Practice locations of graduates of family physician residency and nurse practitioner programs: considerations within the context of institutional culture and curricular innovation through Titles VII and VIII.

BACKGROUND: Studies have described the aggregate results of federal funding for health professions education at the national level, but analysis of the long-term impact of institutional participation in these programs has been limited. PURPOSE: To describe and assess federally supported curricular innovations at East Tennessee State University designed to promote family medicine and nurse practitioner graduate interest in rural and underserved populations. METHODS: Descriptive analysis of a survey to determine practice locations of nurse practitioner graduates (1992-2002) and graduates of 3 family medicine residencies (1978-2002). Graduates' (N = 656) practice locations were documented using specific federal designations relating to health professions shortages and rurality. RESULTS: Overall, 83% of family medicine residency and 80% of nurse practitioner graduates selected practice locations in areas with medically underserved or health professions shortage designations; 48% of family physicians and 38% of nurse practitioners were in rural areas. CONCLUSIONS: Graduates who study in an educational setting with a mission-driven commitment to rural and community health and who participate in curricular activities designed to increase their experience with rural and underserved populations choose, in high numbers, to care for these populations in their professional practice.

The Appalachian Preceptorship: over two decades of an integrated clinical-classroom experience of rural medicine and Appalachian culture.

There is a need to encourage careers in rural medicine and to prepare potential rural physicians for life in rural communities. The authors describe a program that addresses this need, the Appalachian Preceptorship Program, and report the program's experience from 1985 to 2004. The Appalachian Preceptorship is a four-week summer elective conducted by the Department of Family Medicine of East Tennessee State University (ETSU) that offers students clinical preceptorships in rural areas of southern Appalachia. By the conclusion of the 2004 preceptorships, the program had served 225 medical students from 95 medical schools across the country and abroad. The program combines an individual community-based preceptorship with an interactive group instructional block, emphasizes rural medicine, and provides students an understanding of the interface between culture and medicine in southern Appalachia. Follow-up of Appalachian Preceptorship students during the 18-year period studied demonstrates that 82% of the 157 participants who matched before 2004 had selected residencies in primary care, with 60% entering family medicine. Those completing the program were more than three times as likely to practice in a rural community compared with the national average. Fifty-six percent of their practice settings carry multiple rural or underserved designations. The program has helped transform a legislative mandate to train doctors for rural communities into an institutional culture leading to more extensive programs and a greater recognition of ETSU's rural mission. The authors encourage other medical schools to develop combined clinical/classroom electives that reflect their institutional priorities and that can address a wide variety of clinical interests.

A student-run outreach clinic for rural communities in Appalachia.

East Tennessee State University's Department of Family Medicine (DFM) implements a student-run outreach clinic series that addresses health care needs of communities in the southern Appalachians. Offered during the third-year family medicine clerkship, the clinics link academic family physicians and students with community health care providers. Services vary with each community's needs, but include history taking, physical examinations, patient education, and testing. The planning and implementation that begin with an annual meeting of faculty and community representatives include visits by DFM personnel to the rural communities and orientations of medical students conducted by faculty and community representatives. Students rate this experience highly because it provides them with useful hands-on experience, reasonable autonomy, collaboration with community providers, and understanding the needs of the underserved. Community hosts rate students highly in their respect for patients, sensitivity to confidentiality, and professionalism. Identified weaknesses are attributed to the fact that the outreach clinics were established in response to community needs and did not follow a careful curricular development. There was little attempt to standardize the procedures performed by each student or the amount of direct observation and feedback they received from their preceptors. Changes are underway that will strengthen the educational value of the outreach clinics. Participating students are provided a daylong orientation during which they practice full and focused physical examinations and review common medical problems such as diabetes, hypertension, and depression. Students also now document the patients encountered, their medical problems, and the clinical skills practiced.

Pediatric resident perceptions of public health education: learner-based insights into curriculum design and implementation.

OBJECTIVE: The purpose of this research was to evaluate a public health curriculum for pediatric residents from the learners' perspective, exploring resident attitudes, insights, and recommendations as to the most effective and learner-centric approaches to curriculum design and implementation in the context of graduate medical education. METHODS: Forty-five of 59 Children's Hospital of The Kings' Daughters (CHKD) residents participated in focus groups and individual interviews. All sessions took place between June and July 2012 and were audiorecorded, transcribed, and coded for major themes using NVivo software. RESULTS: The 5 major themes identified by this study included: 1) perceptions of public health relevance and impact, 2) time and competing priorities, 3) speaker-audience harmonization, 4) the need for practical solutions, and 5) individual tailoring. Study results paint a distinctive picture of residents' ideal public health curriculum-a less structured, more individualized educational opportunity that prioritizes small group discussions, maximizes speaker-audience interactions, and details a wide array of specific community-based programs and resources available to pediatricians and their patients. CONCLUSIONS: The learner needs identified through this research suggest that effective public health training for residents would include protected time for public health instruction, faculty development workshops, linkages with appropriate local organizations, and opportunities for each resident to pursue his or her own projects. Residencies that wish to address learner preferences in the development and realization of public health training would benefit from considering these characteristics in designing their curriculum.