Residents that are exposed to rural practice during their training may be more likely to consider working in rural settings after training, whether that be in primary or specialty care. The authors describe 3 programs in northern New England that have had rural rotations and opportunities for residents for decades, and discuss curricular similarities and differences, and workforce outcomes postresidency. In addition, they share a collaborative curriculum and approach to advocacy that brings residents together to share ideas and projects to learn from each other.
Key points
- •
Pediatric residency training with embedded rural medicine experiences in a rural setting provides trainees with unique experiences and increases the number of trainees practicing in a rural setting after graduation.
- •
Pediatric residency training in a rural setting prepares trainees for pediatric subspecialty fellowship training, and resident graduates from rural training programs continue to choose pediatric subspecialty training despite overall declining numbers applying to pediatric subspecialty fellowship training nationally.
- •
Rural medicine education and exposure in pediatric residency are inherently connected to advocacy training and provide excellent opportunities for pediatric residency projects as well as collaboration between pediatric residency programs.
Introduction
Training providers to work in rural settings has never been more important than it is today. As pathway programs are considered that expose both medical students and residents to rural medicine, it is important to keep in mind some dire facts. As noted in the AAMC News , of the more than 7200 federally designated health professional shortage areas, 60% are in rural regions, and although 20% of the US population lives in rural communities, only 11% of physicians practice in such areas. The lack of physicians is deeply worrisome. That is in part because rural residents are more likely to die of health issues like cardiovascular disease, unintentional injury, and chronic lung disease than city-dwellers. Rural residents also tend to be diagnosed with cancer at later stages and have worse outcomes. This situation will clearly worsen as many rural physicians near retirement; nearly a quarter fewer may be practicing by 2030.
Equally troubling, medical school matriculants from rural areas—who are most likely to practice in such regions—declined 28% between 2002 and 2017, reports a 2019 study led by Scott Shipman, MD, AAMC, director of primary care initiatives and clinical innovations, and that decline came at a time when the overall number of matriculants increased by 30%.
Many studies have looked at factors that lead medical students to consider careers in rural medicine after training. A recent British Medical Journal article found that even short-term (12 weeks) placement in a rural setting during medical school training positively influenced future practice in rural communities. Another study that evaluated the rural exposure in training to residents from a family medicine training program found a linear gradient between time spent in rural settings during residency and subsequent rural practice.
Elma and colleagues noted that physician maldistribution is a global problem that hinders patients’ abilities to access health care services. They go on to state that medial education presents an opportunity to influence physicians toward meeting the health care needs of underserved communities when establishing their practice and identifies several factors that educators be mindful of in choosing medical students. Some of these factors include consideration for rural experiences during undergraduate and postgraduate medical training, the value of financial incentives, and better understanding the motivations of aspiring physicians, noting that these motivations have considerable impact on the effectiveness of education initiatives designed to influence physician distribution to underserved locations.
The Accreditation Council for Graduate Medical Education (ACGME) along with other higher education organizations has over time moved away from using standardized test scores, grades in core clerkships, and even downplaying letters of recommendation in an effort to give medical students a more holistic review when choosing candidates for residency. Many programs are looking hard at their mission and seeking out candidates that meet that mission more fully by demonstrable past experience. A residency, the focus of which is on training primary care to fulfill an underserved workforce such as that that exists in rural communities, may be more likely to match a student who is from a rural background, or has spent time working in rural underserved settings.
Many institutions and medical schools have developed programs over the last decade with the goal of helping to increase the workforce of those entering rural practice. One of these programs at the University of North Carolina (UNC), School of Medicine is known as the “Fully Integrated Readiness for Service Training (FIRST) Program.” This accelerated curriculum focused on rural and underserved care that links 3 years of medical school with a conditional acceptance into UNC’s 3-year family medicine residency, followed by 3 years of practice support after graduation. Students are recruited to the FIRST Program during the fall of their first year of medical school. The FIRST Program promotes close faculty mentorship and familiarity with the health care system, includes a longitudinal quality improvement project with an assigned patient panel, includes early integration into the clinic, and fosters a close cohort of fellow students. As of March 2020, the FIRST program had recruited 5 classes of medical students, and 3 of those classes had matched into residency—it remains to be seen as these classes finish their training how many of those students choose primary care in a rural setting as their postresidency path.
