I -W @ntents 1 PRELUDE TO AN I NNERVI EW introduction REGIONAL ALTERNATIVES Externship Strategy Regional Map 2 THE RURAL EXTERN PERSPECTIVE Program Profile Externs by Discipline 3 EXCHANGING IDEAS AND EXPECTATIONS Extern/preceptor Orientation FIRST HAND/FREE HAND Community-based Curriculum 4-7 A MULTIPLE REALITY Quotations and Photography 8 PROGRAM PEOPLE Rural Extern Advisory Committee Lakes Area Regional Medical Program, Inc. Acknowledgements Design Richard Macakania Photography Hugo Unger Editorial Janet Gelsinger Anthony Zerbo, Jr. Contents 1 PRELUDE TO AN INNERVIEW Introduction REGIONAL ALTERNATIVES Externship Strategy Regional Map 2 THE RURAL EXTERN PERSPECTIVE Program Profile Externs by Discipline 3 EXCHANGING IDEAS AND EXPECTATIONS Fxtern/preceptor Orientation FIRST HAND/FREE HAND Community-based Curriculum 4-7 A MULTIPLE REALITY Quotations and Photography 8 PROGRAM PEOPLE Rural Extern Advisory Committee Lakes Area Regional Medical Program, Inc. Acknowledgements Design Richard Macakania Photography Hugo Unger Editorial Janet Gelsinger Anthony Zerbo, Jr. Prelude To An lnnerview Regional Alternatives An overview of rural life in America can produce Predominantly rural, the Lakes Area Region the concepts of existing patterns and evolving trends. encompasses Allegany, Cattaraugus, Chautauqua, These concepts provide the framework of an 'inner- Erie, Genesee, Niagara and Wyoming Counties in view' which will localize the scopes of premise, western New York, and Erie and McKean Counties in problems, and alternatives for action. The Lakes northwestern Pennsylvania. A health care manpower Area Regional Medical Program, Inc. is based upon survey, conducted in 1967, revealed that several of this concept - that regions differ; that regional these counties had a distribution of approximately 1 needs differ; and that solutions to those needs must physician per 1,000 population. However, priorities be developed within a regional context. were not directed toward obtaining a 'doctor for every Modern communications and transportation have town'. These communities delineated their problem produced a mobile society, urban and rural alike. as a shortage in health professionals, citing the Radio, television, newspapers, automobiles, super specific need for nurses, physicians, physical highways, and airplanes are serving to reduce rural- therapists, occupational therapists, medical urban differences in health attitudes and needs. Yet technologists, social workers and dental hygenists. the availability of resources and facilities for health This inclusive strategy is representative of the ex- services in rural communities remains dispropor- panded needs of rural health care delivery. Based tionate and fundamentally inadequate. upon this concept of a more comprehensive need, The social, technological and industrial changes the region developed its own alternative, the Rural affecting the society as a whole produce the underly- Extern Program - a community oriented program ing problems in adjusting to the health care needs of whose primary purpose is to increase the availability rural communities. Population shifts to urban, subur- of all health professionals throughout the Lakes Area ban, and rural fringe areas have resulted in a decline Region. Its primary method is to expose health science students to health care delivery within the liv- in the number of farm families; a growing ing context of the rural community. dependence upon service beyond the immediate locality; consolidation of schools, churches, and community action groups; and multi-occupational communities with mixed incomes. Although the fabric of rural life is changing, three basic facts remain generally applicable and must be ALLS. BATAVIA recognized: Rural regions are often economically 0 GENESEE depressed, geographically isolated, and sporadically *BUFFALO COUNTY populated. These represent major obstacles to the adequate delivery of compehensive health care to the )UNTY,N rural citizen. FF CATTARAUGUS NY CHAUTAUOUA COUNTY COUNTY 0 SALAMANCA JAMESTOWN LrAN WELLS. -@E The Rural Extern Perspective I n 1971, the program expanded to include twenty-two Initiated in 1970, the Rural Extern Program was an students, fifteen preceptors and eleven locations. In experimental program designed to place health science students within the rural health community 1972 it was comprised of thirty-four students, thirty- so that they might formulate realistic knowledge of one preceptors, and thirteen locations. In 1973, fifty- the problems and the potentialities of rural life and five students worked with over one hundred precep- health care practices. Emphasis