FINAL REPORT RURAL EXTERNSHIP PROJECT SUMMER, 1974 Lakes Area Regional Medical Program, Inc. 2929 Main Street Buffalo, New York 14214 John R.F. Ingall, M.D. Robert J. Beebe-6 Executive Director Project Director EVALUATION REPORT LAKES AREA REGIONAL MEDICAL PROGRAM, INC.. 1974 RURAL EXTERNSHIP PROJECT I. BACKGROUND The Rural Externship Project was developed by the Lakes Area Regional Medical Program in an attempt to alleviate the problem of shortages in health care personnel in rural areas. The goal of the Project is to increase the availability of all health professionals in the rural areas of Western New York State and Northwestern Pennsylvania. Nine health science students participated in the Project in 1970, the first year of operation. The number of student-participants in 1974 was 57.: In 1971, there were 22 externs; in 1972,, there were 34; and in 1973, there were 55. In addition to the principal objective of interesting health science students in a rural health career following graduation, other objectives of the Rural Externship Project are: 1. To enable students to participate in an interdisciplinary "team" approach to health care based, in many cases, in a rural or semi-rural hospital setting; 2. To expose students to rural health care delivery; 3. To expose students to a rural community and rural life style through actually living in a rural community; and 4. To make students more aware of the characteristics and problems of rural health practice. -2- II. PROJECT ORGANIZATION General administration of the Project was managed by the project director who is a member of the Lakes Area Regional Medical Program staff. An advisory committee was formed which consisted of representatives from each of the@health science schools at the State University of New York at Buffalo, student representatives, past preceptors, health planners, and hospital administrators. This committee, together with the Lakes Area Regional Medical Program as sponsoring agency, determined program policy, advised the director relative to specific problems, and will make plans and recommendations for future continuance of the Project. Health disciplines involved in the 1974 Project included medicine, pharmacy,,dentistry, nursing, physical therapy, podiatry, and others as listed in Table I. TABLE I: Externs by Discipline Medicine 21 36.8 Pharmacy .10 17.5 Nursing 6 10.5 Dentistry 5 8.8 Physicial Therapy 5 8.8 Medical Technology 2 3.5 Podiatry 2 3.5 Hospital Administration 1 1.8 Medical Record Technology I 1.8 Nutrition 1 1.8 Occupational Therapy 1 1.8 Public Health 1.8 Speech Pathology 1 1.8 -3- There were 182 applicants for the 57 externship positions available. Several factors were taken into consideration in selecting the externs. Among the most important ones were years completed in professional school, place of residence, and the needs and requests of the various preceptor sites for a,particular distribution of students in the health disciplines. Second, third, and fourth year students were usually favored over first year students because the experience would be more productive and meaningful to both the student and to his preceptor. In addition, advanced s tudents are nearer,.to the time when they must decide where they will practice. III. OPERATION OF PROJECT Close working relationships were developed between the principal preceptors and their students. The externs lived in the communities where they worked. In addition to the principal preceptors, there were many others who supervised the externs for brief periods, so that the total number of preceptors involved in the program was over one hundred. This permitted the extern to benefit from a broad professional experience With a number of preceptors in various disciplines and specialties. Basically, operation of the program called for a moderate amount of structuring and scheduling, enough to provide stability of planning, but at. the same time not being too rigid, thereby allowing some degree of freedom of action for the externsi This permitted them to participate in deciding how they would like to spend part of their time, according to their own individually developed interests. On June 18th of this year, a general orientation meeting for preceptors and exterhs was held in the Lakes Area Regional Medical Program offices. Approximately 85% of the externs attended this meeting. -4- Chautauqua County in particular held a number of orientation,' discussion, and critique sessions while