From Cornfields to Classrooms to Collaborations

How Our Medical School Can Partner With Your Rural Community

Emily Onello, M.D., Sarah Beehler, Ph.D. & Jim Boulger, Ph.D.

University of Minnesota Medical School, Duluth Campus

The University of Minnesota Medical School – Duluth Campus

Established by Legislature in 1969, opened in 1972

1834 Graduates (as of May 11, 2014)

Original mission set by legislature: Train and provide physicians for rural Minnesota who practice Family Medicine

Faculty added mission: Train Native American physicians and others who will serve that underserved population

Internationally recognized for our success in mission attainment –in Minnesota, not so much

The University of Minnesota Medical School – Duluth Campus

The Duluth campus was separate from the Twin Cities campus until 2003, with different financial support streams, curriculum, admissions procedures, etc. At the time of the merger, assurances were made that the mission of the Duluth school/campus would be maintained.

While the school is located on the Duluth campus, the administrative chain is to the Medical School Dean and Vice-President for Health Sciences in the Twin Cities.

The University of Minnesota Medical School is one of only two US Medical Schools which rank in the top quartile for NIH research funding and in meeting the nation’s social mission in primary care.

Key Success Factors

Admissions Processes and Mission Dedication

Family Medicine Preceptorship and Rural Health Scholars Programs

The people, culture and environment of the school are strongly and historically supportive of our missions.)

Summer Internship in Medicine

Community service projects

Family Medicine Interest Group

University of Minnesota Medical School Funding Sources

Duluth Campus Medical School budget is approximately 1% of this total.

Rural Results

What have been the benefits to rural Minnesota? Have the aspirations of the rural Minnesotans and our legislature more than forty years ago – to train family physicians for rural Minnesota and for Native American Populations – been satisfactorily met?

Key Successes

While only 5% of Minnesota physicians practice in rural areas, 39% of the graduates of the Duluth campus practice in communities fewer than 20,000 population (Brooks, et. al.).

Nationally, about 81/2 % of United States medical school graduates select Family Medicine; since the first class in Duluth, 47.3% have selected Family Medicine – almost six times the national average.

The campus at Duluth has been extremely successful in training more than one hundred Native American physicians – second only to the University of Oklahoma (which is much larger).

34.5

%

50.9

%

30.2

%

45.0

%

39.3

%

39.2

%

8.4

%

10.0

%

13.3

%

9.2

%

11.2

%

8.2

%

7.4

%

8.4

%

8.5

%

8.3

%

8.5

%

8.2

%

0%

10%

20%

30%

40%

50%

60%

2010 2011 2012 2013 2014 5 Year Mean

Pro

port

ion O

f G

roup

Graduating Year

Proportion Of Senior Students Selecting Family Practice In NRMP Match

UMD

UMTC

National

Non-Metro Locations of Duluth Practicing

Graduates (N = 456)

Family Medicine70%

Internal Medicine

6%

Ob/Gyn4%

Pediatrics4%

Surgery4%

Orthopedics2%

Emergency Medicine2%

Psychiatry2%

Radiology1%

Pathology1%

Anesthesiology1%

Dermatology1%

Hospice1%

Med-Peds1%

Ophthalmology<1%

Gastroenterology<1% Occupational Med

<1%

Specialty Choices of Duluth Practicing Graduates In Non-Metro Minnesota (N = 456)

What’s “tried and true” in Duluth?Longstanding collaborations!

• Consistent exposure to Family Medicine during training

• Multiple opportunities to experience rural healthcare in your communities

What’s “tried and true” in Duluth?

First year medical school course entitled Introduction to Rural Family Medicine

• begins the first week of medical school

• daylong rural community visit

• includes Agricultural Medicine lecture by practicing rural Family Physician

What’s “tried and true” in Duluth?

Our students live with the doctor during the rural preceptorship weeks and experience what life as a family doctor is like in that community

• Over the past 40 years, we estimate that our ruralFamily Medicine colleagues have donated over 4. 5 million hours to this program.

• If we had to pay these physicians $50 per hour, this would be a program cost of approximately $225 million.

What’s “tried and true” in Duluth?

What else is happening?