was placed upon ex- tors in every county of the Lakes Area Region as well perience, involvement, and interaction. From its as in Livingston County, New York. onset, the Program's major goal has been simply This rapid growth in numbers is paralleled by an in- stated: To increase the availability of all health crease in represented disciplines. The Rural Extern professionals in the rural areas of western New York Program has included students of Medicine, Den- and northwestern Pennsylvania. tistry, Pharmacy, Nursing, Physical Therapy, Oc- Short term objectives of the Program include: cupational Therapy, Medical Technology, Dietetics, Hospital Administration, Podiatry and Social Work. El To expose health science students to the nature As the visibility of the Program expands, it is ex- of rural health needs and the scope of health pected that the scope of student participation will care delivery in rural communities. continue to widen. El To broaden the understanding of community physicians and health professionals concerning the goals and needs of health science students. n To provide a variety of educational experiences as a stimulus for communication among ex- Rural Extern Program 1970-1973 terns in both the same and different disciplines Externs by Discipline in an interdisciplinary 'team' approach to health 1970 1971 1972 1973 care delivery in a rural or semi _rural primary care setting. Discipline No. % No. % No. % No. % This unique, eight-week interchange between Medicine 7 77.8 12 54.6 12 35.3 16 29.1 students, professionals and communities is based upon a relationship of mutual incentive and benefit. Dentistry 1 11.1 1 4.6 2 5.9 4 7.3 Financial support has come from the rural health professionals, agencies, hospitals, social services, Pharmacy 0 o.o 1 4.6 514.7 13 23.6 businesses, private corporations and such organizations as the Appalachian Regional Commis- Nursing 1 11.1 3 13.6 4 1 1.8 8 14.6 -sion. These facets of the community have contributed toward student stipends, often providing free room Physical and board. A weekly stipend of $1 00 was granted to Therapy 0 0.0 4 18.2 7 20.6 6 10.9 each student participant by the Lakes Area Regional Medical Program, Inc., subject to slight reduction if Medical the community was able to provide room and board. Technology 0 0.0 0 0.0 1 2.9 3 5. The progress of the Rural Extern Program can be readily recorded by its rapid growth. The 1970 Dietetics 0 0.0 0 0.0 0 0.0 1 1.8 summer program was a joint venture developed by the Student American Medical Association, the Ap- Hospital palachian Regional Commission, and the Lakes Area Administration 0 0.0 0 0.0 1 2.9 3 5.5 Regional Medical Program, Inc. A group of nine medical, dental, and nursing students were placed Podiatry 0 0.0 0 0.0 1 2.9 1 1.8 with twelve preceptors in three counties of western Social Work 0 0.0 0 0.0 1 2.9 0 0.0 New York: Allegany, Cattaraugus and Chautauqua. Occupational Therapy 0 0.0 1 4.6 0 0.0 0 0.0 n r , -r, loo.1 Exchanging Ideas Fir-st Hand / Free Han And Expectations The pursuit of prevention and health maintenance The primary prerequisite for acceptance into the directly depends upon the increased use and coor- program is student interest in rural health, primary dination of the 'full range' of health related care, and family or community medicine@ The professionals. The delivery of health care in rural process of selecting appropriate preceptors who will areas will have to be developed through teams of plan and be responsible for community-oriented ex- health professionals, in an interdisciplinary collabora- ternships is based upon their enthusiasm for teaching tion. This concept is the very axis of the Rural Extern and their willingness to arrange a variety of hea t Program. Students in various health disciplines are care experiences for the students. These dispositions able to develop an understanding of the competen- combine to structure an innovative and varied cies outside their disciplines by actually participating curriculum relevant to the circumstances presented in team practice and by experiencing the complex- by each particular location and conducive to the in- ities involved in the delegation of responsibility. This terests and needs of each student. It is this 'free interdisciplinary interaction begins with a general hand' flexibility that enables first hand experience to orientation meeting for the preceptors and externs at become productive. the onset of the program when ideas and expec- The diversity of the extern experience is highly ex- tations can be exchanged and expanded. tensive. In addition to having contacts with all This orientation marks