Clearly, pathway ideas meant to expose medical students (or even high school students) and residents to rural medicine may increase the numbers of those whom complete training and pursue rural medicine. Many larger residency programs have created rural “tracks” designed specifically to give interested students more time in rural communities with the belief that this will lead them to rural practice after training. Indeed, tying this training to guaranteed funding, loan relief, or opportunities for spousal employment will be beneficial in meeting the needs of the rural communities.
Longenecker and colleagues recently published in the Journal of Rural Health some findings regarding the current landscape of rural efforts in US Undergraduate Medical Education (UME). This descriptive study of 182 allopathic and osteopathic medical schools found that few (only 8.2%) of them expressed an explicit commitment to producing rural physicians in public mission statements; however, most (64.8%) provided rural clinical experiences, and many demonstrated their commitment in other ways. It is important to note that of the two-thirds of programs that provided rural clinical experiences, only 39 (21%) did so through a formal rural program.
The American Academy of Pediatrics (AAP) released the Pediatrician Workforce Policy Statement in 2013 with the conclusion that the “current distribution of primary care pediatricians is inadequate to meet the needs of children living in rural and other underserved areas.” The statement also outlines that the shortage of pediatric subspecialists will disproportionately affect rural regions of the country.
The ACGME guidelines for Categorical Pediatrics are changing requirements such that beginning in July 2025, the required time trainees spend in critical care (both neonatal and pediatric) is reduced to 2 blocks of training. For those going into rural medicine, this may be inadequate to prepare residents for covering the delivery room and gaining necessary experience with stabilizing sick children before transport. With the changing ACGME recommendations, programs are committed to providing a focused experience to prepare pediatricians for rural practice, primarily by recommending self-directed elective choices in training that will benefit those who plan to practice in a rural environment. Examples of this curriculum are explained forthwith.
It is with the above in mind that the authors share how 3 pediatric training programs in the northeast that do not have a specified rural track have found success in populating rural communities with pediatricians. They also discuss how the residency programs allow for experiences and autonomy in residency that lead many to pursue posttraining fellowship programs, an added benefit given the workforce issues facing many communities in recruiting and retaining pediatric subspecialists. Finally, the authors briefly share a relatively new advocacy collaborative that brings residents together on a regular basis.
Background
The pediatric residency programs of The Barbara Bush Children’s Hospital at Maine Medical Center , the Children’s Hospital at Dartmouth–Hitchcock , and the University of Vermont Children’s Hospital all have long track records of training pediatricians that ultimately practice in a variety of settings. Like most training programs, each of these programs has decades of success producing pediatricians that go on for fellowship training, careers in academic medicine, or practicing primary care. What is unique about these 3 programs is that the exposure the authors provide for their learners, which includes dedicated, longitudinal time gaining a greater understanding of the practice of rural medicine, has led to many graduates choosing rural medicine either as a generalist or as a specialist as one’s first practice experience after training ( Fig. 1 ).
The following is a detailed description of the rural curriculum, experiences, and graduate data from these three programs.
The Barbara Bush Children’s Hospital at Maine Medical Center
The pediatric residency program at Maine Medical Center (MMC) was first accredited in 1958. The program has graduated hundreds of residents over the ensuing decades, is the only pediatric training program in Maine, and is responsible for producing much of the state’s primary care workforce as well as specialists. A significant number of the workforce that entered rural practice trained at MMC, and in the case of specialties, left Maine to pursue fellowship training and then came back to Maine to practice. The program does not have pediatric fellowships; yet, like many programs, 30% to 50% of graduates go on to complete fellowships at other institutions in any given year. Located in Portland, Maine, The Barbara Bush Children’s Hospital is part of the larger MaineHealth Network that includes regional hospitals and primary care practices throughout Maine.
Approximately 61% of Mainers live in rural counties, and although most children in the state live in southern Maine, children of all ages and developmental stages live throughout the state and require access to high-quality pediatric care. In addition, the catchment area for The Barbara Bush Children’s Hospital at Maine Medical Center is wide-ranging, inclusive of much of the State of Maine as well as parts of southern New Hampshire.
MMC formalized a required rural rotation for all residents in 1997. The rural experience is a required block rotation for all interns and takes place between December and June of the intern year, so as to give learners time to first be acclimated to residency before embarking on time away from the medical center. Residents are placed in one of a growing number of rural practices, most of which are within 90 minutes of Portland, Maine. All communities have populations of less than 8000. From 1997 to 2008, there were 3 sites as the primary location for these learners. All 3 sites had pediatric faculty that were given Clinical Instructor status for their academic appointment with either the University of Vermont (medical school partner until 2010) or the Tufts University School of Medicine (2010 to current). In 2008, the authors expanded to a fourth site, and then in 2017, opened up their other affiliated MaineHealth pediatric practices throughout the state where faculty were eager to accept learners.
