1. Coordinating the Goals and Objectives of Family, Rural, and Community Medicine through a Rotation Merger James Leeper, PhD Professor, Community and Rural Medicine Rural Programs Director of Education and Evaluation Rural Medicine Clerkship Director John B. Waits, MD Assistant Professor, Family Medicine Assistant Professor, Obstetrics and Gynecology Family Medicine Clerkship Director (former) Family Medicine Residency Director University of Alabama School of Medicine Tuscaloosa Campus College of Community Health Sciences

2. Tuscaloosa Birmingham Huntsville

3. Current Structure Birmingham: All students (currently 176 per year) take 2 years of basic science courses on the Birmingham campus. One hundred remain in Birmingham for their clinical training.

4. Current Structure Huntsville: Thirty-five third-year and 35 fourth-year students transfer from Birmingham for clinical training. This program began in 1972 and is 95 miles north of Birmingham, has a Family Medicine residency program

5. Current Structure Tuscaloosa: Thirty-five third-year and 35 fourth-year students transfer from Birmingham for clinical training. This program, began in 1972 and is 60 miles southwest of Birmingham, has a Family Medicine residency program

6. UASOM History of Community/ Rural Medicine Rotation Tuscaloosa was unique among the three- campus UASOM until 1993 in terms of having a required Community Medicine rotation in a rural community for all medical students.

7. Timeline 1975-80: 2 months in 4 th year (During this time there was no Family Medicine rotation. The students were placed with rural primary care physicians and split their time between clinical practice and community medicine.)

8. Timeline 1980-82: 1 month in 4 th year (primarily community medicine) 1982-86: 5 weeks in 3 rd year (allowed some clinical exposure) 1986-90: 6 weeks in 3 rd year integrated with Family Medicine

9. Timeline 1990-93: 4 weeks FM followed by 2 weeks CM in 3 rd year 1993-2005: In 1993 the UASOM decided to have a required rural medicine experience on all three campuses

10. 1993-2007 Tuscaloosa: 4 weeks FM followed by 4 weeks RM in 3 rd year (both in same rural community) (1 week of FM in Tuscaloosa) Huntsville: 4 weeks of primary care in rural community in 3 rd year Birmingham: 4 weeks of primary care in rural community in 3 rd year (recently made a selective and available in 3 rd or 4 th year)

11. Rural Medicine Content Two-week Community Health Assessment (review of community systems) –Agency visits/interviews –Leader interviews –Common citizen interviews –Farm visit

12. Content Two-week Special Project (investigation of specific health-related issue and recommendations to community) Pass/Fail grade based on two oral/written reports. Students keep daily log and log of interviews. Graded by Community and Rural Medicine faculty and community preceptor.

13. Outcomes UASOM Data for Matriculants - % FM Campus1989-19961997-2004 Birmingham10.34.4 Huntsville28.523.6 Tuscaloosa22.225.9

14. Medical Student Comments “My preceptor was excellent, not only for his medical expertise, but also in his willingness to expose me to the entire rural medicine experience from the business aspects to the interactions with the community, including sampling of local culinary specialties. I appreciate the fact that one could experience a great deal of satisfaction from taking care of an individual in all aspects of his/her life. My experience in Carrollton made me consider primary care as an option when once it was not even in the running....I also recommend doing both Family Medicine and Community/Rural Medicine at one site because it allows one to develop a rapport with the community and the health care system so that he/she is better able to analyze the needs and concerns of the community and how they relate to patient care.

15. Medical Student Comment “I learned how it takes a community and everyone contributing in their own way to provide for a healthy environment to live in medically, politically, and socially. I encourage other students to participate in the community as much as possible, to get to know people nad to become a part of that community.... I found that after being here I was more of a member of the community after my rural medicine rotation because of my community involvement than I did after a month of seeing patients in the clinic or the hospital. I’m actually a little disappointed that I have to leave, which I would have never dreamed of a month ago.”

16. New Developments Rural Medical Scholars (RMS) in 1996 –Recruit 10 students per year from rural Alabama into a 5-year program of study. –From 1997 – 2004, 47.8% have selected FM. Tuscaloosa Experience in Rural Medicine (TERM) in 2007 –Third Year: 4 months at rural site (FM, RM, IM, OB/GYN, PEDS, Surgery) –Fourth Year: 2 months of acting internships plus up to 4 months of electives at rural site

17. Family Medicine / Rural Medicine circa 2006 Family Medicine – 1 month –Traditional Family Medicine –Rural location –1 week on Inpatient service in Tuscaloosa –1 day of further contact for Case Presentations Rural Medicine – 1 month –Same Rural Site –Community Diagnosis –Community Medicine didactics and case presentations in Tuscaloosa 2-3 Fridays of the month

18. Challenges and Feedback Students: –More time with preceptor –More time to start (and complete) a project of significance Preceptors: –More time with students “Where do they go for a week? Why?” “Why don’t the full-time faculty teach them about _____?” –More input into their community involvement: “What are they doing for a month in my community? I never see them.” “They studied what? Why didn’t they talk to so-and-so? I’m on the board of such-and-such with them!”

19. Changes for 2007 2 month rotation 60% time (6-7 half-days in preceptors office, doing clinical medicine) 2 Fridays for didactics with the Family Medicine faculty 1 Friday for case presentations with FM faculty Community Diagnosis begun on day #1, 2 months to complete (not 1), and ongoing involvement of preceptor (since they remain in his/her office).

20. Outcomes (Challenging to Measure) Students with more time for project and more longitudinal (i.e., continuity) time in the preceptor’s office Preceptors with more time to teach and more input into projects Faculty with preserved academic input into students on their rotation –… although students interested in Family Medicine still comment that they don’t know the Family medicine faculty well