the project was in operation. In addition, the Chautauqua County group formed a planning and advisory committee which functioned before and during the program period. This committee was an important factor in the outstanding success of the Chautauqua County effort. Externs were paid a stipend of $75 per week. Housing was arranged by the ext6rns, except in Chautauqua County where the W.C.A. Hospital provided rooms. The diversity of experience of the externs was most extensive. In addition to having contacts with all hospital departments, most of them went out into the community under the supervision of various preceptors and enjoyed an enriching experience in many aspects of health care delivery and delivery of health related services. This occurred in rural, semi- rural, and small urban areas and included patients from each of these areas. Medical and dental offices were involved, as well as. public health offices, social service agencies, nursing homes, community pharmacies, family practice centers, physicians' home visits, and home visits with the Visiting Nurses Association and public health nurses. IV. COSTS The following is the budgetary breakdown of the 1974 Rural Externship Project: Stipends $33,800 Salaries & Benefits 12,700 Travel 2,850 Publ ications 700 Other 250 TOTAL $50,300 -5- V. PUBLICITY Interpretation of the 1974 Rural Externship Program to health professionals and the general public in the region was excellent. Externs were well received by both the professional and the general community. Many newspaper articles appeared in a large number of local papers, and the project was carried on the wire services. Articles included several feature stories of personal interviews with externs. and preceptors. Accounts of the undertaking were heard on radio stations. Letters were written to area legislators concerning the project. Interested and favorable replies were received. VI. RESULTS AND EVALUATION Coments of preceptors and externs alike have been overwhelmingly favorable and enthusiastic. Many of the externs have asserted that they plan on a rural practice following graduation. Specific quotations appear in attachments to this review. Following are several tables selected from the evaluation questionnaires of students and preceptors. These tables are significant in their indication of attitudinal changes on the part of the externs. They point out clearly the substantial degree of success apparent at this time in accomplishing the Project's objectives. Contact will be maintained with the students whenever possible so as to be able to determine the degree of accomplishment of goals and objectives over the longer term of severa 1 years.. -6- TABLE II: Career Plans of Students Regarding Rural Practice On both the pre-program questionnaire and the questionnaire given after the externship, students were asked the following two questions: -1. Would you consider the possibility of working in a rural -areai when you complete your training? 2. Do you have plans to work in a rural area when you complete your training? "Yes" Before "Yes" After Would you tonsider... 7. 81.5% 97.1% Do you plan... ? 31.5% 42.9% (N 54) (N 35) TABLE III After completion of the program, students and preceptors were asked: "Would you like to see this program incorporated into the school curriculum?" Students Precpptors Yes 68.6% 56.3% No 11.4% 25.0% Uncertain 20.0% 18.6% TOTAL 100.o% 99.9% (N 35) (N 36) -7- TABLE IV Answers to the post-program questionnaire indicated that several significant changes had occurred in the students' perceptions of rural practice. For example, "How would you rate the facilities available to the health professionals of a rural area?" Pr@cept6rs Students Before After Excellent 47.2% 5.8% 17.1% Very Good 30.6% 9.6% 31.4% Good 16.7% 40.4% 31.4% Fair 2.8% 38.5% 20.0% Poor 2.8% 5.8% 0.0% TOTAL 100.1% 100.1% 99.9% (N 36) (N 54) (N 35) TABLE V "What is your overall impression of the qual'ity of health care services offered by your profession in a rural as opposed to a metropolitan area?" Students Before After Excellent 5.8% 28.6% Very Good 13.5% 45.7% Good 44.2% 22.9% Fair 30.8% 2.9% Poor 5.8% 0.0% TOTAL 100.1% 100.i% (N 54) (N .35) TABLE VI "The facilities most in need of development/improvement relative to health care needs in rural areas are primarily related to:" Preceptors Students Before After Prevention 28.6% 36.5% 41.7% Primary Care 40.0% 38.1% 30.6% Rehabilitation 31.4% 25.4% 27.8% TOTAL 100.0% 100..O% 100.1% (N 36) (N 54) (N 35) TABLE VII "I believe that the variety of health care services provided in rural areas is as great as in metropolitan areas." Preceptors Students Before After Agree 52.8% 13.2% 31.4% Disagree 41.7% 66.0% 57.1% 11.4% Don't Know 5.6% 20.8% TOTAL 100.1% 100.0% 99.9% (N 36) (N 54) (N 35) -9- VII. SUMMARY AND RECOMMENDATIONS 1. Fifty-seven externs participated in the 1974 program, funded entirely by the Lakes Area Regional Medical Program. 