the beginning of an explora- hospital departments, both preceptors and externs go tion for the students in which they can experience the into the community and experience the many aspects full range of existing health services - solo practice, of health care delivery in rural, semi-rural, and small partnerships, group practice, hospitals, health urban areas. Externs are exposed to the practices in departments, nursing homes, clinics and extended medical and dental offices, public health offices, care facilities. The Program's flexibility allows for the social service agencies, nursing homes, community realistic exposure and evaluation of rural health care pharmacies, family practice centers, physicians' delivery as it actually exists. Debriefing sessions are home visits, and the home-based activities of the interdispersed throughout the eight weeks to allow Visiting Nurses Association and the public health for the verbalization of the student/preceptor inter- nurses. pretations of their individual experiences. This con- In addition to this broad exposure to the rural tinual dialogue is integral to the Program's dynamic learning process. It is the start of individual and health care system, students are able to contribute to group confrontations that will serve to construct health care delivery and to obtain valuable clinical expectations into well-founded, well-experienced experience. Many function as 'physician assistants', attitudes. performing routine procedures and initial patient 'work ups', taking histories and blood pressures, in- terpreting instructions for patients and monitoring follow-up. Others function as 'health guides' making home visits, distributing information on health care, accompanying patients to clinics and relaying infor- mation on nutrition, hygiene, and accident preven- tion. The emphasis is on active involvement and the viable curriculum is best characterized by the con- cept of day-to-day growth@ The important feature of the Rural Extern Program is that the student will live in the community and become an active part of its fabric of health care and ways of life. A Multiple Reality In the 1971 summer program, both the preceptors and the externs were asked to write down their daily experiences, reflecting their opinions and personal perceptions. In later programs, the ogs were supplanted with group meetings where personal en- counter and verbal dialogue served to reveal in- dividual feelings and experiences. In all of the programs, student and preceptor 'letters' have provided a nucleus for interpretation in which probler-ns were surfaced and progress was recorded. N All of these written or verbal impressions represent the realities behind the Rural Extern Program. It is a multiple reality that encompasses the shared lives and needs of preceptors, students, and the rural communities. The following photographs and quotations combine to form a total statement reflecting the four years of effort, experience, and progress that comprise the concept of the Rural Extern Program. They are ex- tracted from logs, letters, conversations and ex- periences; and they encompass them all, "This summer experience has enhanced and enriched my understand- ing of physical therapy and total patient care in a rehabilitation facility. My preceptors arranged several additional opportunities for me to observe and to work with other people in various health and medical areas and these too were fascinating and informative. I hope that I have been able to contribute to their professional lives as they have to mine." "We saw all facets of medical and health professions, instead of remaining solely in our own fields. One of the most important parts of the program was to communicate with the other students and the efinitely the hospital staff. This working together as a team is d trend of the future." "I met with the migrant workers in the ciinic during the evening. I did not realize the nature of the problem before." Health teaching is a great part of rural nursing, but it is slow. Little accomplishments are important." "One of the side benefits to the community and physicians is al- ready starting to appear. Many of these health professionals have been out of a teaching situation for varying times up to 30-40 years and were originally a little apprehensive about acting as preceptors for the students. I found that they have quickly resumed the role as teacher and have surprised themselves with their ability to discuss the basics of the disease process of t the patient presented to the students. I am sure that this will continue and stimulate many of the physicians long out of training to