Group Prenatal Care vs. Traditional Prenatal Care: A Parity-Matched Comparison of Perinatal Outcomes in a Rural Community.

PURPOSE: Prenatal care is important for positive outcomes for both mother and infant. The traditional one-on-one method remains the most common. This study aimed to compare perinatal outcomes of patients attending group prenatal care with traditional prenatal care. Most previously published comparisons did not match for parity, a key predictor of perinatal outcome. DESCRIPTION: We collected perinatal outcome data for 137 group prenatal care patients and 137 traditional prenatal care patients, matched for contemporaneous delivery and parity, who delivered at our small rural hospital during 2015-2016. We included key public health variables, including the initiation of breastfeeding, and smoking at the time of delivery. ASSESSMENT: There was no difference between the two groups for maternal age or infant ethnicity, induced or augmented labor, preterm deliveries, APGAR scores less than 7, low birth weight, NICU admissions, or cesarean deliveries. Group care patients had more prenatal visits and were more likely to initiate breastfeeding and were less likely to report smoking at the time of delivery. CONCLUSION: In our rural population matched for contemporaneous delivery and parity, we found no difference in traditional perinatal outcome measures and that group care was positively associated with the key public health variables of not smoking and initiating breastfeeding. If future studies in other populations have similar findings, it may be wise to provide group care more widely to rural populations.

Empathy and Burnout During Residency: Which Changes First?

BACKGROUND AND OBJECTIVES: The issue of declining empathy and increasing burnout among residents is of concern for most programs. Numerous studies have shown these changes in both medical students and residents. However, the sequence of empathy decline and increasing burnout is unresolved and most studies have been cross sectional. This paper reports an individually-paired longitudinal analysis intended to clarify the sequence of these changes. METHODS: Beginning in 2017, 35 family medicine residents across all 3 years of training at a rural program completed an established empathy survey and a previously-validated single burnout question at the start of each year and at the midpoint. First, the empathy score for each resident was aligned with the next following burnout measure, and then the reverse sequence was followed, with burnout aligned with the following empathy score. RESULTS: With 125 responses to 133 survey opportunities, we saw a 94% response rate. Empathy scores across residency years decreased slightly and then improved almost to baseline. However, the analysis of variance test for quadratic trend was not significant. The burnout measure increased significantly over the residency years (J-T Statistic=4.89, P<.001). The correlation of the empathy score changing first showed a nonsignificant correlation (Rs=-.150, P=.133). The Spearman's ρ of the burnout measure changing first was significant (Rs=-.300, P=.006). CONCLUSIONS: In this group of residents, changes in burnout occurred before changes in empathy. If further research supports this finding, residency programs could focus more on efforts to address burnout to mitigate decreases in empathy.

Detection of Breeding-Relevant Fruit Cracking and Fruit Firmness Quantitative Trait Loci in Sweet Cherry via Pedigree-Based and Genome-Wide Association Approaches.

Breeding for decreased fruit cracking incidence and increased fruit firmness in sweet cherry creates an attractive alternative to variable results from cultural management practices. DNA-informed breeding increases its efficiency, yet upstream research is needed to identify the genomic regions associated with the trait variation of a breeding-relevant magnitude, as well as to identify the parental sources of favorable alleles. The objectives of this research were to identify the quantitative trait loci (QTLs) associated with fruit cracking incidence and firmness, estimate the effects of single nucleotide polymorphism (SNP) haplotypes at the detected QTLs, and identify the ancestral source(s) of functional haplotypes. Fruit cracking incidence and firmness were evaluated for multiple years on 259 unselected seedlings representing 22 important breeding parents. Phenotypic data, in conjunction with genome-wide genotypic data from the RosBREED cherry 6K SNP array, were used in the QTL analysis performed via Pedigree-Based Analysis using the FlexQTL™ software, supplemented by a Genome-Wide Association Study using the BLINK software. Haplotype analysis was conducted on the QTLs to identify the functional SNP haplotypes and estimate their phenotypic effects, and the haplotypes were tracked through the pedigree. Four QTLs (two per trait) were consistent across the years and/or both analysis methods and validated the previously reported QTLs. qCrack-LG1.1m (the label given to a consistent QTL for cracking incidence on chromosome 1) explained 2-15.1% of the phenotypic variance, while qCrack-LG5.1m, qFirm-LG1.2m, and qFirm-LG3.2m explained 7.6-13.8, 8.8-21.8, and 1.7-10.1% of the phenotypic variance, respectively. At each QTL, at least two SNP haplotypes had significant effects and were considered putative functional SNP haplotypes. Putative low-cracking SNP haplotypes were tracked to an unnamed parent of 'Emperor Francis' and 'Schmidt' and unnamed parents of 'Napoleon' and 'Hedelfingen,' among others, and putative high-firmness haplotypes were tracked to an unnamed parent of 'Emperor Francis' and 'Schmidt,' an unnamed grandparent of 'Black Republican,' 'Rube,' and an unknown parent of 'Napoleon.' These four stable QTLs can now be targeted for DNA test development, with the goal of translating information discovered here into usable tools to aid in breeding decisions.