2. Externs were placed in all nine counties of the region. 3. Reports on the results of the 1974 program were generally very favorable, from both preceptors and students. 4. 42.9% of the externs.are definitely planning on rural health practice following graduation; 97.1% are considering it. 5. Problems involved were basically minimal. Such concerns as housing, board, and personality conflicts offered only minor difficulties. 6. The basic structure of the program was generally accepted. General activity guidelines and schedules allowing for ample flexibility were by and large the methods of choice of preceptors and students alike. 7. Existing preceptors'are more than willing to continue in a future project, with several others already asking to be included in a 1975 program. 8. The following specific recommendations for a future summer program are offered: a. Generally speaking, a-continuation of the 1974 mode of operation, especially with reference to program structure, content, and scheduling. Ridigity should be avoided. Most exterhs and pre- ceptor sites prefer flexibility. b. Pe'eo'a"r'ation of brief outlines for preceptors in the various health disciplines so that they can Understand more full what they might y cover, also including project background and what is expected of the preceptors. -1 0- C. Where possible, each extern should be assigned a primary pre- ceptor to whom (s)he can relate over the eight-week period. d. Recruit more advanced health students. Those who are in the later years of their studies are able to benefit more from their experience and make it a more satisfying one for their preceptors also. Besides, the advanced students are nearer to the time when they must decide on their locale of practice. e. More in--depth screening of student applications. longer, more detailed application form could help accomplish this, seeking more knowledge of students' interests and background. A final recommendation can be made which will serve also as a fitting conclusion to this report. It may be stated simply that it is to be hoped that continuity of the project can occur, thereby assu ring steady and progressive future implementation of its goals and objectives. In this manner, the Ru ral Externship Project will im art a lasting effect upon the region it seeks to p serve. Selected Student Comments Following Their Externship Experience "I feel this type of program would be extremely interesting and helpful to professional students uncertain of the area in which they intend to practice." "I feel this is beneficial for all students working toward a career in. the medical profession -- what could be better than working in your profession and being exposed to related health professions." "The experience, both cl-inical and patient contact, has been invaluable." "I personally feel that the first-hand experience makes the classwork more relevant." "I was surprised to find such-competency in a small hospital." "I was not sure that health care would be as integrated as it was. The health professions were really interested in knowing the total picture." "I have lived in a rural community all my life and this summer's experiences have served to confirm and expand my previous expectancies.'! "The regular medical care was what I expected, but the Atmosphere that pre- vailed was unique -- that of a small united community." "I expected medical practice in the rural area to be somewhat 'backwards' and I found thi s not to be true at al 1 . "I feel that this sort of exposure has enhanced my educational career greatly." "I was very satisfied with this year's program. It proved to be an invaluable experience for me." "I think it would be very challenging and self-satisfying to be employed in a rural setting; people seem to be more dependent on you, and more grateful for your services. "I will practice in a rural area with no reservations." "I enjoy the atmosphere in rural areas; although not sophisticated, there is still an air of professionalism on the part of