Rural Graduate Medical Education: Choosing the Road “Less Traveled By” : Academic Medicine

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Invited Commentaries

Rural Graduate Medical Education: Choosing the Road “Less Traveled By”

Pauwels, Judith MD1

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Academic Medicine 97(9):p 1268-1271, September 2022. | DOI: 10.1097/ACM.0000000000004745
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Abstract

Two roads diverged in a wood, and I –

I took the one less traveled by,

And that has made all the difference.

—Robert Frost, “The Road Not Taken,” 1915

Health professions in rural communities are experiencing both the best of times and the worst of times. The best are the rewards on a deep level: the intimate connection with patients and the community; the provision of services to those who have limited access to care and poorer health outcomes as a result; the satisfaction of walking down the street and running into someone whose daughter you just delivered and whose father you just cared for in the hospital, and sharing tears and laughter. The worst are the realities of what is happening to rural health care delivery and its impact on those communities: the low number of physicians relative to population and declining overall access to health care services 1; the number of rural hospital closures nationwide, forcing people living in those areas to travel farther for health care services 2; worsening access to care for women seeking obstetrical and reproductive health services 3,4; and decreasing access to general surgery. 5 Further, providers who remain passionately committed to rural practice and communities face the frustration of low payments, long hours, constant demands, and the complexity of a health care environment created by and for large centers with layers of administrators to assist in those tasks.

What ideas and strategies, then, have the greatest potential to encourage reengagement of our health care system in encouraging the health workforce to choose that road “less traveled” into our rural communities? Specifically, what can those of us in graduate medical education (GME) program development aspire to achieve?

Supporting trainees in developing their professional identity as rural physicians through rural-specific competencies and positive training experiences in a rural environment has been demonstrated to improve recruitment and retention of new physicians in those communities. 6 Physicians who receive this support can develop deep connections and understand practice in a lower-resource environment where adaptability and resilience are essential. Many rural hospitals and clinics have also found that having trainees stabilizes the local health care community through improved recruitment and retention of other physicians, enhancing skill development and incorporation of new knowledge, and improving quality and safety of care as well as professionalism. It is critical that we establish these educational opportunities before a health care system in a rural community is so limited that no potential teachers and mentors remain to train students and residents.

Creating a Culture of Learning in Rural Settings

Many rural health care professionals are unaccustomed to thinking of themselves as teachers, yet they are often quintessential role models in both health care and their communities. Embracing concepts such as learner-centered observation and feedback and “Master Adaptive Learners” 7 may be disconcerting at first to those of us who trained under prior learning models. However, developing a rural “culture of learning” is very achievable through coaching and expert support, collaboration and sharing with other rural programs, regional urban health education partnerships, and faculty development opportunities provided by many organizations.

Additionally, emerging opportunities offer hope to rural education and practice: attracting trainees to rural settings through educational innovations, advancing interprofessional models of care, addressing burnout and promoting well-being, elevating the integral role of public health, incorporating cultural elements that impact rural training and practice, and advocating for policy issues that uniquely affect rural training, among many other ideas. One such opportunity is the emerging idea of the teaching health neighborhood, a team-based interprofessional training model to develop the health care “village” needed in the rural community. Under this model, learners in multiple disciplines—medical specialties (including family medicine, psychiatry, general internal medicine, pediatrics, obstetrics, and general surgery), advanced-practice nursing and physician assistant, dentistry, social work, behavioral health, and other health care professions including nursing and a variety of therapies—could work together toward nurturing the rural health professions pipeline. The rural community itself would determine its capacity and breadth for providing training for the disciplines it requires. Regional partners can help establish the training models; state Area Health Education Centers (AHECs) are often ideally positioned to assist rural communities in educational planning.

In many rural areas, often with leadership from state AHECs, there is a focus on developing the pipeline of students considering health professions careers, beginning in grade schools and high schools and continuing through community colleges and universities. 8 Identifying interested students and nurturing them through role-modeling, targeted mentorship, and career development has been embraced by many as essential to cultivating a diverse workforce, particularly for students from disadvantaged backgrounds and from groups historically underrepresented in medicine.

