Tracing new pathways to rural practice
 Suzanne Cashman |
 Linda Cragin |
 Rebecca Kasper |
Mirroring trends across the country, Massachusetts has had its share of health, economic, and social inequalities between — and within — its urban and rural populations. In response to these gaps, in 2000 the University of Massachusetts Medical School initiated an optional enrichment program, Rural Health Scholars Pathway (RHSP), to offer students hands-on experience in rural and small towns.
RHSP students participate in clinical placements in a range of provider locations developed to treat traditionally underserved populations. Monthly seminars complement these placements, with topics reflecting student interests and offering skill sessions, as well as discussing the realities of rural medicine from a professional and personal standpoint. Advanced practice nurses also participate, making the pathway interprofessional.
There are now 84 RHSP alums scattered across 25 states working in a variety of settings. More than half of graduates have chosen to practice a primary care specialty, and 70 percent are practicing in communities designated as underserved areas. To take a more detailed look at graduates’ career paths, Rebecca Kasper, MPH, a UMass class of 2018 RHSP participant, conducted interviews with a dozen alums, adding to seven that had been conducted the previous year. Using a questionnaire developed to trace the pathway’s impact on students’ career choices, Rebecca heard about the joys, challenges, and tough decisions of being a rural physician.
“Being the doc I want to be”
For interviewees in rural practice, a combination of professional and personal appeal drew them in, including the opportunity to have a larger scope of practice as a primary care doctor and to be more self-reliant. They are often the first to see complicated cases and enjoy the challenge of navigating diagnoses with fewer specialists readily available. Many are drawn to the slower pace, access to outdoor hobbies, and chance to settle into a small, tight-knit community.
A pediatrician in rural Washington describes how smaller communities support more diverse roles for their physicians: “I have time to offer other parts of myself to the community. I can be brought into the public in memorable ways outside of medicine — to really help inequity and make a difference in the community.” Her passion project is women’s leadership.
Interestingly, just as some wanted to “live, work, and treat my neighbors,” others wanted to live a few towns away to help reinforce the line between work and home that reflects both the blessing and challenge of rural medicine. Several spoke of the dream of being that “old-school family doc who everyone knows around town.” One family medicine physician in New Hampshire says her job allows her to “take advantage of my humanitarian aspirations every day I show up.”
Others spoke of pursuing their field of choice primarily so they could practice in a rural area. An emergency medicine doc bound for an EMS fellowship plans to move “north and rural” afterwards. Her goal is to work at a critical access hospital and help small towns gain access to emergency care. RHSP taught her how fundamentally different people’s lived experiences can be in rural and urban areas; she chose EM in part so she can help address these differences and their associated inequalities.
For the specialists among the alums, patient volume has kept most of them in cities, even if their hearts long for rural. Interviewees in urban practice cite resources and the need for university-based research opportunities as main tethers to big population centers. Others spoke about having a change of heart in residency: Despite planning on rural practice, a few realized they loved the acuity and pathology only a big city has the patient volume to provide. One alumna, however, found a way to combine care for very sick children with practice in a small community. She is one of three pediatricians running a 20-bed NICU in rural Washington State, and she knows exactly what that acuity can look like: “A NICU makes money for a hospital, so there is pressure to build more NICUs across small hospitals to help keep them afloat. With that comes a lot of stress about which babies to keep. We don’t see many really small, really sick kids, and so it can be stressful for the staff to mobilize people and resources quickly when something like a 25-weeker is born. And then we have to debate whether we can support the baby. There’s pressure to keep those kinds of patients. As a NICU attending, I am making those decisions about what is best for the baby, who can we care for, etc. This is the stuff that keeps me going.”
An orthopedist in Charlestown, S.C., with an interest in the visiting specialist model describes the upfront challenges of offering care to smaller outlying communities on a consultation basis: “Facilities with the right staff and equipment are needed, contracts must be negotiated, and it can mean significant provider commuting time.”
Commuting and family pressures were common challenges interviewees cited when leaving rural practice or not considering it in the first place. One grad describes it as a double-edged sword: “There’s a lot of draw to being out there by yourself, having the practice of your dreams, feeling like you’re really making a difference in your town. But I wanted my kids in better schools, so I was commuting almost an hour each way.”
Others described the challenges of having a partner also in medicine and trying to balance two career ambitions. Less access to specialists and support staff such as nutritionists or mental health specialists within the clinic also featured prominently as RHSP graduates’ biggest challenges in rural practice.
Benefits of community
To learn about rural health and grow as medical students, RHSP provided a small, like-minded community within the UMass family. Most RHSP students entered medical school with some inkling that they would like to work in rural practice or have a practice with a small-town feel — the camaraderie among staff and colleagues, a larger scope of practice, independence, and appreciation for the realities of the patients’ lives.
The companionship and support of like-minded students had particular impact on graduates bound for primary care, regardless of whether their practice was technically rural. One suburban pediatrician described going through each rotation of residency thinking, “What would a rural doc need to know here?” He cites RHSP as nurturing a self-reliant mentality: “I want to be able to start my own workups, do my own suturing, be a well-rounded doc and serve my patients as thoroughly as possible.”
Another describes feeling less afraid of rural medicine now that she has had the chance to shadow rural practitioners throughout medical school: “I can envision myself out there. Once I feel confident in my clinical skills, I think it would be really satisfying to go to a rural place and provide care to people who really need it. RHSP showed me new experiences and planted these seeds.”
Many spoke of how RHSP helped them see how every community, regardless of definition, has a special set of needs and nuances. Even if graduates don’t end up in rural areas, the opportunity to train with and be mentored by rural providers showed them the importance of learning to appreciate the impact every community has on patients’ health. For one pedi GI specialist, RHSP helped her become a doctor who is always tapped into local resources and knows how to serve her community. “As a pediatric specialist, my life will most likely always be urban. But I think learning about community and how to serve it was the most invaluable part of RHSP. It was the most impactful program I participated in at UMass Med.”
All interviewees agree that the pathway leaders had a tremendous influence on them. Each spoke of the leaders’ mentoring and support, as well as their creativity and humility in the work they do to benefit Worcester health care and advocacy. Many spoke of the specific value of having a mentor who was not a physician to challenge them to think about a broader health care landscape and create something if you don’t have what you need.
Developed on a slim budget, RHSP has found a strong partner in its state area health education center. Through this partnership, the program has been able to expand its reach and identify a modest source of funds to help underwrite student placements.
Whether in Massachusetts, Montana, South Carolina, or Washington, RHSP has had a significant impact on UMass Med alums, an influence felt in how as well as where they practice. Their patients are fortunate for it.