the pharmacist. I also enjoyed the confidence the rural people had in the pharmacist in many areas." "Overall, I think it is a great program, and I wouldn't have traded my two summers for anything. I hope others got as much out of it as I have. The one important lesson I've learned is that all disciplines must work together to deliver quality medical care, no matter whether it is rural or metropolitan The people in Jamestown were great and more. than willing to help." -12- Student Comments (Continued) "I think.the program is very good. It offers the student some practical experience in his aspired discipline and provides a little incentive along side. I would encourage that the program be considered in future years." "I felt the program was a definite success. The people and experiences I encountered greatly enriched my appreciation of pharmacy, health care, and the patient.- 'The encouragement .,I received from my preceptors was deeply appreciated. I am going to strongly recommend the program to anyone in Pharmacy School as invaluable experience in their undergraduate training." "Thank you for allowing me to participate in this program. I gained valuable clinical'experience and enjoyed living in Wyoming County." "I enjoyed the program very much. It has helped me greatly. I hope that I may participate next year. Thank you." PARTICIPANTS 1974 RURAL EXTERNSHIP PROJECT LOCATION EXTERN DISCIPLINE PRECEPTOR Andover, New York Richard Cudahy Medicine Daniel Tartaglia, M.D. Arcade, New York Leonard Wagner Medicine Gerald Diesfeld, M.D. Batavia, New York Robert Baron Public Health. Victoria Markellis, M.D. Bradford, Pennsylvania Arthur Goodman Pharmacy William Killen,,-. Kim Keneske Medical Records Genevieve Chiodo, RMA Patti Kulka Speech Pathology Ann Confer Debra McCracken Nursing Dorothy Ekas, R.N. Janet Schoonmaker Physical Therapy Melody Pollock, RPT Dunkirk, New York Margaret Mitchell Medicine George McNaughton David Nash Medicine George McNaught6n Erie, Pennsylvania Lucienne Conti Pharmacy Frank Mozdy, RP William Davis Pharmacy Prank Mozdy, RP Rita DePhilip Pharmacy Frank Mozdy, RP Sui-Hing-Ho Pharmacy Frank Mbzdy, RP Candace Johnson Pharmacy Frank Mozdy, RP Helen Li Pharmacy Frank Mozdy, RP Joel Owerbach Pharmacy Frank Mbzdy, RP Terri Smith Physical Therapy Ange LaFuria George Walker Pharmacy Frank Moidyi RP Franklinville, New York John Norbund Medicine Ovid Knight, M.D. Gowanda,, New York, Stanley Scott Dentistry Robert Watson, D.D.S. PARTICIPANTS 1974 RUML EXTERNSHIP PROJECT LOCATION EXTERN DISCIPLINE PRECEPTOR Jamestown, New York Marc Fedder Medicine John Voltmann, M.D. Joseph Felsen Medicine Carl Hammerstrom, M.D. P. Scott Forsberg Physical Therapy George Lawn, D.M., P.T. Peter Guzzetti Dentistry F. Palmer Lindblom, D.D.S Marsha Larson. Nursing Marilyn Hale Bruce Nohejl Medicine Glen Ebersole, M.D. Cheryl Nohejl Medicine Lillian Neyi M.D. James Nord Physical'Therapy George Lawn, D.M., P.T. Rita Pridgen Nursing Cynthia Dauch, Ed.D. Albert Schlisserman Medicine H. Gregory Thorselli M.@u. Martha SI e Hospital Admin. Murray Marsh Y. George Toufexis Medicine R.X. Williams, M.D. Dale Voelker Dentistry Charles Sinatra, D.D.S. Jonathan Woodcock Medicine Wilson Shaw, M.D. u David Wuertzer Podiat Bert & Eunice Klein O.P*F'#, 4 ry Lewiston, New York Elaine Jansen Medical Technolo y Polly Artley, ASCP 9 Lockport, New York David Cavallaro Podiatry Gordon Mittleton, D.P.M Jessica Kort Physical Therapy Hanna Juul Stephen Stockton Dentistry John Kugler, D.D.S. Mayville, New York Mary Costello Nursing Arnold Mazur, M.D. Mark Strassberg Medicine Arnold Mazur, M.D. Kathleen Szymkowski Nutrition Arnold Mazur M.D. Newfane,'New York Barbara Penn Medicine Consan Dy, M.D. N. Tonawanda, New York Joseph Bylebyl Medicine ichard Carlson, M.D. Mark Polis Medicine rry Bylebyl, M.D. PARTICIPANTS 1974 RURAL EXTERNSHIP PROJECT LOCATION EXTERN DISCIPLINE PRECEPTOR, Olean, New York, Robert Krall Medicine Arthur Beck, M.D. Ellen To Medical Technology Elaine Brown Victor Vena Pharmacy Donald Jones Perry, New York Joseph Graham Medicine Paul Murphy M.D. Springville, New York David Sokal Medicine Timothy Siebel, M.D. Warsaw, New York Susan Bruch Occupational Therapy Gail Riley, OTR Fabia Kwiecinski Medicine R.T. Williams, M.D. John Verby Medicine M.F. Smallwood, M.D Patricia Stopen, RiN. Vivian Wasik Nursing Wellsville, New York Marilyn Jordan Nursing' Ln Wellsville Nursing Home West Seneca, New York Warren Krutchick Dentistry Ronald Zeilin, D.D.S.