November 2019, Volume XXXIII, No 8

Special Focus: Rural Health

Medical Care in Greater Minnesota

The changing face of community needs

rom its inception, the clinical mission of the University of Minnesota Medical School’s Duluth Regional Campus has been to prepare students to address the unique health needs of Native Americans and other patients in Greater Minnesota—and to encourage them to remain in rural areas as they launch their practices. Classwork, special programming, active solicitation of rural preceptors, and increased rural rotations and residencies are all key to this effort.

History

The 1960s were formative years; rural Minnesota physicians were very concerned with the lack of rural physicians being trained by the University of Minnesota Medical School and with the increasing need for rural access to health care. The Legislature responded by forming the Rural Physician Associate Program (RPAP) in 1971 and the School of Medicine in Duluth in 1972. RPAP has remained true to its mission, producing nearly 63% family medicine and 75% primary care physicians. Both programs also produce future rural general surgeons and other specialists. There are nearly 1,200 RPAP graduates, with approximately 40% now practicing in rural communities. A four-year school medical school in Duluth was proposed, but this final promise was never fulfilled.

Our first class of 24 students matriculated in 1972 and has since grown to 65, with a steady increase in Native American students. Our Native American graduates are second highest in the nation. Among the students we have trained, 44% practice in communities of 25,000 or less, and 63% practice in Minnesota.

Family medicine is still the best answer for small communities.

It is important for all medical students to have early and frequent clinical patient care experiences. Rural-focused family medicine residency sites are essential in providing training and capturing as many of these students as possible and in promoting future rural health needs, since residents tend to practice in the areas where they trained.

Duluth is a two-year basic science school, making it one of the few in the nation. We have learned over the decades the importance of carefully evaluating each applicant to determine whether they fit our mission. Admission criteria include a rural background, comfort living in rural communities, intention to practice family medicine or other primary care specialty, and to do so in rural Minnesota. Our curriculum further reinforces our mission with a rural focus in basic sciences and rural clinical rotations in years one and two.

A changing rural workforce

Rural medicine physicians in the 1960s were usually general practitioners who covered most of their community’s needs, including office visits, hospital care, some surgical procedures, obstetrics, and nursing home and emergency care. Many of them were solo practitioners, but small single and multispecialty groups were emerging. Since then we have seen many changes. We have been training a broader range of health care providers and preparing them to deal with increasing regulations, complex electronic medical record systems, payment requirements, continuing education requirements, and more.

At many clinics, rural family physicians now cover emergency rooms, work as hospitalists, serve in nursing home-focused geriatrics, and practice in numerous other settings in concert with an increasing number of nurse practitioners and physician assistants. The demand for rural physicians and other health care professionals remains high to cover both this increased workload and vacancies due to retirements.

Changing demographics

Rural populations—along with populations across the nation—are aging. In Greater Minnesota, more of our youth are leaving and families are dispersing. Our aging population struggles with following family or remaining in the community. Many of them prefer to receive care at home or at local providers. When they must travel to receive care, transportation can be a major challenge. In every way possible, we must afford all Minnesotans uniform standards of care, respecting the golden years and access to specialty care.

At the same time, birth rates are dropping. Financial and risk models are causing Critical Access Hospitals to drop obstetrics. Geographical coverage areas can be huge, and with shrinking populations, we will see further closures of rural hospitals. Telemedicine has helped, but also has changed the skillset required of rural health care workers and providers.

Medical education is aware of these issues but cannot turn on a dime. It really is akin to changing the course of an ore boat on the Great Lakes, since changes made today will not become apparent until students complete four years of medical school and at least three years of residency before practice.

These challenges face health care providers across the country, but are compounded by the lower numbers of physicians in rural areas.

Bringing rotations to Greater Minnesota

The need for primary and specialty physicians continues to grow across the state, with medical school class size expansion dependent in part on access to clinical rotations. In response, we must extend our reach for basic and specialty clinical rotations beyond the Twin Cities to include Duluth, St. Cloud, and rural Minnesota. Health provider clinical teaching at practice sites should be expected, recognized, and rewarded.

The demand for rural physicians ... remains high.

My vision is that the 65-member student class from Duluth—and RPAP participants in the Twin Cities—will be trained in rural Minnesota. It would be ideal if each Twin Cities student could participate in a one–two week rural rotation in year one or two—or in both years. Learning in a rural community teaches important skills of isolation, distance, resource limitation, and disposition needs that cannot be taught in the classroom or an urban rotation. Year four may also require time in an academic center.

But increasing rural clinical training raises issues of student housing. We cannot expect our clinical learners to pay for housing at the site during short rotations while also maintaining a permanent address elsewhere. Rural communities could help by providing housing for students with financial support from local trades and professions, thereby ensuring a future community workforce. Hospitals also recognize this problem, and I am hopeful that they can step forward to help make housing available for learners. Local communities might also convert tax-forfeit housing to free or low-cost student housing.

Keeping it local

Former Sen. Dave Durenberger once stated that “all health care is local.” Medical care in the future will continue to reflect local needs, changing treatments and diagnostics, regulations, health plan reimbursement, and more. National support is needed to maintain access in our rural and other diverse communities, and to ensure adequate practice sizes that will decrease burnout risk and possible loss of physicians.

Family medicine is still the best answer for small communities. Telemedicine cannot replace human-to-human interaction. Because of skills and experience, broadly trained family physicians are necessary to ensure the breadth of rural health care. Emergency services are also vital, particularly in Minnesota’s frontier and mountain-like areas, where travel is difficult, particularly for the elderly.

All of this requires a renewed focus on training health professionals and health administrative professionals in rural areas. Reading the “tea leaves” is difficult. Variables include insurance coverage, personal responsibility for care, family support, and so much more. Consolidations and changes in service models will continue, many locally driven. Local system success must include the voice of the local physicians.

Training physicians in rural areas and boosting clinical rotations could be part of the solution.

A personal appeal

Rural Minnesota hospitals and physicians need your help. Students who have served in rural rotations report excellent teaching and experiences. They appreciate being welcomed by preceptors, staff, and patients. Rural physicians, please consider precepting, and work with us to make sure that the value is recognized locally, both in training and as a recruitment tool. Many of our students have returned to the sites of their rotations.

Also, help us with housing. Make learners welcome at your sites; they may be future partners. I enjoy the buzz listening to students returning from preceptorships, comparing experiences, and learning. Medical students generally are in medical school to learn and practice patient care. It is always a joy to see students excited about heading out to preceptorship.

Rural Minnesota needs you.

Raymond G. Christensen, MD, is a rural family physician and co-founder of Gateway Family Health Clinic, Ltd., where he practices one day per week. Since 2002 he has served as the Assistant and now Associate Dean for Rural Health for the University of Minnesota Medical School. His office is on the Duluth campus. 

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Raymond G. Christensen, MD, is a rural family physician and co-founder of Gateway Family Health Clinic, Ltd., where he practices one day per week. Since 2002 he has served as the Assistant and now Associate Dean for Rural Health for the University of Minnesota Medical School. His office is on the Duluth campus.