum is these areas are not the ones in desperate need of well-trained providers.

Medical schools and professional training programs need to adapt and build strategies into their curriculum that promote exploring practicing in rural areas. Integrating exposure to rural practice early in a student’s training can promote practice in these locations after graduation. Program developers for trainee and residency programs alike advocate for exposing students to rural practice early in their career development to eliminate misinformation and give them an understanding of what life in a rural area truly looks like.

Understanding rural practice

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Rural practice is different than urban practice, so many medical students typically trained in urban settings are hesitant to work in an unfamiliar setting.

In rural Oregon, Karen Deveney, MD, FACS, professor of surgery emerita at Oregon Health and Science University, helped create the Rural Health Surgical Training program. The partnership between Oregon Health and Science University and Asante Three Rivers Medical Center aims to demystify the practice of rural healthcare.

“If residents don’t have an opportunity to taste what practicing in a rural setting is like, they’re not going to ever do it,” Deveney explained. “A resource-limited rural area might not be enticing for people if they’d lose all those amenities and sub-specialists. They have to know more.”

To teach students about practicing in a rural area, Deveney and her team conducted a needs assessment of their hospital network to ensure rural hospitals could offer the number of surgeries and surgical variety required for training programs. The assessment revealed that many of the surgeons in rural areas were approaching retirement and no new surgeons were being trained to fill their shoes.

“We surveyed all the of rural general surgeons in Oregon,” Deveney said. “We looked at their training, their caseload, what they wished they learned in residency, and what advice they would give to residents who were potentially planning to practice in a more rural setting.” 

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The assessment also showed that many of the general surgeries performed in rural settings were gastrointestinal endoscopies related.

“We needed to provide this in our education in greater numbers if they are going to be successful by going into rural practice and having the skillset they need,” stated Deveney. “If we could find a fertile ground of people who liked to have the help of a resident and in return would teach them the basic things that people need to know in order to be successful in rural practice, then that would be a great training program.”

To help finance the program, Deveney’s team leveraged funding sources from the American College of Surgeons (ACS). An advisory council associated with the ACS focuses exclusively on rural training programs.  

“The American College of Surgeons has a mastery of general surgery one-year fellowship that places a graduate surgeon into a hospital where they can work with surgeons and learn skills even after their residency, enabling them to go into practice even if they didn’t stumble onto the idea during residency or didn’t have rural residency training available to them,” Deveney said.

While Deveney noted their best partnerships developed from large rural hospitals, not all training programs are the same.

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“Each location is an n of one,” she explained. “It depends on what your local environment will support and how you can fund it, how you can convince a location, and generate buy-in.”

Creating opportunities for exposure

Many healthcare professionals do not go into rural practice because there is a disconnect between their expectations and their knowledge. This gap makes many young professionals nervous about signing up for something without truly understanding what care in a rural setting looks like.

Carolyn Sliger, MSEH, rural programs coordinator at East Tennessee State University helped form the Appalachian Preceptorship Program. This mentorship program allows students interested in working in rural areas to gain exposure during their medical training.

“The goal of the program is to invite students who have completed at least one year of medical school to come to the Appalachian area and learn about our rural areas,” said Sliger.

After participating in the program, program administrators followed up with students to see where they matched for residency and followed them through their first job. Those who completed the program were three times more likely to practice in a rural setting compared to the national average, demonstrating the program’s success since 1985.

“About 75 percent of students who participate in the program go into primary care and work in a rural or underserved area,” Sliger pointed out.

She further explained how this program helps with a bigger picture problem: filling the physician shortage in the United States.

“We have a physician shortage in every state across the United States. Our goal with this program is to reduce the number of shortages of physicians in rural and underserved areas,” Sliger continued. “We need around 4,000 more physicians nationwide to fill in the gaps. This program has seen success to work towards filling in those gaps.”

Sliger credits the commitment of the preceptors and emphasizes that the enthusiasm around the program is why there is “always a funding option on the table.”

The program has received funding from a variety of sources, whether it be state-based workforce development programs, grant funding, or university-based funding sources. Funding is primarily needed for a living and housing stipend to support the students relocating to rural areas for a month.

“The success of the program stems from where we’ve had preceptors and faculty who have longevity in the program and see how the students learn,” Sliger maintained. “It’s all hands-on and how they apply what they’ve learned when they go back into their own school setting.”