Accelerated 3-Year MD Pathway Programs: Graduates' Perspectives on Education Quality, the Learning Environment, Residency Readiness, Debt, Burnout, and Career Plans.

PURPOSE: To compare perception of accelerated and traditional medical students, with respect to satisfaction with education quality, and the learning environment, residency readiness, burnout, debt, and career plans. METHOD: Customized 2017 and 2018 Medical School Graduation Questionnaires (GQs) were analyzed using independent samples t tests for means and chi-square tests for percentages, comparing responses of accelerated MD program graduates (accelerated pathway [AP] students) from 9 schools with those of non-AP graduates from the same 9 schools and non-AP graduates from all surveyed schools. RESULTS: GQ completion rates for the 90 AP students, 2,573 non-AP students from AP schools, and 38,116 non-AP students from all schools in 2017 and 2018 were 74.4%, 82.3%, and 83.3%, respectively. AP students were as satisfied with the quality of their education and felt as prepared for residency as non-AP students. AP students reported a more positive learning climate than non-AP students from AP schools and from all schools as measured by the student-faculty interaction (15.9 vs 14.4 and 14.3, respectively; P < .001 for both pairwise comparisons) and emotional climate (10.7 vs 9.6 and 9.6, respectively; P = .004 and .003, respectively) scales. AP students had less debt than non-AP students (P < .001), and more planned to care for underserved populations and practice family medicine than non-AP students from AP schools (55.7% vs 33.9% and 37.7% vs 9.4%; P = .002 and < .001, respectively). Family expectations were a more common influence on career plans for AP students than for non-AP students from AP schools and from all schools (26.2% vs 11.3% and 11.7%, respectively; P < .001 for both pairwise comparisons). CONCLUSIONS: These findings support accelerated programs as a potentially important intervention to address workforce shortages and rising student debt without negative impacts on student perception of burnout, education quality, or residency preparedness.

Community-based medication disposal pilot initiative in southwest tribal communities.

BACKGROUND: Misuse and abuse of prescription drugs including opioids has been a driving force behind the drug overdose epidemic plaguing communities across the USA for more than two decades. Medication accumulation in the home environment can contribute to this issue. However, research on proper disposal in rural communities is limited. For this project, an applied public health approach was used to raise awareness and improve prescription drug disposal practices by pilot testing prescription drug disposal systems in participating communities. METHODS: A community-based disposal project was facilitated with assistance from community partners. The project centered on distribution of drug deactivation bags in homes and medication drop boxes at multiple healthcare facilities. RESULTS: The team distributed 215 drug deactivation bags to 162 community households resulting in destruction of 8011 pills, 8 medicated dermal patches and 777 mL of liquid medication. A total of 4684 pounds of medication were collected and disposed of through healthcare facility drop boxes. CONCLUSION: The strategies identified are scalable and easy to replicate to meet any community's needs in reducing potential challenges of medication diversion.

Rural Medicine Realities: The Impact of Immersion on Urban-Based Medical Students.

