Doing a rural training rotation? You may be eligible for some reimbursement

You don’t have to travel to the ends of the earth for a transformative learning experience that is truly cross-cultural, especially as it compares to an urban medical school and academic medical center.

For the second year in a row, during the 2012-2013 academic year, the Rural Training Track (RTT) Technical Assistance Program is offering up to $1,000 in reimbursement to students doing a rotation at an RTT. The rotation must be for a minimum of 14 days, and reimbursement only applies to travel and lodging expenses.

• See list of eligible RTT programs

It is easy to participate, and any medical student of a U.S. allopathic or osteopathic medical school is eligible! After contacting the RTT program for their approval and clearing your participation with the appropriate official in your medical school, a simple Notice of Intent submitted to the National Rural Health Association prior to the rotation is required to assure your place in this program.

Receipt of reimbursement following the rotation is contingent upon the student’s submission of:

1.  A report and reflection upon the experience (500 word minimum)
2. Paper or electronically scanned receipts of travel and lodging expenses
3. Verification by the RTT Program Director, Site Director, or Coordinator that the student has in fact satisfactorily completed the rotation and met the 14 day requirement.

All three conditions must be met to be considered for reimbursement. For more information and a packet of materials, visit the Train Rural website.

Some lessons, medical school can’t teach

Bonnie Wong at her residency.

By Bonnie Wong

In my third year of medical school, I was privileged to have a career-changing rural rotation in a small town of about 2,500 inhabitants. There, I experienced medicine the way I had always imagined it should be practiced. Patients, who were neighbors, friends and family of the staff, were treated with the utmost respect and kindness. I consistently observed that patients’ medical conditions and proposed treatments were explained in detail, and unnecessary testing and procedures were not routinely performed. I felt end-of-life issues were confronted head-on, rather than avoided.

One of the most powerful experiences of my medical career occurred in that town. In the clinic, I had seen a 7-year-old boy who was dying of a brain tumor. I knew his history but was not prepared to see a child in a coma when I entered the room. “What was I supposed to do for the child?” I desperately thought, “This is not something we are taught in medical school.”

Unfamiliar territory
I did the only thing my stunned brain could think to do. Turning to the parents, I asked how they were doing. “Pretty well,” they said, relatively cheerfully. I was taken aback. They seemed to be handling things so well. “How long has he been like this?” I asked. “Oh, we were told (by a traditional healer) that he is sleeping peacefully in a theta state, gathering his energies and trying to heal.”

I was shocked when I realized the parents were unaware how close their obviously beloved boy was to passing away. In a panic, my brain searched for ways to break the news to them. They needed to be made aware, but in the most gentle way possible. I had a vague idea how I would proceed if these were my patients, but didn’t feel it was appropriate for me to take over this task for somebody else’s long-term patient. Desperately, I fled the room with some lame excuse and a promise of, “I’ll be back.”

I notified the superb resident who was in charge of me about the situation. He too was unaware the boy was in a coma, since the child had been conscious at his last visit. I was asked to go back in and give the boy a palliative osteopathic treatment. The entire family had experienced osteopathic treatments before, and had made the appointment for their son for that purpose as well as to discuss the next step in his treatment. They knew their son’s course was likely fatal, but at that point were not ready to give up.

I went back in a much more somber mood and treated the child. The feeling of gently touching the fragile body was inexplicably powerful. The parents relaxed and held hands peacefully, the mom leaning on the father’s shoulder and briefly shutting her eyes. Finally, the resident joined us. He took one look at the child and asked the parents the same thing I had asked “How long has he been this way?” Again, the parents said he had been resting peacefully for 4 days without waking up and without food. “He is storing up his strength,” they reiterated. Surprisingly, the boy did not look like he was suffering from dehydration, but his respirations were shallow and he was hooked to a portable oxygen tank.

Breaking the news, making a bond
The resident gently broke the news to them. “Yes, he is quite peaceful. I’ve seen a lot of people get to this stage and I believe he is really at the edge of this world and the next. I may be wrong; I hope I am. Anything can happen. But from all of my experience with people in this situation, I think that he is quite close to leaving this world.” I watched as their eyes welled up with tears. After giving them a few minutes of silence to digest what he had said, the resident proceeded. “So, the question now that you have to decide is how you want things to go for him. If you want we can admit him to the hospital. We will hook him to an IV and keep him comfortable. Or, if you want, you can take him home and we can send hospice to stay with him. He will also be comfortable and if he is in any pain, we will be able to give him medications at home.”