Leveraging Telemedicine

Telemedicine allows providers from anywhere to remotely monitor and treat patients, which is why it is frequently seen as a solution to overcome the inaccessibility of healthcare in rural areas. In resource-limited settings, telemedicine can bring specialized care to vulnerable populations.

The University of Wyoming Clinical Psychology Training Program incorporated telemedicine into their program to help reach the most vulnerable populations in the state.

Matt Gray, PhD, professor of psychology at the University of Wyoming explained how psychological counseling was a perfect fit for a telehealth program.

“Pretty much everything we do is face-to-face. There’s no reason that we can’t do this through secure, encrypted videoconferencing technology,” he explained.

Many of the Wyoming Trauma Center’s referrals come through the local Sexual Assault and Domestic Violence Crisis Center Safe Project. Gray explained that telehealth can be particularly helpful for this population.

“If you are in a violent relationship in which you’re being monitored and controlled or not allowed to have access to transportation, 20 miles might as well be 500 miles,” he said.

While many rural health initiatives struggle with funding, Gray explained that this was not an issue for them.

“Because our clinic is staffed and serviced by doctoral students, they’re doing the work for free,” he noted. “Students were actually thrilled when we established this because we’re in a pretty small town ourselves and telehealth allows our students to get a more concentrated experience with this population.”

There is also no cost to staffing Gray or other supervisors, as he explained, “I have to supervise clinical cases as a part of my job requirements.”

Telehealth provides students with the opportunity to obtain the clinical hours needed for their training and makes program sustainability easier. As long as students are applying to the clinical psychology training program at the university, the clinic will always be staffed.

One of the biggest barriers to starting this program was institutional buy-in. Gray explained that he needed to be convinced of the project’s feasibility and the organization’s infrastructure needed to support the technology required to maintain the program.  

“I didn’t have much telehealth or distal service delivery background, so I had some trepidation going into that partnership,” Gray noted. “I was assured that the tech end would be handled. All I needed to do was see if there were entities out in the state who might be interested in connecting clients with our clinic.”

Gray is optimistic about beginning a telemedicine program at other institutions as he said the task is simple with the proper will.

“If people start getting creative about videoconferencing and thinking about university partnerships, the program doesn’t have to be grant funded or have a huge budget. You just need a little bit of money to get technology and computers, maybe an IT person to consult with initial set-up,” he maintained. “This holds great promise to deliver services to people who otherwise wouldn’t have them.”

To start the program, they needed to undergo HIPAA compliance verification to use the video conferencing services. Now, Gray says, these platforms are more common and provide high-quality audio and video.

“Telehealth has been tremendously valuable in terms of allowing people who otherwise would have had no options to access those services to begin to connect with urban treatment centers and university-based treatment centers,” said Gray.

Creating a Win-Win Opportunity

The key driver to success for all three programs was that they mutually benefit all parties involved.  

In Oregon Health and Science University Surgical Residency Program, the university wanted to help train students and many of the rural hospitals were in need of trainees to take over for the older physicians.

“It’s a win-win for everyone because it’s a shot of energy for the surgeons and for the community who take a great deal of pride in being a teaching hospital,” said Deveney.

The Wyoming Trauma Program leveraged the fact that their students needed clinical hours and rural residents needed specialized care.

“Our model works phenomenally well. It’s a perfect symbiotic relationship that is based in a training clinic. It’s a natural partnership that is often overlooked,” stated Gray. “The symbiotic relationship has solved a lot of practical problems for us.”

Sliger and the Appalachian Preceptorship Program benefited students interested in studying rural health by exposing them to practices in that setting and providing rural hospitals with an extra pair of hands to maintain workflow.  

“We had to find physicians in rural areas who are willing to take on students in the summer, who are good teachers, and who are committed to rural medicine. We don’t place our students with just anyone,” Sliger said.

Mutually beneficial partnerships can drive students to rural practice benefit and provide areas in need with more trained providers.

“The rural situation was becoming desperate and some people being trained didn’t see role models for what practice in a rural area would look like. They couldn’t see the advantages of it and the attractiveness of it,” concluded Deveney. But she is confident that is changing with new rural health training programs that focus on supporting and exposing students to rural healthcare.