As the ACGME Pediatric Residency Review Committee requirements expanded to include 6 months of individualized training in 2012, the authors have had many residents choose a second or even third experience in a rural setting during the final 2 years of training. These experiences are optional for the learners.
The rural medicine curriculum is part of the authors’ comprehensive ambulatory pediatric curriculum ( Box 1 ), which includes several ambulatory rotations. The authors emphasize to learners that the curriculums for these various rotations should be viewed in a continuum of learning such that they are encouraged to make connections between the various experiences occurring in the different ambulatory experiences.
Postgraduate Year (PGY-1)
- •
Acute Care Pediatrics—general pediatric resident clinic
- •
Continuity Clinics—dispersed throughout the year in “Y” block rotations
- •
Rural Pediatrics—4 weeks at one of the authors’ affiliated rural sites (see addendum for curriculum)
- •
ACQUIRE—introduction to Advocacy, Community Pediatrics, QI, Research, and Education-
- ○
Block month designed to introduce all interns to these topics with goal of project initiation to continue into Advocacy year 2
- ○
Residents can select a rural-focused project of interest
- ○
Occurs as 2- to 2-week blocks—one in fall, one in spring
- ○
- •
PGY-2 Year
- •
Continuity Clinics—dispersed throughout the year in “Y” block rotations
- •
Advocacy Rotation
- ○
Focused education on advocacy with a goal of completion of project from year 1
- ○
Exposure to statewide advocacy work highlighting the needs of urban and rural populations
- ○
- •
Community Pediatrics
- ○
Completed in a local practice under guidance of the authors’ faculty
- ○
Can be in a rural site per resident choice
- ○
- •
PGY-3 Year
- •
Continuity Clinics—dispersed throughout the year in “Y” block rotations
- •
Additional opportunities for Rural Exposure via Individualized Curricular Experiences
- •
Thus, the authors’ acute care pediatrics, continuity clinic, community pediatrics, rural medicine, and advocacy rotations all share a common curriculum and then have specific competencies that are met in the individual experiences, as depicted in Box 1 . Although there are many shared competencies between these multiple experiences, there are rotation-specific competencies unique to each experience as well. An example from the rural rotation may be “ to learn the role of the pediatrician as school health advisor ” or “ developing a care management plan for a child with complex health care needs ,” which the authors found held more value for their residents when discussed on the rural rotation where primary care pediatricians are managing these patients with specialty consultation in a way that differs from practices that are co-located with specialists (as seen in the more urban centers of the state).
In terms of satisfaction with the rural rotation, resident and attending feedback has been strong. Residents note that they appreciated the complexity of primary care without tertiary care support, and the ability for greater community involvement (attending sports events as the team physician, participating in group sessions with adolescents, prenatal visits). They also note great satisfaction with the rural faculty with comments, such as “ I want to be a pediatrician just like Dr. X ” or “ Unbelievably devoted to pediatrics, teaching, and the community .”
Faculty also appreciate the opportunity to interact with resident learners noting comments, such as “ having residents provide a stimulus to stay up to date; the residents make me feel more connected to the tertiary medical center in Portland; and meeting the residents during the rural block makes it so nice when transferring sick patients to the inpatient services at the medical center.”
Although exposure to rural primary care likely increases the workforce in this much needed area, what is also noteworthy is the feedback the authors receive from the graduates that pursue pediatric fellowships after training. Many patients in the region may present to critical access hospitals throughout the state, and the residents have the opportunity, with support from the pediatric critical care team, to participate in these transport calls and to be part of the transport team that goes out and brings these children back to MMC. For those entering procedural-based fellowships (neonatal intensive care unit [NICU], pediatric intensive care unit [PICU], cardiology), most note that they have had significantly more “hands-on” experience than many of their co-fellows that trained in larger programs with critically ill children. The authors think this is a direct result of training at their institutions where residents have the chance to participate in these transports and have more autonomy and direct patient care opportunities within their hospital services, as there are no fellows to share these procedures in training.
In terms of data over the last 15 years, the authors’ program has graduated 89 residents; 65% pursued primary care or a non-fellowship hospitalist job after their training, and 35% pursued fellowship. Fig. 2 depicts this as well as showing a split between rural and urban practice.