The parents decided with hardly a discussion to take him home. As they left, they gave me a giant hug. “Thank you for treating him. I know that treatment helped him.” I had a hard time choking back my own tears. After only one 30-minute visit I felt a strong bond to this family.

About a week later, I was working late and it was a quiet evening at the hospital. The resident got a call from the family asking if the two of us wanted to come out to the house because they thought the time “was near”. We left after getting an attending to cover for us for a few hours.

Learning beyond the classroom
We drove out snowy country roads that would have left me lost for weeks and arrived at a small group of tiny homes with many cars parked out front. I entered, not sure what to expect. Inside the house was permeated with the smells of home-cooked food. At least 3 children were running around playing, energetically but not loudly. Half a dozen adults and a hospice worker were talking in quiet tones. This environment was full of life yet peaceful, a stark contrast to seeing terminal patients hooked up to machines while invasive tests are performed.

On the couch, an aunt held the child in her arms. He was taking rapid, shallow respirations. “Oh god,” I thought, “he’s going to die soon.” I didn’t know what to do. “Go treat him,” the resident told me, while he talked with the parents.  Again, I laid hands on the child, this time with some trepidation. I had never been in the room when another human being actually passed away. I was nervous. As the treatment slowed the boy’s breathing, I also calmed down. The resident joined us and helped with the treatment. After a while, I played some games with the other children and chatted with the family. Then it was time to go back. We had received a call that more patients were rolling into the emergency room.

About 20 minutes after we arrived back at the small rural hospital, we received a call saying that the boy had passed on. I felt strange inside. I didn’t know if I felt like I had missed a pivotal experience or if I was glad that I didn’t have to be there. I did know I was very glad we had gone at the family’s request. Much later, I was able to reflect on how much I had learned from that experience. To paraphrase my resident, it was a million-dollar experience, something medical school cannot teach you.

Priceless experiences
This was an experience that I know I could never have had in a large city. I slept less during that month than I ever have on any other rotation, but no matter how tired I felt, I always had a warm glow inside; a sensation of reward for the work we were doing. The experience with the boy was a part of what made me fall in love with rural medicine. But it was by no means the only amazing experience I had during that month. I would say at least 90% of my encounters with patients on that rotation felt significant.

I sometimes wonder if doctors and medical students in urban areas have the opportunity to experience such an encounter in a year. I haven’t seen it very often on my other rotations. And I wonder how can they keep doing medicine without feeling the awe of fulfillment that comes from truly helping? No amount of money can buy that experience.

If you’ve had an experience in rural medicine from medical school and want to share your story, please send it to Samantha Simpson, IT/Media Liaison, NRHA Student Constituency Group.

Expectations of excellence

By Jenna Kennedy, MS3 at KUMC-Salina

Before I went to medical school, I spent a year researching and writing about the patient-centered medical home (PCMH) and how such a program would affect rural areas. When I first read the definition of a PCMH, I thought to myself, “Isn’t this the standard of care?”  I grew up in a small town and experienced first-hand the benefits of rural family medicine. My family’s doctor knew and cared for everyone in my family, including my grandma. He cared about my health, but also about how well I played in Tuesday night’s basketball game and how I was doing in school.

This is what I knew about medical care. If my doctor referred me to a specialist, he was sure to follow up regarding the referral. In practice, his skill set was so wide-ranging, the only specialist I ever saw was an orthopedic surgeon. I soon learned that few patients experienced this type of comprehensive, coordinated, accessible care.

From fragments to excellence
I began medical school in Kansas City, completing my basic sciences curriculum and doing a small amount of precepting. My limited experiences led me to believe that few patients had a primary care provider, let alone one who knew their health history and their socioeconomic reality. After completing second year, I spent six months at the Wichita campus. Again I met patient after patient receiving fragmented care, seeing a different provider every time they had a new health problem. This approach isn’t the fault of the provider or the patient. It’s simply the way the system is set up and I, along with many others, believe it must change.

To my pleasant surprise, when I began my rural training track in Salina, Kansas, I observed many patients receiving the type of care that I experienced growing up. Admittedly, Salina isn’t all that rural, especially by Kansas standards. Its population is nearing 50,000 and it has both Wal-Mart and Target, which earn it “big city” status in my mind. However, it has a small town feel, and this culture carries over to the medical community.

