October 21, 2010

Dear RoundTable readers:

Here in New England we're very fortunate to have two thriving Rural Health Scholars Programs, one at Dartmouth Medical School and the other at the University of Massachusetts Medical School.

Although we've written about the programs in past issues, it's time to do a "special" and introduce you to the outstanding students and their program directors who are passionate about rural health. You'll meet some of the students, learn about their backgrounds, and get a sense of the motivating forces behind their decisions to "go rural."

Dartmouth Rural Health Scholars Get Early Taste of Rural Medicine

At Dartmouth the RH Scholars Program, founded 12 years ago, is co-directed by Dr. Cathy Morrow and Susan Linsey and is based in the Department of Community and Family Medicine. Usually there are 4 or 5 students coming into the program each year but last year there was a bumper crop - 14 interested students, all exceptionally well qualified, and so, "going out on a limb," Dr. Morrow accepted all. Many had already had a variety of work experiences in rural areas, some in the Peace Corps or other service agencies. This week Dr. Morrow will be interviewing 8 applicants from the incoming first year medical school class. Students already in the Program are her best recruiters, Dr. Morrow said.

After completing the first two years of basic sciences, the Rural Health Scholars then have a variety of opportunities to get a taste of rural medicine. In their fourth year, the Scholars do a month long rotation in rural communities, working in community health clinics, FQHCs, rural health clinics, and with private physicians. Dr. Morrow is especially grateful to all the physicians and agencies who take the time to mentor the Rural Health Scholars and give them real-world rural health exposure. It's an enormous contribution, she said, and a crucial part of the rural experience.

On Nov. 5, Dr. Morrow and the staff are running a "Medical Student for a Day" program, to introduce students with an interest in medicine to see what it's really like be a student at Dartmouth. Students from Plymouth State and Keene State Universities, the University of New Hampshire, and Colby Sawyer College are invited, with the Rural Health Scholars acting as hosts. And a similar "day" will take place in the spring. This very successful event is a way to attract students who might not have thought of going into rural medicine. With all the pressure of being in medical school, the Scholars still have time for fun and bonding- such as their recent Leadership ( learning) weekend on Oct. 22. They rented a cabin from Dartmouth and had faculty on hand to guide them in a session on rural leadership.

Meet Neil Young

Rural Health Scholar
Neil Young

Neil is now in his second year as a Rural Health Scholar; his very varied background is probably rather typical of those in the program - that is, it's definitely a-typical! In other words, Neil didn't proceed straight from undergraduate college to medical school. After finishing with a degree in biology from Southern Connecticut State University, he served in the military for 5-1/2 years as a Navy Hospital corpsman, four of those years on a Navy ship and then at a VA hospital in Rhode Island.

At Dartmouth, Neil created the "Partners in Community Health" project, which involved developing a list of health-related resources to be distributed at community health fairs, farmers markets, and other venues (even super markets). Neil explained that resources in NH and VT are listed and explained in a binder that is carried with the health fair equipment. Volunteers working at the health fairs receive training on the resources and can help those who come to the fairs (especially the un and under-insured individuals) find the best contacts - i.e., federal and state agencies, hospitals and other agencies set up to help people in need. As Neil says, having someone knowledgeable about resources can really help the hypertensive from Fairlee, Vt or the hyperglycemic from Claremont, NH in following up on treatment.

Read more about the Dartmouth Rural Health Scholars program.

New Leadership for UMASS Rural Health Scholars Program

Dr. Stephen Martin is now co-director with Dr. Suzanne Cashman of the UMASS Medical School Rural Health Scholars Program, created in 2000 by Dr. Cashman. He succeeds Dr. Joe Stenger (well known to RoundTable members and a former recipient of our Rural Clinician award in 2005), who has gone on to pursue a fellowship in palliative care.

Dr. Martin is a graduate of Harvard Medical School, served in the National Health Service Corps where he worked in a federal prison medical center, and was on the staff of a clinic in the North Quabbin (MA) area for several years. He and Dr. Cashman oversee some 27 students which includes both medical and graduate nursing students.

The best way to describe the successful UMASS program is to let the students speak for themselves! We recently interviewed by phone two of the scholars and although their life experiences are different, their enthusiasm for rural medicine comes through loud and clear.

Genevieve Verrastro has already chalked up more volunteer experience than some of us have in a lifetime. When we spoke with her, she had just returned from a stint doing patient care with the Indian Health Service in New Mexico. As a fourth year student in the Rural Health Scholars Program, Genevieve has a degree of flexibility in her work this year. At the moment, she is doing a one month cardiology rotation at University Hospital, Worcester.This summer she joined students from the University of Connecticut to bring medical care to migrant workers in the tobacco fields of Connecticut. This was challenging work: the men (mostly Mexican and Jamaican) worked long hours in the hot sun. The students, who worked in mobile health clinics, were fairly limited in the treatment and medications they could offer. Those workers in need of more treatment were usually seen in a local community health clinic. Each day she traveled from her parents' home in Massachusetts to a different farm.

