The Rural Physician Associate Program (RPAP) of the University of Minnesota Medical School, USA, has been training medical students since 1971. The program was established to address a shortage in primary care physicians in rural Minnesota. A 36 week community-based elective, RPAP places between 30 and 40 third year medical students per year in communities ranging in population size from 3000 to 20 000. Students apply from two campuses: Twin Cities and Duluth.
While interest in primary care residency training has been declining over the past several years, the RPAP program continues to produce students interested in primary care. To date, 78% of the 843 former RPAP students now in practice are in primary care (including family medicine, internal medicine, and pediatrics). Seventy-six percent of former RPAP students currently in residency training are in primary care programs.
Since 1971, 1063 students have completed the RPAP program. While in RPAP, students evaluate and treat patients in the clinic, hospital, emergency room and nursing home, assist in surgery; consult with other health care professionals; serve as a resource to the community; and participate in educational activities during the year. Depending on the site, students may complete up to 24 required weeks from specialty rotations including urology, orthopedic surgery, general surgery, pediatrics, obstetrics and gynecology, and the primary care clerkship.
In a typical day, a student will accompany a physician on hospital rounds, assist in surgery or a delivery, pursue independent study and evaluate patients in the clinic. Students learn about problems commonly encountered in primary care from routine health maintenance to medical emergencies and rare and unusual diagnoses. They take call with their preceptors and see patients in the emergency room, admit patients to the hospital or are involved in after-hours surgery or deliveries. During the 9 months, students often diagnose a pregnancy, follow for 9 months, participate in the delivery and see the newborn for a first examination in the clinic. They diagnose patients in the emergency room with a surgical problem, first-assist in surgery, follow the patient post-operatively and see that patient for follow-up visits in the clinic. Occasionally they diagnose patients with cancer or another terminal illness and follow that patient until they die.
A recent article speculating on the future of primary care medicine reflects on the decreasing trend of medical students matching in primary care residencies1. Suggesting that this might be the harbinger of a crisis in primary care medicine, the authors consider the possible causes and solutions.
If residency programs were designed to impart the knowledge, skills and attitudes needed to care for patients with chronic disease, students who were genuinely interested in meeting the most important challenge facing medicine-providing high-quality ambulatory care for such patients-would recognize the exciting opportunity that primary care medicine offers.
RPAP students write essays about their experience primarily to inform future students about their experience and their community. They consistently write about the value of functioning autonomously - as an independent learner and a as a healthcare provider. They write about working side-by-side with preceptors who teach by word and caring example the essence of primary care. They value the relationships with patients and the opportunity to provide continuity of care and to make a difference in patients' lives and in the life of the community.
Historically, in the US, the number of students who were matched with primary care residency programs increased each year from 1992 to 1997. In 1998, this number began to decrease and has continued to decrease every year since. Participation in the RPAP program has ranged from a low of 19 students in 1984 to a high of 43 students in 1996. The average participation is 32 students. Of the 843 former RPAP students in practice, 541 (64%) are practising in Minnesota, and 521 (62%) are practising in rural communities in Minnesota or other locations. Of the 843 practising physicians, 656 (78%) are in primary care, including family medicine, internal medicine and pediatrics. Of the 135 residents currently in training, 103 (76%) are in primary care programs. Since 1998, 83% of our RPAP students have gone into primary care residency programs.
What are the factors that lead to the ongoing success of the RPAP program in meeting the original objectives of providing rural primary care physicians to the State of Minnesota? Certainly selection is one factor. Those students who choose to spend 9 months in a primary care setting in a community site have an increased interest in that experience. The Duluth campus curriculum emphasizes the training of rural primary care physicians and provides a foundation for students interested in other types of rural medical practices. Since 1971, the rate of RPAP students from Duluth going into primary care is 89%; since 1998 it is 87%. Comparatively, the Twin Cities campus rate since 1971 of RPAP students going into primary care is 79% and remains 79% since 1998.
Whitcomb and Cohen suggest that the traditional third and fourth year clerkships, which are primarily inpatient, provide few opportunities to experience models of chronic disease management by teams of health professionals guided by principles of care and supported by information technology1. Further, they suggest that students are discouraged from primary care, based on a concern that they will not be adequately prepared to meet the responsibilities of such a practice.
Ludmerer writes about the 'persistent concern among medical educators that medical education has ceased to be an invigorating intellectual experience'2. He suggests that students need tutorials and individualized instruction, in addition to close interactions and conversation with experienced, mature physicians in the work of ongoing patient care. He is promoting learner-centered medical education and writes that 'meaningful, ongoing relationships between faculty and students are essential for the development of true professionals'.
While the RPAP program attracts students with an interest in primary care or community-based patient care, the fact that there has not been a significant decrease in interest in the program or the rates of matching and practising in primary care, is evidence of the value of the program in meeting its original goals. RPAP was designed from its inception as a learner-centered medical education experience in the context of a mentoring relationship with a primary care preceptor, many of whom are former RPAP students. While each community and preceptor varies in the approach to the management of chronic disease and access to supportive resources (some actively participate in the use of practice guidelines and have electronic medical records that support quality initiatives), all have the common variable of providing a continuity experience with physicians and patients. Students leave their RPAP communities with an excellent understanding of what it really means to practice primary care in a community and many continue to make it their specialty.
Thanks to former directors Drs John E Verbey, Jr and Walter M Swentko for developing and nurturing the RPAP program and to our RPAP site preceptors for the mentoring and learner-centered education they provide.
1. Whitcomb ME, Cohen JJ. The Future of Primary Care Medicine. New England Journal of Medicine 2004; 351: 710-712.
2. Ludmerer KM. Learner-centered medical education. New England Medical Journal 2004; 351: 1163-1164.