Family medicine resident rural rotation: A successful program

By Cindy Passmore, M.A.
Research Director
Faculty Development Center, Waco, Texas

The Resident Rural Rotation program is funded through the Texas Higher Education Coordinating Board with the objective of encouraging residents to choose a rural medical practice. Since 1991, Texas family medicine resident physicians have been offered the opportunity to participate in an elective one-month rural rotation.

Upon approval and proper submission of paperwork, a resident physician may receive: 1) a stipend of $1,000 in addition to his or her regular stipend, 2) up to $500 for travel costs for one round trip between the residency program and rotation site, and 3) up to $500 for living expenses incurred during the rotation. Additionally, reimbursement not to exceed $1,500 may be made to the residency program for loss of the resident’s services during the rotation.

The Faculty Development Center recently studied the RRR program for the five-year period from 2000 to 2004. The purpose of the study was to evaluate and review the program including recommendations for modifications.

The FDC found that the program is well subscribed, with about 80 residents and 13 to 14 residency programs participating per year. At an annual cost of a little over $215,000, the program is producing good to excellent results with the great majority of the trainees going on to practice in Texas with underserved populations, many of these underserved rural populations.

The study data were obtained from two sources: RRR archival data (electronic and paper) held by the THECB staff and survey data collected by FDC during September and October 2005.

Sites and Supervisors

Are the sites too far from the programs? Most family medicine residency programs in Texas are within 30 to 40 miles of a rural rotation site, with the exception of those in El Paso and Amarillo, which are about 220 and 75 miles, respectively, from the nearest sites. Neither of these programs participates in the RRR program.

Ninety-five rural rotation supervisors participated over the five-year period. The top five sites trained 33 percent of the residents; the top seven trained 42 percent.

Funding, Residents and Residency Programs

Twenty-one residency programs participated over the study period, ranging from 12 to 16 per year. (See Figure 1) A total of 402 residents, about 80 per year, participated in the RRR program.

Figure 2 shows the funding for the five-year period and reflects an annual average of about $215,000. The average funding per resident over the five-year period is about $2,680, ranging from a low in 2003 of $2,575 to a high of $2,880 in 2004.

Evaluation Data

Ninety-nine percent of residents either agreed or strongly agreed when asked if the rotation was beneficial to their education as a physician. Most of the 389 responding residents (85 percent) reported that their interest in considering practice in a similar community was either reinforced or increased significantly as a result of the RRR experience, while 13 percent remain unchanged and only 2 percent reported a decrease in interest. Ninety-eight percent of the residents would recommend the RRR to a colleague.

Over 99 percent of the residency program directors said they would use the same rural rotation site for future rotations. Almost every respondent — residents and program directors alike — listed strengths associated with the rotation. They included comments regarding the excellent learning environment, which encompassed: wonderful teachers, broad scope of practice, large volume, diverse patient populations, and variety of procedures.

Here are some representative comments from residents:

• “Tremendous opportunity to live the life of a country physician. As the doc, you do just about everything! ”
• “Great attendings. Fun town and very nice community. They welcomed me like an old friend from day one. ”
• “Family-oriented medicine. Patients were always given a sufficient amount of time. The supervisor did his best to incorporate me into the community.”
• “Strengthened my decision making and developed my confidence.”
• “Opportunity to view “real” practice outside of a residency program. Opened my eyes to feasibility of a solo and/or rural practice.”
• “Friendly office environment with supportive staff. Always appeared willing to teach without hesitation.”
• “Real-world setting as opposed to that experienced in residency. High volume of patients. Exceptionally resident-friendly.”
• “Excellent prenatal experience and surgical experience.”

Some weaknesses were listed, the most frequent having to do with patient volume, numbers of procedures, and distance from program and family. The weaknesses were often prefaced with a qualifier suggesting that the rotation was a valuable experience despite the weakness.

Current Practice Site

Seventy percent of the former RRR participants who have completed training now practice in Texas. Twenty-two percent of these physicians practice in rural Texas cities or counties. Although not a specific target of the RRR program, most (96 percent) of the participants practice in underserved areas of some sort.

Survey Data

To determine the knowledge, interest and attitudes of Texas family medicine resident physicians, program directors, coordinators and administrators regarding the Resident Rural Rotation Program, a survey packet was sent to 30 residency programs. A secondary purpose was to heighten awareness of the RRR program.

Although most residents (82 percent) were aware of the RRR and the $1,000 stipend (54 percent), in general they were less aware of the reimbursement benefits offered for travel (30 percent), living expenses (26 percent), and to the residency program (25 percent). Ninety-two percent of program directors, coordinators and administrators were aware of the RRR program and the reimbursement program.

Twenty-seven percent of residents anticipate practicing in a rural site, while another 27 percent are still undecided.

Conclusions and Future Directions

The Resident Rural Rotation Program is doing what it was created to do. This study confirmed that about 80 Texas family medicine resident physicians are experiencing a rural rotation every year through this program. The experience is valuable and beneficial and reinforces or increases the participants’ intent to practice in rural communities. In fact, more than 20 percent of those RRR completers who practice family medicine in Texas do so in rural communities. Virtually all of these are underserved communities.

An annual mailing of a RRR packet to the Texas family medicine residency programs is an economical way to keep RRR program awareness high without the expense of mailing to individual residents. The packets would contain an instruction kit for the program director and the coordinator or administrator and a one-page fact sheet and application instructions for each resident. This pamphlet will remind all Texas family medicine residents of the opportunity that the Resident Rural Rotation program offers. Additionally, we will increase the opportunities to expose residents to the RRR program and thus increase the chance to influence their choice of practice site — especially those 27 percent that are as yet undecided about their future practice site.

For more information and to apply, go to www.thecb.state.tx.us.