PURPOSE: The purpose of our study was to determine what effect a rural-based 8-week surgical clerkship during the third year of medical school in a rural setting has on students' opinions about rural living and practice. METHODS: Thirty-three third-year medical students completed a rural health opinion survey at the beginning and end of their 8-week rural rotation and a survey measuring their interest in rural practice after the rotation. The setting was a rural hospital with an average acute care census of 100 that is a regional referral center for 5 rural counties. FINDINGS: Urban campus-based students had a statistically significant positive change in opinions about rural comfortable living, availability of quality services, community support, and medical resources. The urban campus-based students also showed a significantly increased interest in small town practice after the rotation. CONCLUSIONS: Our hypothesis that urban-based students would report an increased level of rural community support at the end of the rotation was confirmed. These urban-based students also reported positive opinions about rural living and practice. The students primarily based at the urban campus also showed a statistically significant more positive attitude toward pursuing a career in a small town after the 8-week experience. This suggests that brief rural immersion experiences may make the larger student pool at an urban campus available to address rural workforce challenges. Future studies at multiple rural sites with a larger sample size are needed to confirm this possibility.

Increasing the Rural Physician Workforce: A Potential Role for Small Rural Medical School Campuses.

PURPOSE: To address the issue of physician maldistribution, some medical schools have rural-focused efforts, and many more are in the planning or early implementation stage. The best duration and structure of the rural immersion experience are unclear, and the relative effects of rural upbringing and rural training on subsequent rural practice choice are often difficult to determine. METHODS: To determine the effect of adding a rural clinical campus to our school, we analyzed the variables of rural upbringing, demographics, family medicine residency choice, and campus participation using a multivariate model for association with rural practice choice. We included graduates from the classes of 2001-2008 from both campuses (urban and rural) in the analysis. FINDINGS: We found similar associations to those reported previously of rural upbringing (OR = 2.67 [1.58-4.52]) and family medicine residency (OR = 5.08 [2.88-8.98]) with rural practice choice. Even controlling for these 2 variables, participation in the full 2 years at the rural clinical campus showed the strongest association (OR = 5.46 [2.61-11.42]). All 3 associations were significant at P < .001, and no other variables were significant. CONCLUSIONS: We conclude that the investment of resources in our rural campus may add an increment to rural practice choice beyond the established associations with rural upbringing and family medicine residency. The decision of practice site choice is complex, and collaborative studies that include data from several schools with differently structured rural exposures, including those with rural clinical campuses, are needed.

A Medical School Prematriculation Program for Rural Students: Staying Connected With Place, Cultivating a Special Connection With People.

PROBLEM: Rural medical students who attend urban medical schools experience urban disruption that may make it less likely that they will return to rural practice. Most prematriculation programs focus on academic preparation and are in urban areas, potentially adding to urban disruption. Most initial learning experiences concerning communication with patients are also in urban areas. INTERVENTION: Fifty-nine rural preclinical students completed a 3-week summer rural prematriculation program from 2009 to 2014. The focus was on learning a holistic approach to interviewing patients and experiential learning based in a rural practice. Group reflection sessions focused on understanding health beliefs, psychosocial details of the patient's life, and the importance of the sense of place. Measures included student reports, program evaluations, and a pre- and post- 10-item opinion survey focused on the students' perceived importance of traditional biomedical and psychosocial knowledge. CONTEXT: The program was based at the Trover Campus, a regional clinical campus of the University of Louisville School of Medicine, in a town of 20,000 in the western Kentucky coalfields that is 150 miles from the main urban campus. Practice site assignments were in surrounding medically underserved towns in family medicine practices. OUTCOME: After the 3-week experience, students became comfortable with interviews concerning health habits using the Prochaska model of lifestyle modification and expressed an increased importance of some psychosocial factors and a corresponding decrease in importance of traditional biomedical factors in choosing treatment for an individual patient (significant results by Mann-Whitney, two-tailed, ranged U = 1136.0, p = .001 to U = 1377.5, p ≤ .05). Student reports showed that the students gained a new detailed understanding of rural practice. Students also expressed an appreciation for having developed a support network of fellow rural students with whom they would begin medical school on the urban campus. LESSONS LEARNED: These results support the value of a summer prematriculation program for rural students based in a rural area. New appreciation for psychosocial patient factors, new skills in communication with patients, new understanding of the details of rural practice, and new relationships with other rural classmates were perceived as positive aspects of the program. Longer term measures of whether the program decreased urban disruption significantly will require continued tracking of the students until they make a practice choice 7 to 9 years later. Wider collaboration with other medical school rural programs is necessary to determine which aspects of rural-focused training are most effective.