Since 2003, summer opportunity for students to experience rural healthcare settings;

“Summers In Medicine” program (SIM)

What’s new? Curricular innovations

What’s new? The “rural laptop preceptors”

Rural “lap top” preceptors

• Funded by Health Resource Service Administration grant (D56HP20690)

• 6 rural Family Physicians “meet” via laptop with smaller groups of medical students

• Initiated January 2014 and ongoing

• Opportunity for students to hear about the joy, challenge and unique qualities of rural medical practice

MartinFaribaultJackson

FillmoreHoustonMower

FreebornNoblesRock

Watonwan WinonaCottonwood OlmstedWaseca Dodge

Steele

Murray

PipestoneBlue

Earth

Wabasha

Nicollet

Brown

RiceLe SueurLyonLincoln Redwood Goodhue

SibleyScott

RenvilleDakotaYellow Medicine

CarverMcLeod

RamseyChippewa HennepinLac qui

Parle

WashingtonMeekerSwift Kandiyohi

Anoka

Wright

SherburneBig Stone

ChisagoIsan

tiPopeStevens Stearns

BentonTraverse

DouglasGrant Kanabec

Mille

LacsMorrison

ToddPine

WilkinOtter Tail

CarltonCrow

Wing

WadenaAitkin

Clay Becker

Hubbard

Cass

NormanMahnomen

Itasca

Red Lake

Clearwater

Pennington

Polk Lake

CookBeltrami

Marshall

Saint Louis

Koochiching

RoseauKittson

Lake of the

Woods

Duluth

Warroad

Decorah

Glenwood

Staples Moose Lake Kathy Brandli, MD

Dave Heine, MD

DebErickson, MD

Julie Benson, MD

“Laptop” Preceptors

MartinFaribaultJackson

FillmoreHoustonMower

FreebornNoblesRock

Watonwan WinonaCottonwood OlmstedWaseca Dodge

Steele

Murray

PipestoneBlue

Earth

Wabasha

Nicollet

Brown

RiceLe SueurLyonLincoln Redwood Goodhue

SibleyScott

RenvilleDakotaYellow Medicine

CarverMcLeod

RamseyChippewa HennepinLac qui

Parle

WashingtonMeekerSwift Kandiyohi

Anoka

Wright

SherburneBig Stone

ChisagoIsan

tiPopeStevens Stearns

BentonTraverse

DouglasGrant Kanabec

Mille

LacsMorrison

ToddPine

WilkinOtter Tail

CarltonCrow

Wing

WadenaAitkin

Clay Becker

Hubbard

Cass

NormanMahnomen

Itasca

Red Lake

Clearwater

Pennington

Polk Lake

CookBeltrami

Marshall

Saint Louis

Koochiching

RoseauKittson

Lake of the

Woods

Duluth

Redwood Falls

Preceptor: Dr. Alan Olson

Dr. Alan Olson

Redwood Falls, MN

June 24th, 2014

What’s new in the student rural experience?

• Lengthening the longitudinal rural experience

• Expanding topics to include:

• community service project

• community health assessments

• rural class research project

• Lengthening the longitudinal rural experience

• Expanding topics to include:

• community service project

• community health assessments

• rural class research project

What’s new in the student rural experience?

All students are required to complete a service project during their time in the community. Many choose to serve as guest presenters in community sixth grades during “Brain Awareness” week.

To date, more than 480 medical students have presented classroom sessions to more than 12,000 small community grade school pupils.

Additionally, many students also complete other types of community service projects.

Community Service Projects

• Lengthening the longitudinal rural experience

• Expanding topics to include:

• community service project

• community health assessments

• rural class research project

What’s new in the student rural experience?

Data on community health assessment from student 2014 survey…

“At this point in my medical training, I can explain what sorts of Community Health Assessments the ACA expects of hospitals and health systems in the future”

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

1 2 3

Agree Disagree Strongly disagree

• Lengthening the longitudinal rural experience

• Expanding topics to include:

• community service project

• community health assessments

• rural class research project

What’s new in the student rural experience?

Class Research Project

Goals:

1. Enhance student research experience and skill

2. Utilize our extensive network of Family Physicians

3. Collaborate with rural communities to explore topics of mutual interest

Advancing the rural health research mission

The mission of the University of Minnesota Medical School, Duluth campus is to be a leader in educating physicians dedicated to family medicine, to serve the health care needs of rural Minnesota and American Indian communities, and discover and disseminate knowledge through research.

1. Infrastructure to support partnerships

2. Partnerships to understand & improve rural health

3. Conducting partnered research

Why conduct partnered research?

• Ethical/moral stance – it’s the right/nice thing to do• “Nothing about us without us”• Empowering individuals, organizations, & communities• Decreasing disparities & achieving health equity

• Scientific stance – it produces the best data/outcomes• Asking meaningful questions, collecting actionable data• Capitalizing on diversity of perspective/approach• Learning from effective, local solutions• Developing sustainable knowledge, processes, interventions

• Difficult, complex, political work AND productive, rewarding, enduring!!

Partnering For Rural Health

• Duluth Campus• Center for Rural Mental Health Studies

• Duluth Medical Research Institute (DMRI)

• Research for Indigenous Community Health (RICH) Center

• Student training experiences (RMSP, SIM, etc.)