What Do Rural Communities Need in Their Future Workforce?

Rural communities must identify their own individual health care workforce needs. Training programs can then be tailored to meet those needs as well as to build on the resources of that community, collaborating broadly with regional partners when specific resources are not available, such as through developing robust telehealth linkages. In general, many rural communities are experiencing gaps for obstetrics and maternity care; treatment for opioid and other substance use disorders; behavioral health services and suicide prevention; and emergency care and procedural expertise. Regardless of specialty, all rural health care professionals must tend toward generalism in skills and attitudes to allow them to adapt to the needs of the community.

Rural communities are desperate to recruit and retain physicians. The concept of “place-based education,” with its focus on the importance of relational connectedness in both work and broader social environments, has identified promising approaches to address this need. 9 Multiple studies have demonstrated that coming from a rural background, or having lengthy prior experiences in a rural area, is one of the highest predictors of long-term practice in rural areas, but this factor alone is not sufficient for predicting sustained rural practice. Other key influencers are learning experiences that enhance the learner’s self-efficacy and interest in rural practice; the development of local relationships that help learners feel like members of the community and part of the larger health care team; and lifestyle appeal. 10 For trainees and for new physicians recruited to a rural community, the emphasis remains on relationships: the need for a strong sense of professional support, including feeling welcomed; access to supportive mentors; opportunities to enhance skills and knowledge; collaborative relationships with the entire health care team; connectness with the community; and, of course, the essential consideration for the trainee’s or physician’s own family and personal relationships, and for those individuals’ employment and relationships in the broader community.

Partnerships in Rural GME

Education in any setting takes a “village” of dedicated individuals and supportive organizations to thrive. Rural GME exemplifies this concept. In addition to needing the support of their communities, rural GME programs require partnership from health systems, including sponsoring institutions, participating hospitals, and community health care organizations that are committed to training learners. The healthiest partnerships are grounded in an alignment of missions, mutual respect, a governance structure that codifies an appropriate division of authority and decision making among rural and urban partners, clear communications systems, and financial transparency and trust. For rural organizations collaborating with urban ones, an additional key concept is equity in the division of authority and decision making. Health system partners and rural GME programs alike must be adaptable and resilient, given the varied models for these partnerships determined by the needs of the communities, and the fragility of many rural training sites due to the stressors already noted.

Creative ideas again abound here. Examples of successful partnerships for rural health entities include direct connection with urban programs and institutions; community health, rural health, and Indian Health Service (IHS) clinic systems; public and private foundation investment; and other rural partnerships. The Veterans Health Administration (VA) has significantly invested in new GME positions, and many training programs and health systems are seeking to expand GME engagement with the IHS. GME development and workforce planning is increasingly happening at the state level, driven by the feedback from rural communities and workforce data on maldistribution of physicians both geographically and by specialty. This has led to a variety of state-based initiatives to fund rural training directly, invest in start-up funding for new rural programs, offer loan payback for rural placement, and stabilize funding for existing GME programs.

Opportunities and Barriers in Rural GME Development

Many organizations are stepping up with significant new support for developing physician training in rural communities. Organizations that have made key contributions to creating milestones and identifying important tools for this work include the Health Resources and Services Administration (HRSA) Rural Residency Program Development grant program (ruralGME.org) and the Rural Training Track Collaborative (https://rttcollaborative.net). In 2019, the Accreditation Council for Graduate Medical Education approved a framework 11 to address the need for more rural GME positions, creating a new advisory committee and infrastructure, and examining accreditation processes to evaluate more flexible solutions to meet requirements. HRSA has established start-up grants 12,13 to fund rural residency program development and provide technical assistance to grantees to help them achieve initial accreditation. The Centers for Medicare and Medicaid Services (CMS) reinterpreted its rules regarding how Critical Access Hospitals may participate in rural training tracks as nonprovider settings for GME purposes, and new rule interpretations for GME changes 14 included in the Consolidated Appropriations Act of 2020 are anticipated to make significant improvements to some current rules affecting rural programs. The U.S. Department of Health and Human Services established a “rural action plan.” 15 As noted, states, the VA, and IHS are all taking steps to develop rural-facing supports.