A rural pathways program for high school students: reinforcing a sense of place.

BACKGROUND AND OBJECTIVES: The affinity model predicts that students from rural areas who train in smaller towns will be more likely to choose rural practice. Most pipeline programs based on this model begin in college or medical school. Many rural students first encounter academic and career planning challenges prior to college, and a few programs are focused on high school students. METHODS: We report pre- and post-program opinions and American College Testing (ACT) practice scores from 151 participants in a high school rural scholar program over the first 10 years of the program. RESULTS: After participation, the students showed significantly more positive opinions about their county's health care resources and their knowledge of career options, and they knew more names of the providers in their county. Their practice ACT scores increased slightly, and their assessment that they were well prepared to take the ACT improved. Seventy-five percent have pursued a health career, and 10% have entered medical school. CONCLUSIONS: A summer program that allows high school students to shadow health professionals in their hometown and study in a virtual classroom can accomplish modest academic gains while producing more positive opinions about the health care in their county. They also report better understanding of the career options available to them.

Rural track training based at a small regional campus: equivalency of training, residency choice, and practice location of graduates.

PURPOSE: Ten years of data for the rural-based Trover Campus (ULTC) were compared with data for the main campus of the University of Louisville School of Medicine to determine whether educational outcomes were equivalent and whether this method of optimizing the affinity model was effective in placing graduates in rural practice. METHOD: Demographic data and academic measures were compared for 1,391 graduates (60 from ULTC) for 2001-2010. A noninferiority model was developed to compare clinical experiences for each campus cohort. Residency match lists were examined for specialty choice. Graduates from 2001 to 2006 were matched to the American Medical Association Masterfile to determine practice site. RESULTS: ULTC students scored lower on United States Medical Licensing Examination (USMLE) Step 1 and Step 2 Clinical Skills (CK) but tended to close this gap after clinical training when compared with Louisville graduates. The noninferiority model indicates that ULTC students' scores were noninferior to Louisville students' on adjusted shelf exams for obstetrics-gynecology, pediatrics, and surgery, and Step 2 CK (P<.001). ULTC graduates were 4.5 times more likely to choose family medicine (P<.001) and over 6 times more likely to choose a nonmetropolitan area as a practice site (P=.001). CONCLUSIONS: These data support the value of a small regional rural clinical campus in optimizing the affinity model to place rural students into rural practice. The ULTC students showed equivalent adjusted test scores and slightly narrowed the gap in unadjusted USMLE scores compared with the main campus students.

Outcomes of a preclinical rural medicine elective at an urban medical school.

BACKGROUND AND OBJECTIVES: The University of Louisville School of Medicine Trover Campus (ULTC) was established in rural west Kentucky in 1998 with the purpose of increasing the number of rural physicians. Utilizing the affinity model, a primary goal of the ULTC is to encourage rural students to pursue a medical education and return to rural Kentucky for practice. One aspect of this geographically separate clinical campus includes a Rural Medicine Elective (RME) offered during the basic science years. We report here the effect of the RME on student opinions and knowledge concerning rural practice, as well as initial effects on specialty and rural practice choice. METHODS: Opinion responses and knowledge on a written exam using a pre-RME and post-RME survey for the 2004-2009 classes were analyzed. Pre-RME opinion items were examined descriptively (n=36). Pre-and post-opinion responses (n=23) and summation scores of 11 domains on exam questions (n=50) were compared using the Wilcoxon Signed Rank test. The proportion of students choosing family medicine and subsequent practice site choice were also measured. RESULTS: RME student opinions about rural practice indicated improved agreement with information as presented in the course material. Similarly, on 11 knowledge examination summation scores, pre- and post-exam results showed significant increases in 10 domains. The pre-test answers provided an interesting baseline of beliefs. RME students were far more likely to choose family medicine than their classmates, and initial results show an increased likelihood of subsequent rural practice. CONCLUSIONS: The initial outcomes of the RME are encouraging and indicate such an elective can maintain positive opinions about rural practice among rural students attending an urban medical school. The RME is also successful in increasing students' knowledge about rural practice and may maximize the likelihood that they will choose rural practice.

