Rural Medicine

Overview

During the third year of residency, each resident does a two-month rotation on rural medicine at the Williamsburg satellite family practice office. While on this rotation, each resident spends four half-days per week seeing patients under the precepting of AFP faculty, primarily Drs. McLellan, Siems and Morrow. The resident is responsible for the medical care, diagnosis, treatment, and follow-up of patients who are seen while at the Williamsburg office. Also, the resident is often called upon to deal with patients presenting with walk-in urgencies such as lacerations to be repaired. Occasionally the resident will also perform pre-participation sports physical exams on Williamsburg grade school and high school students, as well as routine school physical exams on the kindergarten, sixth, and eleventh grade students.

Additionally, the resident on the rural medicine rotation spends two half-days rounding on nursing home patients, again under the supervision of AFP faculty. That resident also sees patients at the AFP office for four half-days per week while on this rotation.

Altoona Family Physicians

Rural Rotation Goals and Objectives

Resident Year: PGY-3

AFP Faculty Contact: Fiona M^cLellan, MD

Rotation description:

The rural rotation is located primarily at Williamsburg Family Practice located in Williamsburg, PA, about 18 miles from the Altoona Hospital Campus. An alternate rural location is the Glendale Medical Center in Coalport, PA, also about 30 minutes from the main hospital campus. Four half days per week are spent in the Rural setting, two half days at the Center for Nursing Care in Altoona caring for acute and long-term nursing home patients, and the remaining four half days are spent seeing continuity patients. This rotation allows the resident to experience first-hand the challenges and rewards of practicing in a rural setting with limited medical resources. Additionally, this rotation exposes the resident to the qualities of community life, such as local pride in and support of its hospital, the schools, churches and community activities. Williamsburg Family Practice serves as the school physician for the Williamsburg School District. The practice frequently performs pre-participation sports physicals as well as age-appropriate school screening physicals for the school district. Faculty and residents are closely involved with the school district serving on the Pandemic Flu Committee and providing Team Physician support for the high school football games. The resident on the rural rotation has ample opportunity to draw upon his/her accumulated pool of knowledge in a real life setting some distance from the training program.

Goal:

The overall goal of the rural rotation is to train family medicine residents to be competent and confident to practice in remote community settings.

Patient Care:

Goal:

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:

Competencies:

	Demonstrate an ability to gather essential and accurate patient information to assess patient concerns including common ambulatory complaints and possibly serious advanced disease states in patients who have not had routine healthcare.
	Demonstrate the ability to practice medicine in a rural setting without immediate access to consultants and sophisticated diagnostic equipment.
	Demonstrate the ability to provide immediate management for urgent medical problems that present as walk-in cases such as acute asthma, chest pain, bee sting anaphylaxis and acute injuries/lacerations, including stabilization and preparation for transport to the hospital if needed.
	Demonstrate the ability to provide healthcare in the acute and long-term nursing home setting.

Objectives:

Residents are expected to:

	Become increasingly proficient at evaluating patients presenting in the rural setting with both acute and chronic problems.
	Learn how to manage common injuries and urgent or emergent conditions that may present in a setting some distance from the nearest hospital.
	Be flexible with scheduling of patients who have urgent needs given the distance to the hospital and the frequent likelihood of the patients having transportation problems.
	Become independent in the performance of procedures such as skin cryotherapy, joint injections, skin lesion removal and other common ambulatory patient procedures.
	Become independent in the care of the nursing home patient including taking calls from the nursing home and making rounds on acute and long-term care patients.

Medical Knowledge:

Goal:

Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents are expected to:

Competencies:

	Demonstrate knowledge and understanding of the need for rural primary care practitioners to be proficient in all areas family medicine including OB/Gyn, pediatrics, orthopedics, and office procedures.
	Be able to develop patient-centered treatment plans for patients presenting in the rural setting based on comprehensive, risk-based assessments that take into account the cultural, linguistic and socioeconomic background of each individual.
	Demonstrate the knowledge required to manage the acute and long-term care nursing home patient.

Objectives:

Residents are expected to:

	Learn the components of both problem-focused and preventive care examinations, including pre-participation sports physicals, and demonstrate how to perform these exams in the rural office setting, including necessary procedures and/or office laboratory testing.
	Demonstrate knowledge of office based emergencies sufficient to independently manage patients presenting with urgent or emergent health care needs in the rural setting.
	Complete FP Essentials topics including pre and post tests on Adult Office Urgencies, No. 289 and The Patient in the Long-Term Care Facility, No. 315, and Care for elderly individuals, No. 297. Review pertinent topics covered in earlier rotations including Childhood Office Emergencies, No. 338, and Healthy Older Adults, No. 344.

Practice- Based Learning and Improvement:

Goal:

Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life long learning. Residents are expected to develop skills and habits to be able to:

Competencies:

· Identify strengths, deficiencies and limits in one’s knowledge and expertise

· Set learning and improvement goals

· Identify and perform appropriate learning activities

· Use information technology to optimize learning

· locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems.