Genevieve Verrastro at Machu Picchu, Peru

Genevieve grew up in Pelham, MA and attended Oberlin College. She loves the out doors and said when she decided to become a doctor she knew she wanted to practice in a small town. After graduating from college, she joined AmeriCorps and spent a year in Providence, RI and another year in New Mexico living in very isolated communities. In her first year at UMASS she was part of the Rural Health Scholars and the Pathways program in international health. After completing her first year she spent six weeks volunteering in rural communities in Peru. Although she is a member of the class of 2011, Genevieve has decided to spend an extra year either doing public health research or working overseas before graduation. Eventually she will apply for a residency in family medicine. Genevieve says she has found the RHS program to be a "fantastic" resource.

Matt Ducey, class of 2012, says that working with Dr. Alexandra Schultes, a family medicine doctor in the Barre (MA) Family Health Center during his first two years as a rural health scholar gave him the vision of what a "small town doc" should be. He describes his preceptor at Barre as "awesome." (The Barre Center is partnered with UMASS Medical School.) Matt grew up in Wareham, MA and attended Providence College in Rhode Island. There he decided that city life wasn't for him! He quickly joined the Rural Health Scholars Program when he arrived at UMASS and says he's enjoyed everything it has to offer. Currently, Matt is on a psychiatric rotation at Worcester State Hospital, where he is working on an adolescent unit with 14 to 18 year olds. Matt's early contact with the health care system stemmed from his experiences growing up, from the viewpoint of "patient and patient advocate" as he observed his family physician treating a family member. As he moves through the various clinical rotations in his fourth year, Matt says he is leaning toward working in a rural area upon graduation. He's an enthusiastic advocate for the RH Scholars program and encourages new students to join the program to learn more about rural medicine and the opportunities it offers.

Although we weren't able to speak directly with Hannah Melnitsky, a 2010 graduate of UMASS Medical (she is currently in a family medicine residency in Dallas), her "bio" includes a variety of experiences that had an impact on her life choices. She spent more than two years in the Peace Corps, working as a rural health and sanitation volunteer in a remote village of El Salvador and found that she loved living in such a rural area. This led her to joining the Rural Health Scholars program when she began medical school in 2006. She did a community clerkship in the rural North Quabbin area and other clerkships in the Berkshires. Hannah had a distinguished career in medical school; she was named one of two UMASS Medical School 2010 Massachusetts Medical Society Scholars for "excellent academic performance, community involvement, and financial need."

Read more about the UMASS RHS Program.

Rural Health Scholars Programs Across the U.S.

As you might expect, there are rural health scholars programs across the country - in Kentucky, Mississippi, Texas, Tennessee, and W. Virginia, to name a few. In some instances, the rural track begins in the undergraduate years - or even in high school - to help students move smoothly into the health professions in graduate school.

It's no surprise that medical students from rural communities are the most likely to practice in a rural setting when they complete their training. This factor, combined with the often-expressed "love of the outdoors," and "opportunity to work with people in a small community" are among the most powerful reasons for going into a rural scholars program.

The University of Louisville has this observation: "A student who begins with an affinity for small town practice often attends college in a larger city. Next, many students enter training programs that require them to be in large medical centers for another 4-12 years. By the end of this phase, termed 'urban disruption,' the student has become accustomed to big-city amenities." To counteract this, The Trover Campus (U of Louisville) offers students from small towns another two years away from the "urban distraction."

A quick search of PubMed pulls up recent articles on rural medicine and education. Here are some citations:

Journal of Rural Health, 2010 Winter; 26(1):97-9
WJ Crump et al., University of Louisville School of Medicine, Trover Campus, Madisonville, KY

Just What are Rural Premedical Students Thinking?
The paper assessed outcomes of the first 6 years of a program designed to facilitate medical school admission for rural premedical students. 

Rural Health. 2008 Fall;24(4):375-83.
The primary care physician workforce in Massachusetts: implications for the workforce in rural, small town America.
Stenger J, Cashman SB, Savageau JA, Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts, USA.

"Small towns across the United States struggle to maintain an adequate primary care workforce." The authors surveyed factors contributing to physician satisfaction and retention in largely rural areas in Massachusetts.

CONCLUSIONS: "Our findings reaffirm the importance of rural medical education opportunities in physician recruitment, retention, and practice satisfaction." They also indicate that in a small New England state, a major source of physicians for rural and small town communities is physicians who have been raised in urban/suburban communities and who were trained outside of the region but who were prepared to live and to practice in rural and small town communities."

J Agromedicine. 2007;12(4):51-61
Rural health leaders pipeline, 1990-2005: case study of a second-generation rural medical education program.
Wheat JR, Brandon JE, Leeper JD, Jackson JR, Boulware DW, Community and Rural Medicine, University of Alabama College of Community Health Sciences

A pipeline model has been suggested to increase the rural physician supply. This study is an institutional case report used to describe the context, development, and in-house evaluation of the University of Alabama Rural Health Leaders Pipeline, 1990-2005.

Please send your news to Dot Bergin - dobergin@gmail.com or 781-275-7071.