Education Columns

Valerie L. Hearns, MD; Susan M. Anderson, MD; Laura Harmelink, RN

Health care access can be a challenge for citizens living in rural and frontier communities. South Dakota is faced with an aging population and aging primary care physicians, thereby setting the stage for severe health care shortages. To address this issue, the University of South Dakota Sanford School of Medicine developed the FARM program. The program places selected third-year medical students at a rural clinic/hospital site for 9 months.

A call for proposals and site applications was sent out to communities that meet the definition of rural and/or frontier. After submitting a formal proposal to participate, interested sites were carefully screened by a team that includes the FARM director, co-director, chair, and vice-chair of Family Medicine, among others. Site selection is based on the ability to provide meaningful and comparable clinical experiences in each of the major disciplines of family medicine, internal medicine, neurology, OB-GYN, pediatrics, psychiatry, and surgery, with a family physician serving as the site coordinator. Telemedicine may be involved in delivery of certain disciplines. FARM students receive hands-on education and gain an understanding of the rewards and challenges of rural practice. Students assist in community health education and implement a community project to benefit their site. Projects to date have focused on concussion assessment for middle school and high school athletes, educating high school students about health careers opportunities, mentoring at-risk children, and diabetic community education.

Since its inception in 2014, 12 students were accepted and 11 students have completed the program in five sites. One FARM student withdrew from medical school for inability to pass Step 1 board exams. Five students out of 63 in the Class of 2016 and six students out of 57 in the Class of 2017 have completed the program. This is in line with our expectations of approximately 10% of the total class. For the 2016–2017 academic years, three more sites have been added. A FARM orientation is presented to first-year students. Interested students are asked to submit an application. Applications are reviewed by committee who consider academic performance, ability to learn independently, interest in rural primary care, commitment to living in a FARM community, and interview.

In comparison with students at our non-rural LIC campuses, FARM students have performed equally well on objective assessments such as NBME subject exams and school OSCE. For the Class of 2016, the overall composite, average raw score on seven NBME subject exams was 77.59%, compared to 77.43 % for FARM students in the class. For the school OSCE, the overall composite class average score on seven stations was 80%, compared to 81% for FARM students. All scores for USMLE Step 2 exams are not available in order to draw an analysis. Students in the Class of 2017 have not completed their assessments at this time.

FARM program students return to one of the three main clinical campuses for required hospital-based mini blocks in internal medicine, neurology, surgery, OB-GYN, pediatrics, and psychiatry. Main campus preceptors have been pleased with their clinical skills and knowledge. Returning FARM students have successfully completed these hospital-based experiences on the first attempt.

Toward our goal of providing a sustainable rural health provider work force, one of the former FARM students is in negotiations with his FARM site to return after completing residency. Four out of the first group of five FARM students have applied to family medicine residency programs, with hopes of practicing in a rural community.

Testimonial comments from one of our recent FARM students speak to the effectiveness of the program.

“Having now experienced over 8 months at my clinical site I can very proudly say that I believe I made an excellent choice in my learning career by participating in this program. I have had the chance to become involved in the data collection and decision-making process of care teams for rare cases such as Kawasaki’s disease and Wernicke’s encephalopathy at their entry levels to the health care system. I have also been able to scrub in and first assist for every surgery case that I have been present for. Our facility consistently has physicians in from the fields of urology, orthopedics, cardiology, psychiatry, audiology, vascular, podiatry, allergy medicine specialists, and ophthalmology rotating throughout each month for outreach clinics. I have consistently filled days with experiences in the clinic, hospital, and OR throughout the week.

Further, I have come to greatly appreciate the easy access and consistent exposure that I am allowed with the physician and midlevel providers at my facility. Such an environment is designed exquisitely for functioning to supply the full spectrum of opportunities intended within the environment of the Longitudinal Integrated Curriculum.”

The FARM program has successfully completed two cohorts of students and is expanding in sites and number of students. With continued administrative support, the program is well positioned to provide in-depth rural medicine education. Oversight of the FARM program and students is multi-layered. Monthly meetings with the FARM director and co-director with hospital/clinic administrators at each site occur via teleconference. The FARM steering committee (representatives from the Department of Family Medicine, Student Affairs, and office of Medical Student Education) meets monthly to discuss and review the monthly teleconferences, student performance and requirements, and other student concerns. In addition the clerkship directors meet via another teleconference with the FARM site coordinators to review student performance and address concerns and expectations on a monthly basis. Clerkship directors are also expected to make in-person FARM site visits once a year. The South Dakota Governors Primary Care Task Force is a major stakeholder and receives regular updates on the program.

The first group of FARM faculty participated in an STFM “On the Road” faculty development workshop. Subsequent FARM faculty development sessions occur during the SDAFP Winter Seminar. In 2012 the South Dakota State Legislature appropriated funding to establish and support the FARM program. The sites provide housing in the community at no charge to the students. The hospital systems further provide some free meals, study space, and on-call space for the students. Our educational stakeholders are committed to the concept and success of the program. Through this experience and collaboration, FARM futures look bright for years to come.