• Twin Cities Campus• Clinical and Translational Sciences Institute (CTSI)

• Rural Health Research Center (RHRC)

Infrastructure to Support Rural Research Partnerships

Center for Rural Mental Health Studies• Carlton County Public Health and Human Services• Human Development Center• Crisis Connection (Minneapolis)• Minnesota Department of Human Services• Northland Medical Clinic (Bigfork)• Scenic Rivers Health Care Center (Cook)• Cook Hospital (Cook)

Individual Faculty Members• Bois Forte (MN) and Lac Courte Oreilles (WI)

Partnering For Rural Health Research

• Many successful, ongoing research partnerships

• Example 1 – Surveys of Local and Rural Preceptors

• Physician/clinic characteristics

• Patient unmet social needs

• Physician research interests

• Learning & adapting as we go

• Future possibilities:

• Student research elective

• Cross-state research collaborations

• Practice-based research network

Partnered Research

• Physician/clinic characteristics• 51 preceptors (26 rural; 28 female; 1998 median graduation year)

• Majority (67%) are employees with no ownership

• Average 73 patients/week

• Unmet social needs• 28% of each visit spent on unmet social needs

• Majority (92%) felt unmet social needs interfered with providing quality care

• Majority (67%) somewhat confident addressing unmet social needs

Partnered Research – Preliminary Data

Number of Preceptors Expressing Interest (N = 51)

Selecting topics/issues for research* 9 (17.6%)Writing grants* 2 (3.9%)Designing studies 0Collecting data* 15 (29.4%)Participating in surveys, interviews, or focus groups 25 (49%)Reviewing and interpreting results 4 (7.8%)Writing up results for presentation and/or publication 0Presenting results at conferences* 2 (3.9%)Receiving final reports, publications, and/or presentations 12 (23.5%)

Example 2 – MN Veterans Coming Home Study (funded by UMN CTSI): Survey of returning veterans & spouses at 2014 Minnesota State Fair

• Neighborhood/community satisfaction• Social integration • Social support• Relationship satisfaction• Reintegration/social functioning• Health care access/use• Focus on rural – urban variation

Project team includes members from 148 FW Air Guard, MAC-V, Minneapolis VA, Med School Duluth

Future possibilities:• Follow-up interviews• Outreach at rural county fairs (“road show”)• NIH/DoD grant to study rural reintegration of veterans and families

Partnered Research

In conclusion….

We need you!

And we hope we’ve convinced you that you need us, too!

Thank you!

For more information on training or research partnerships with the University of Minnesota Medical School in Duluth,

please contact:

Emily Onello, MDeconello@d.umn.edu

218.726.7820

Sarah Beehler, PhDsjbeehle@d.umn.edu

218.726.7016

James Boulger, PhDjboulger@d.umn.edu

218.726.8895

References

Brooks KD; Cieslak JE; Radcliffe PM; Sjogren K. Minnesota Medicine; 91(5): 40-4, 2008 May.

Mullen F, Chen, C, Petterson, S, Kolsky,G and Spagnola, M. The Social Mission of Medical Education. Annals of Internal Medicine. 2010;152(12):804 - 811.

Spike C; Hildebrandt M. Community Health Needs Assessment: Planning and Collaboration Kickstart the Journey. Minnesota Physician. 2013;27(8):24-25.

Students involved in Family Medicine research:

Some examples…

• Trends in Obstetrical Care in Rural Minnesota: Prevalence of Surgery Due To Incontinence Following Vaginal and Cesarean Section Delivery (2009)

• Rural Family Medicine Physicians’ Impressions of Rural Practice and their Perceptions of the Future of Rural Medicine: A Qualitative Study (2009)

• Evaluation of Cultural Competency Curricula in U.S. Medical Schools (2010)

• Services provided to Spanish-speaking Latinos in Minnesota Hospitals and their cost. (2010)

• Physician Acknowledgment of Obesity and Overweight in a Health Maintenance Exam (2011)

• Barriers to colorectal cancer screening in rural family practices. (2011)

• Current State of Care Provided to Sexual Assault Survivors in Rural Minnesota Emergency Departments Management and Antibiotic Resistance in Urinary Tract Infections (2011)

• The Skinny on Fat: Weight Loss Interventions in the Primary Care Setting (2012)

• Searching For A Relationship Between Dysfunctional Families And Symptom Burden In A Hospice Care Setting (2012).

• A critical Evaluation of iPad Applications Supporting Medical Student Learning (2012)

• Cookin’ Up Change: Community-Based Disease Prevention (ongoing)