do some independent study for these presentations. AIV, "Today I made rounds worked up a patient for the doctor-dictated history and physical; read EKGS; examined cardiac stress unit; attended an executive staff meeting; examined an emergency cardiac case: visited pediatric ward to examine acutely ill child; revisited the emergency ward. The day began at 8:30 a.m. and ended after 1:00 P.M." "in my spare time, I have been learning how to read EKGS. Several of the doctors have given me books on the subject. I have also obtained first hand knowledge in clinical measures as performed by local physicians." "The idea of having preceptors who will share their practices with you is a fantastic way to learn a great deal." r "To My Surprise, a good many of the patients presented interesting clinical problems and notable physical findings." "Several patients who were recently discharged from the hospital came in for an examination. I found this very unusual. In a big city hospital, if you can follow a patient from the time he arrives at the hospital to discharge it is remarkable. And everybody talks about continuous care programs!" "We became familiar with many of the procedures, so that by the end of the program, when emergencies were piling up, we could help set up patients for X-ray and could develop the films. The radi- ologists also took many hours of their time showing us how to read films and calling us in on many interesting cases." r The general directions of the Rural Extern The Rural Extern Program' Advisory Committee is Program are coordinated by a Program Director who an extension of regional imperative, whereby needs is a member of the Lakes Area Regional Medical are defined; alternatives are delineated; and action is Program, Inc. The Director works closely with an Ad- determined, directed and continued. They are the visory Committee consisting of representatives from people who shape the program and, together with the each of the health sciences schools at the State student and preceptor participants, they are the im- University of New York at Buffalo, past and present petus that moves local need into local initiative. preceptors, student representatives, health planning groups, and hospital administrators. These com- ponents assure maximum local input into the program's development and direction. Together with the Lakes Area Regional Medical Program, Inc., the committee determines the policy, advises the Program Director relative to specific problems and concerns, and develops recommendations for future parameters in program development. Rural Externship Advisory Committee - 1973 G. Donald Bissell, D.D.S. Mary Mogan,. R.N., M.P.H., (moved) *The student component of the Clinical Associate Professor Director of Nurses Advisory Committee varies each year. School of Dentistry - S.U.N.Y.A.B. New York State Health Department Participants on the Rath Building - Room 285 Regional Office 1973 Committee included'. 95 Franklin Street 584 Delaware Avenue Buffalo, New York 14202 Buffalo, New York 14202 Dorothy Ackerman David Breen John Coulter, Assistant Dean J. Warren Perry, Ph.D., Dean John Frischolz School of Pharmacy - S.U.N.Y.A.B. School of Health Related Professions Barry Kilbourne 118 Health Sciences Building 19 Diefendorf Annex - S.U.N.Y.A.B. Sara Lane Buffalo, New York 14214 Buffalo, New York 14214 Thomas Cummiskey, M.D. Martha Reddout, R.D., M.P.H. Assistant Dean, School of Medicine Department of Nutrition S.U.N.Y.A.B. S.U.C.A.B. Buffalo, New York 14214 1300 Elmwood Avenue Buffalo, New York 14222 Martin Gerowitz Com' prehensive Health Planning Council Jeanette Spero, Ph.D., M.P.H. of Western New York, Inc. Chairman, School of Nursing S.U.N.Y.A.B. Genesee Building, Suite 300 Health Sciences Building - Room 121 Buffalo, New York 14202 Buffalo, New York 14214 Ernest R. Haynes, M.D., Director (moved) Patricia Stopen, R.N., M.S. Family Practice Center Public Health Administrator 840 Humboldt Parkway Wyoming County Health Department Buffalo, New York 14211 400 North Main Street Warsaw, New York 14569 Bert S. Klein, D.P.M. 16 West 6th Street H. Gregory'Thorsell, M.D. Jamestown, New York 14701 21 Porter Avenue . Jamestown, New York 14701 Murray Marsh, Administrator Duncan C. Wormer, M.D. W.C.A. Hospital Wormer Medical Center 207 Foote Avenue Jamestown, New York 14701 Main Street Portville, New York 14770 Advisory Committee Chairman Lakes Area Regional Medical Program, Inc. John R.F. Ingall, M.D. Reverend Cosmas Girard, OFM. Ph.D. executive director Chairman, Regional Advisory Group LARMP, Inc. William Crage Robert J. Beebee Rural Extern Rural Extern program director-1973 program director-1974