Objectives:

Residents are expected to:

	Use the pre and post tests and other resources listed to identify limitations in knowledge needed to practice in a rural setting, and to set learning and improvement goals in conjunction with their faculty advisor.
	Use the information technology available to them to manage and retrieve information and support their own education in rural medicine.
	Learn to recognize the impact of geographic and cultural specific environments on patient care.

Systems Based Practice:

Goal:

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:

Competencies:

	Coordinate patient care within the health care system relevant to their clinical specialty
	Incorporate considerations of cost awareness and risk-benefit analysis in patient care

Objectives:

Residents are expected to:

	Learn about the operation of a small rural office within the context of the larger regional health system, demonstrating an understanding of the barriers to, and limitations of healthcare in a rural area.
	Demonstrate familiarity with the resources available within the community, as well as how to effectively access resources outside of the community in the care of rural patients.
	Gain an appreciation for the lifestyle in a rural community and the important role the family physician has in a small rural community.
	Learn how to select formulary drugs in the nursing home and rural ambulatory setting to optimize cost-effective care for their patients.

Professionalism:

Goal:

Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate:

Competencies:

	Compassion, integrity, and respect for others
	Responsiveness to patient needs that supersedes self-interest
	Respect for patient privacy and autonomy
	Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation

Objectives:

Residents are expected to demonstrate:

	Responsibility in patient care by responding in a timely fashion to all pages from the nursing home and to telephone messages from patients.
	Respect for patient privacy in a small rural office where patients in the waiting area and other areas of the office frequently know each other, and often the patients are neighbors or acquaintances of the staff members.
	Sensitivity and responsiveness to each patient’s culture, age, disability and sexual orientation during every patient encounter in the rural and nursing home setting.

Interpersonal and Communication Skills:

Goal:

Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Residents are expected to:

Competencies:

	Communicate effectively with patients, families, physicians, other health professionals, and health related agencies
	Maintain comprehensive, timely, and legible medical records

Objectives:

Residents are expected to:

	Continue to develop communication skills with special attention to the unique medical needs of a rural population, especially regarding coordination of care between the specialist and the primary care team.
	Be able to retrieve and discuss patient information handouts from reputable internet sites such as www.familydoctor.org. This is especially important in the rural setting where internet access may be limited for financial and geographic reasons.
	Maintain complete, timely and legible medical records on all patients seen in the nursing home and in the rural office, relaying care information to the primary care physician where applicable in a timely manner.

Teaching Methods:

The principal teaching during this rotation occurs during precepting of patients seen in the rural office setting. The faculty use the patient encounters to illustrate aspects of care that differ in the rural setting. Teaching also occurs at the Center for Nursing Care where acute and long term care patients are discussed with the attending and on occasion clinical bedside rounds occur together. The resident also learns about the many facets of care in a nursing home setting by meeting with representatives from the different departments such as physical therapy, speech therapy, occupational therapy, as well as meeting with the dietitian and wound care specialist.

Assessment Method (residents):

Each resident on the Rural rotation is evaluated using a competency-based evaluation tool at the end of the rotation. These evaluations are completed by the rural attending physicians. They are reviewed by the family medicine faculty quarterly and reviewed with the resident at the resident’s quarterly evaluation.

Assessment Method (Program Evaluation):

Each resident is expected to complete a written evaluation of the rural rotation and of the attending physicians involved in teaching at the rural site. These evaluations are reviewed by the faculty member that coordinates the rural curriculum.

The rural curriculum is reassessed annually as part of the Altoona Family Physicians annual curricular review.

Level of Supervision:

The rural resident is supervised while seeing patients in the rural office by the on-site attending physician preceptor for each half day. At the Center for Nursing Care the resident has attending supervision either in person while rounding or via pager if not on-site with the resident.

Educational Resources:

Geyman JP, Norris TE, Hart LG, Textbook of Rural Medicine, 2000, McGraw-Hill Professional.

Howard K. Rabinowitz, Caring for the Country: Family Doctors in Small Rural Towns, 2004, Springer.

Rosenblatt, A View from the Periphery--Health Care in Rural America, 2004 N Engl J Med 351:1049.

AAFP FP Essentials, No. 289, Adult Office Urgencies.

AAFP FP Essentials, No. 315, The Patient in the Long-Term Care Facility.

www.familydoctor.org for patient education materials

www.ruralhealthweb.org for resources about rural healthcare

Sample Schedule:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
AM Noon PM	CNC Conference AFP	WFP Conference WFP	AFP Conference AFP	AFP Conference CNC	WFP Conference WFP
AM Noon PM	CNC Conference AFP	WFP Conference WFP	AFP Conference AFP	AFP Conference CNC	WFP Conference WFP
AM Noon PM	CNC Conference AFP	WFP Conference WFP	AFP Conference AFP	AFP Conference CNC	WFP Conference WFP
AM Noon PM	CNC Conference AFP	WFP Conference WFP	AFP Conference AFP	AFP Conference CNC	WFP Conference WFP