Examples of support for rural training programs are heartening, yet the movement to create more rural GME positions will only fulfill its goals by tackling one fundamental ongoing issue: the need for an equitable payment stream for rural GME programs on par with what new urban programs can obtain. 16 All the new GME positions being made available through start-up funding and short-term grants will not create the strong, sustainable rural programs that will endure into the future. Rural hospitals have multiple regulatory barriers to obtaining CMS GME payments—and often state-level Medicaid GME payments when available—at a level that will even approach the costs of training. These barriers apply across specialties, and while a few solutions create opportunities for some family medicine programs, they seldom work to support specialty rotations even in rural areas of need.

So, what is a rural health care advocate to do? To truly solidify rural physician training, even a brief legislative agenda would include entirely changing the payment model for rural GME positions, as has been proposed in several iterations of the Rural Physician Workforce Act 17; leveraging Medicaid payments to prioritize rural workforce goals; and assuring transparency in data reporting on the outcomes of GME investments to demonstrate that rural health professions education and practice have, in fact, been impacted in a positive way.

The Council on Graduate Medical Education 2021 rural report recommendations 9 (quoted here) ring true as a blueprint for making a difference for rural communities:

  • • Expand and extend successful place-based training initiatives that promote access to care.
  • • Identify and eliminate regulatory and financial barriers and create incentives for expansion and innovation.
  • • Develop a set of measures to ensure value and return on investment in rural health education.
  • • Support and test alternative payment models that enhance team-based interprofessional practice.
  • • Authorize the creation of a Strategic Plan for Rural Health Workforce Financing Reform, including developing a network and support system for rural clinicians across their career continuum.

We have a choice between walking the road of investing in these and other specific, innovative, and essential strategies to commit to improving rural health, and taking the easy path of inaction, resigning ourselves to an ongoing “worst of times” for health care for people living in rural communities and those struggling to serve them. If we choose the easy path, more counties will find themselves without physicians to serve their residents; more rural hospitals will be at risk of closure; and fewer rural residents will be able to access maternity and reproductive health care, receive cancer screening and treatment, and have the ongoing personal care that is the foundation of health for individuals and communities.

My personal hope is that we will choose the road “less traveled by,” and that it will become a route to better health and strong rural communities through targeted changes in funding and a “village” of support within states and regions.

Acknowledgments:

The author has so many to thank in the world of rural residency education but will particularly note the collaborations with Randall Longenecker, MD, executive director, RTT Collaborative; and Louis Sanner, MD, professor of family medicine, University of Wisconsin, Madison, Wisconsin.

References

1. Larson EH, Andrilla CHA, Garberson LA, Evans DV. Geographic Access to Health Care for Rural Medicare Beneficiaries: A National Study. Seattle, WA: WWAMI Rural Health Research Center, University of Washington; September 2021. https://familymedicine.uw.edu/rhrc/publications/geographic-access-to-health-care-for-rural-medicare-beneficiaries-a-national-study. Accessed May 5, 2022.
2. U.S. Government Accountability Office. Rural hospital closures: Affected residents had reduced access to health care services. GAO-21-93. https://www.gao.gov/products/gao-21-93. Published December 22, 2020. Accessed May 5, 2022.
3. National Advisory Committee on Rural Health and Human Services. Maternal and obstetric care challenges in rural America: Policy brief and recommendations to the secretary. https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/rural/publications/2020-maternal-obstetric-care-challenges.pdf. Published May 2020. Accessed May 5, 2022.
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