Just what are rural premedical students thinking? A report of the first 6 years of a pathways program.

PURPOSE: To assess outcomes of the first 6 years of a program designed to facilitate medical school admission for rural premedical students. METHODS: Students completing the University of Louisville School of Medicine Trover Rural Scholar program were surveyed using a 23-item survey. FINDINGS: Twenty-two of the 24 (92%) students responded. Overall, 12 (55%) were in the physician pipeline (medical students or re-applying to medical school) and 10 (45%) had left the physician pipeline for other careers (7 were pursuing other health care careers). Differences between the 2 groups included income expectations and perceptions of intellectual challenges and physicians' job satisfaction. CONCLUSIONS: Attrition can be explained by student interests, maturation and influences of pre-professional advisors and practicing physicians. Successful pipeline programs should address these issues.

An analysis of the transitions between down and up states of the cortical slow oscillation under urethane anaesthesia.

We study the dynamics of the transition between the low- and high-firing states of the cortical slow oscillation by using intracellular recordings of the membrane potential from cortical neurons of rats. We investigate the evidence for a bistability in assemblies of cortical neurons playing a major role in the maintenance of this oscillation. We show that the trajectory of a typical transition takes an approximately exponential form, equivalent to the response of a resistor-capacitor circuit to a step-change in input. The time constant for the transition is negatively correlated with the membrane potential of the low-firing state, and values are broadly equivalent to neural time constants measured elsewhere. Overall, the results do not strongly support the hypothesis of a bistability in cortical neurons; rather, they suggest the cortical manifestation of the oscillation is a result of a step-change in input to the cortical neurons. Since there is evidence from previous work that a phase transition exists, we speculate that the step-change may be a result of a bistability within other brain areas, such as the thalamus, or a bistability among only a small subset of cortical neurons, or as a result of more complicated brain dynamics.

A sense of place: rural training at a regional medical school campus.

CONTEXT: Traditionally, rural students experience urban disruption during the many years of education and training in urban environments before choosing a practice site. Regional rural campuses that allow students to live and work in small towns during the last 2 years of medical school are one strategy to address this issue. PURPOSE: To report the results of the first 10 years of a rural campus in western Kentucky, including response to difficulties filling openings for third- and fourth-year medical students at the campus. METHODS: A survey was sent to all 76 students who had shown interest in the rural campus, asking them to prioritize the important issues in their campus choice. FINDINGS: Students not choosing the rural campus placed a higher priority on large-city amenities, better opportunities for their spouse, and proximity to family in eastern and central Kentucky. Students who chose the rural campus placed a higher priority on one-on-one clinical training and interest in small town life. CONCLUSIONS: For the rural clinical campus to reach its potential, more rural students from the western part of the state must be admitted to medical school and then choose this campus. Strategies to reinforce the sense of place among rural students focus on experiential programs in rural areas. Initial results suggest that medical educators should consider geography more carefully when designing approaches to address physician maldistribution.

An innovative method for preparation for rural practice: the high school rural scholars program.

Recent studies have shown that the most effective strategy to increase the number of practicing rural physicians is to admit more students with affinity for rural practice to medical school. A significant limitation of this strategy is the generally lower scores made on standardized tests by those from smaller high schools in rural areas. Although once admitted these students perform on a par with their urban counterparts, admission remains an obstacle for many. This report summarizes the second year of an innovative program that placed rising high school seniors in shadowing opportunities in their home towns while providing preparation for the ACT exam in a virtual classroom environment. Results show that the 20 students involved increased their knowledge of the strengths and weaknesses of health care in their towns as well as their understanding of how various health professionals function. The ACT composite score increased by 1.2 points, to 23. The reading and science subscores showed the largest increase. Although labor-intensive for the coordinators, the program was successful in meeting the stated goals.