When in R.O.M.E.
UND health workforce experts share research and collaboration efforts with rural providers.
The University of North Dakota Department of Family & Community Medicine (FCM) and the UND Center for Rural Health (CRH) have built a synergistic relationship that pairs research and service together to provide a stronger health workforce for the people of North Dakota.
It is this collaboration and support that drew Dr. David Schmitz to FCM.
“All of the workforce efforts that were happening within the Department of Family & Community Medicine have grown due to the partnership with the Center for Rural Health and the State Office of Rural Health,” said Schmitz. “That is part of why I came and interviewed for the job of department chair, because I knew that it was a great team focused on rural health and access to healthcare.”
FCM and CRH are housed within the UND School of Medicine & Health Sciences (SMHS), and the faculty and staff who work on these efforts recently shared their work with health professionals from across the state during the 38th Annual Dakota Conference on Rural and Public Health.
During this conference, which was held in Bismarck this past June, faculty and staff of the SMHS presented “Rural Workforce: Innovations and Outcomes in North Dakota.” Presenters included Schmitz, Dr. Kamille Sherman, assistant professor of family medicine at the SMHS, and Stacy Kusler, workforce specialist at CRH. The trio presented to more than 50 professionals from critical access hospitals, rural health clinics, public health districts, and other organizations, all looking for tools to improve recruitment and retention of health workers for their facilities.
Two workforce-specific programs were shared: Rural Opportunities in Medical Education (ROME) and Community Apgar.
Rural Opportunities in Medical Education
The ROME program is a 20-28 week interdisciplinary experience in a rural primary care setting, open to Phase 2 (clinical training time with doctors throughout the state) students at the SMHS. The program began in 1998 with two students.
“It’s a program where students self-select,” said Sherman. “Students are choosing to learn in a rural setting. Typically credit is given in family medicine, internal medicine, pediatrics, surgery, and Ob/Gyn.”
Since celebrating the twentieth anniversary of ROME in 2018, the program engaged a research partner to look at data and outcomes from the program in order track where the students have come from, and where they go after they finish the program.
“One of the outcomes we found is that more than 60% of students who choose to do the ROME program came from zip codes that are not urban,” continued Sherman. “We’re seeing that students who grew up in a rural community and attended a rural high school end up loving rural medicine. Another outcome is that about one-third of students who self-select for this program ultimately choose family medicine as a specialty. A third outcome is that a quarter of students who finish this program choose to remain in rural communities after residency and starting a practice. This is significantly higher than the national average of where physicians choose to work.”
Original rural sites for the program included Williston, Dickinson, Hettinger, Jamestown, and Devils Lake. Since then, additional ROME sites have been added in Ortonville and Benson, Minn., as well as Grafton, N.D. Each medical school class has about 13 students enrolled in ROME and each class consists of an initial cohort of 78 students.
A community Apgar score
Likewise, the Community Apgar Project originally began 12 years ago when Schmitz was working as a family physician in Idaho. At the time, there was a maldistribution of physicians in the state, and he and others wanted to know why.
“I was curious and wanted to help rural communities,” continued Schmitz, “so through a research and service project, I was able to help empower communities to be more successful in recruiting and retaining family physicians to rural communities.”
The Community Apgar project was born out of a desire to help communities understand what factors determine why some physicians choose one community over another, and what factors cause physicians to either stay or leave a community. The project helped communities showcase their own unique factors to appeal to, and match up with, the right physician for their area.
Schmitz brought this work with him when he moved to North Dakota in 2016 to chair the Department.
“In the end, this is really about getting the right match for the community. We have to give credit to the State Offices of Rural Health, both in Idaho and in North Dakota, because they have helped to fund this project over the past decade.”
Health Professions Education in Rural Communities
Originating as the Community Apgar Project, six different iterations of the research tool have been created, including the Health Professions Education in Rural Communities (HPERC) and the CEO Apgar. Each assessment consists of 50 questions, categorized into five sections of ten questions each.
One of the tools used to help in this process is the HPERC Community Apgar Questionnaire (CAQ), an objective measurement tool to assess the characteristics and parameters of rural communities related to successful health professions education.
“One of my jobs when I came here,” said Schmitz, “was to engage communities in North Dakota with regard to maximizing the opportunity to teach health professions students and resident physicians in rural places, because we know the more time these individuals spend in a rural environment the more likely they are to be more competent and be confident about practicing in that rural area, staying in that rural area, falling in love with the rural area, falling in love with someone in that rural area. All of these things help with retention of professionals.”
“This questionnaire looked at the entire experience in the community,” said Kusler. “It is a warm fuzzy experience, or is it challenging to get there and do what the student needs to do? This is what we are evaluating.”
The questionnaires are done through interviews. All of the information gathered is confidential to that community. Then the data are assessed statewide to create aggregate data.
“This helps us take a pulse of common challenges, what things are going well, and finding best practices that can be applied to each unique community,” said Schmitz. “This is research but also service, helping get the right providers to the right communities.”
Top and bottom factors
The top scoring factors for North Dakota include: having clinicians willing to precept, quality of preceptors, teaching opportunities, and facility leadership. The bottom scoring factors included travel support, housing costs and scholarships, mental and behavioral health education, and significant other involvement.
“We would not have a community medical school without members of the communities willing to teach our students, and that shows, being the top factor,” continued Schmitz. “And all of these factors together tell the story that we have a community medical school with willing clinicians, quality people who can teach, and facility leadership that support that process of education.”
The SMHS is a community-based medical school, which means students are largely training in communities throughout the state. Students spend the first 18 months of their training in Grand Forks. For the last two and a half years of training, they go to a home campus in Bismarck, Fargo, Grand Forks, or Minot. Family medicine students spend a minimum four to eight weeks in a rural community, and often they will stay there after graduation.
“We have a fantastic network of family medicine doctors across North Dakota, and often they help teach future physicians,” said Sherman.
‘Community is the curriculum’
Schmitz never forgets the importance of the community throughout his work with medical students and family practice residents.
“The community is the curriculum,” he said. “Engaging with the community and having our learners experience their education is what allows the workforce to fit into their roles after students finish the program. And we need to continue to collaborate with our other partners as well, and continue to do research and service that help communities recruit and retain hospital leadership, like CEOs. That’s a conversation that is helpful in being able to train family physicians to live in and be a part of those communities.”
In the end, all the efforts showcased during the trio’s presentation pointed at the recruitment and retention spectrum – from training students in rural health through ROME, to empowering rural facilities to focus on factors that make training a positive experience, to researching what factors make a rural community attractive for healthcare workforce.
While there may not be a one-size-fits-all approach to healthcare workforce issues, these tools provide support to help each community find their best solutions.