From one of the American Academy of Family Practice Medical Rural Health Association listserve newsletters.

TOPIC: The Dilemma of Family Practice in The Medical School- March 2001

As a rural physician (10 years in a town of 4500) who invaded the city for 12 years as a teacher after rural

practice, I have to say that I did not enjoy the patient care rendered even by my family physician

colleagues in the residency program I was in. I found my colleagues wonderful people, good friends, talented in research, administratively sound, but who lacked patient care and practice management experience. I am back in rural practice but still teaching,

I felt that my faculty colleagues resisted change and protected their academic and administrative, time at the expense of the family practice values that were supposed to be role modeling, While at the University Residency program, 1 found the values of family practice largely eroded. 1 felt like a lone ranger on faculty Approximately 90% of the 30 or so faculty there had had very minimal (2 years or less of negative experience, most of them none) private sector experience. It was often said to me that I didn't realize the differences between a teaching environment and the private sector as I tried to uphold such things as continuity of patient care, office efficiency, and working in communities.

These limitations resulted in fewer comprehensive practice role models for residents interested ill rural practice where a more comprehensive set of clinical practice skills is needed I was one of few. As a generalist, I felt alone at faculty meetings.

It is much more rewarding for me to be back in rural practice. I now feel I can share my experience with residents in my RTT. I can actually write letters of recommendation for residents now with more confidence because I have seen them deliver more than one baby, take care of hospital patients, do office procedures, and practice in the nursing home. My interactions with 42 residents at 4 different clinics, 2 inpatient hospital services at 2 different hospitals, and 2 maternity delivery suites at 2 different hospitals prevented me from writing these letters with confidence before. I had scant exposure to even my own clinic residents. I do hospital work now more than 4 weeks/year (the usual for the faculty in the residency). This makes me a better teacher I feel. I see our RTT residents' intraining exam scores above the core residency average score and above the national average in every area, every year. I see our graduates want to go into private practice and do obstetrics ( 100% of our graduates so far) rather than wish to take a fellowship in research, work urgent care, or a sub specialize in a family practice subspecialty area.

The challenge is getting residents out to learn with my colleagues and I in the rural area. None of us desire the type of fractionated care that was modeled in our urban academic family practice residency one hour away. I feel these rural. faculty have much to offer. F our of us in our practice in Baraboo are authors and/or editors in the ALSO provider syllabus including one pediatrician in our practice who teaches in our RTT-yes family physicians and pediatricians can get along. Our loca139 yr. old board certified surgeon feels strongly that "his residents" should learn how to do an emergency C-Section and teaches them this

procedure (see latest ALSO syllabus chapter on this). He loves to bike with the residents and often ends up forming a personal friendship with many of our residents as the rest of us do. These rural faculty have talent, they get along, are friendly with students, and they are happy in their lifestyles. They are confronted with much sicker patients in their rural practices and know how to problem solve without neonatologists, obstetricians, and trauma surgeons in house. They may not quote studies as well but they know what to do when the patient arrives sick on the floor.

Not all is bad with academic centers however. Collaboration between community and academia is important. Research is better done in these academic departments. Rural physicians can learn teaching skills from experienced academic family physician teachers through faculty development programs. Academic family physicians can broaden their horizons by observing the case management as practiced by clinicians skilled in rural medicine. "Town/gown" rivalries that might exist can be bridged by having these physicians work together on an educational venture1o improve access to health care in rural communities. The University of Wisconsin Department of Family Medicine is now supporting the RTT model in Wisconsin. I am able to do what I am doing because of the people I met in the academic center. I feel there is much development that can be done for family medicine education with proper support. I strongly feel that RTTs need more exposure and have much to offer.

James R. Damos, M.D.

St. Marys/Dean Venture

Baraboo Medical Associates 1700 Tuttle Street

Baraboo, Wisconsin 53913