For the first four weeks of my family medicine clerkship, I spent time with the faculty and residents of Salina Family Healthcare, a federally qualified health center. To get a better idea of the aspects of the practice, I spent time in the outpatient clinic, the emergency room and the inpatient service. I was amazed by the preventative care and services offered to patients, how well providers knew their patients, and how well the transition from outpatient to inpatient and back to outpatient went for patients who needed to be admitted. This was helped by the clinic’s EMR, but more than anything, it was the providers’ expectations of excellent care.

Continuity in a Small Community
Now I’m completing my second four weeks in a private practice clinic and, once again, I am amazed by this provider’s dedication to her patients. Even when she is not officially consulted, she makes a point to see her patients in the hospital. She knows her patients thoroughly, and in many cases is providing multi-generational care. Her patients love her because she is willing to delve into the difficult stuff: everything from family drama and bad habits to why they haven’t been exercising regularly.

She’s accessible by personal cell phone to many of her patients. It is a common occurrence for her to make a house call if she knows that the patient will have a difficult time making it to her clinic. She’s brilliant, caring, loves a challenge, and has fun at what she does. She, too, is a patient-centered medical home. She goes above and beyond, and if someday I am half the provider she is, I’ll be doing great.

Jenna Kennedy is a third year medical student at the University of Kansas School of Medicine. She is one of four students in the rural training track in Salina, KS, and is completing her family medicine clerkship.

If you’ve had an experience in rural medicine from medical school and want to share your story, please send it to Samantha Simpson, IT/Media Liaison, NRHA Student Constituency Group.

The Dynamics of Rural Training

By Daniel Tseng

I recently finished a four-week rotation with the Mad River Family Practice Rural Track Training Program in Bellefontaine/West Liberty, Ohio. Dr. Randall Longenecker is the director. Briefly, my rotation was set up on a weekly schedule. On Monday, Tuesday and Wednesday, I performed inpatient care (including obstetrics, gynecology, and newborn nursery), and operating room time with general surgeons, orthopedic surgeons and one urologist at Mary Rutan Hospital in Bellefontaine. Thursday was a day of clinic at the Mad River/Oak Hill family practice location in West Liberty, with emergency department service at Mary Rutan Hospital on Friday.

During the last two weeks of my rotation I was able to follow adult psychiatrist Dr. Griffith in Bellefontaine for a half day and child psychiatrist Dr. Wallenbrock in Urbana, Ohio, for a half day. These psychiatry experiences were especially tailored for me as I plan on pursuing psychiatry training with the eventual goal of becoming a child and adolescent psychiatrist.

I had an excellent four weeks working with Dr. Longenecker and the various other attendings and residents of not only the Mad River Family Practice but also of Mary Rutan Hospital and area clinics.

Sharpening skills
I came into this rotation with the expectation of receiving a varied case load and broad exposure to large portions of primary care and common surgical conditions, and I was pleasantly provided with all of that and more. Because I plan on becoming a psychiatrist, I wanted to develop basic competencies in the care of an “average” hospitalized patient, that is, one who is not so critically ill as to warrant admission to the intensive care unit or transfer to a larger urban institution. I also wanted to further my communication skills as they relate to interactions with patients, and my Thursdays at the clinic provided wonderful opportunities for me to do just that. I saw patients from five to 95 years of age, from well-dressed to uniquely malodorous, teens, expectant women, rashes, depression; the list goes on. If child psychiatry did not have such a draw for me, I probably would have become a family physician.

Witnessing dedication        
The rural component of this rotation added another dynamic to this rotation in a way that enhanced my experience. I developed an appreciation for the dedicated physicians who don’t think twice about being on-call for what seemed like days on end, who drive for hours to set up shop and see patients in a neighboring town for a few days, then head back to their primary residence only to repeat the trip the following week, and the week after. I witnessed a genuine care and devotion to the patients of a rural community, and concluded that these people were fortunate to have this small group of committed family doctors provide quality and up-to-date primary care. I’m still in the early stages of my medical career, but my feeling is that rural communities throughout the country will be increasingly hard-pressed to find such medical care as the profession trends toward specialization.

Great value
Although I will not become a family physician in the foreseeable future, assuming my plans run their course, I will still value the four weeks I spent with the Mad River program. I learned and experienced a little of what rural medicine is and what it means to practice as a rural physician. Being committed to the Army, I probably will not be stationed in as rural a setting as Bellefontaine/West Liberty, but the skills I honed and experiences I had will serve me well as I encounter patients from all walks of life and all corners of the country. It’s not often medical students are even offered the chance to rotate through a rural clerkship, which is why I am privileged to have had this exposure and education. As a future psychiatrist, one of my greatest challenges will be building patient rapport. My rural rotation provided me invaluable experience in this aspect of my training and I will continue to build on this foundation.

Daniel Tseng is a medical student at The Ohio State University College of Medicine. His rotation in Bellefontaine/West Liberty, Ohio was from August 29 to September 23, 2011.

If you’ve had an experience in rural medicine from medical school and want to share your story, please send it to Samantha Simpson, IT/Media Liaison, NRHA Student Constituency Group.

From dread to delight

Samantha Simpson (second from left) performing exams on her favorite patients in Guatemala

As a third year medical student, I dreaded my family medicine rotation. My belief about family doctors was that patients came to see them with vague complaints. The doctor would order a bunch of tests and then send the patient to a specialist, unless the patient had hypertension or diabetes. I wanted to be that specialist. I wanted to solve those complex problems.

Challenging assumptions
My family medicine rotation in a rural area challenged that belief. What do you do when the patient doesn’t have the time to find a cure but simply wants to tolerate a medical problem so they can keep their job, which is inevitably heavy on manual labor? What do you do when you know the patient or their family and care deeply about titrating the perfect insulin regimen? What do you do if there is no specialist?

I can’t count the number of times I saw a rural family medicine doctor doing something I had been told I would only see on my orthopedics rotation, or dermatology rotation, or internal medicine rotation in the ICU, or in psychiatry…the list goes on.

In rural areas, family practitioners are also the hospitalists who see their own congestive heart failure patients in the ICU. They remove questionable moles. They take care of post-partum depression. They diagnose meniscal tears. They are like superheroes!

Making connections
In my month at a rural practice, I saw a lot of the same patients or families more than once. One couple was struggling financially and emotionally when the husband lost his job after suffering several small strokes. Our conversation in gathering their social history ran the gamut from talking excitedly about a daughter’s upcoming wedding, to the wife’s distress about her husband’s failing memory and coordination. My own emotions during this deeply personal conversation made me understand what compassionate care in medicine means.

I came to know and understand my patients’ points of view, and I saw patients with a wide variety of complex medical issues. I helped make decisions about treatment plans, learning so much more than I could have in an urban setting.

We had a developmentally delayed female come into the office several times for evaluation and follow-up of a superficial abscess on her abdomen. I saw her, drained the abscess and explained how to care for it at home. I was pleased to see she understood my instructions and with the help of antibiotics, it cleared up over the next 4-5 days.

One of the residents at the practice was the woman’s primary physician, and was explaining that she would be leaving to start practicing on her own and that the patient needed to pick a new doctor in the practice. The most touching experience I have had yet in medicine is when the patient turned to me and said, “Can Samantha be my doctor?”

Yes, I will. You can bet on it.

Samantha Simpson is a third year medical student at The Ohio State University College of Medicine. She is a recipient of the United States Air Force Health Professions Scholarship and hopes to put her rural medicine training to work.

If you’ve had an experience in rural medicine from medical school and want to share your story, please send it to Samantha Simpson, IT/Media Liaison, NRHA Student Constituency Group.

Real stories from rural residency

Connecting with people who share your interests is easier than ever, and it’s also harder than it ever has been. That may seem like a contradiction, but reflect on all the information that comes your way every day. Then add the demands of class schedules, career planning, professional growth and, when there’s time, your personal life.

That’s where the Train Rural blog comes in. Along with our Train Rural website, we’re here to help medical students learn about the people and the stories behind residency, rotations and practice in rural areas. You’ll be able to connect with the people that have been there, done that, and liked what they accomplished.

Blog postings here tell the story of individuals who have chosen to focus on rural practice and why they’ve done so. We encourage you to share your stories as well.

If you’ve had an experience in rural medicine from medical school and want to share your story, please send it to Samantha Simpson, IT/Media Liaison, NRHA Student Constituency Group.