ree er Bete fos RUST, ay Sean 4-7 Contents | PRELUDE TO AN INNERVIEW Introduction : REGIONAL ALTERNATIVES Externship Strategy Regional Map . THE RURAL EXTERN PERSPECTIVE Program Profile Externs by Discipline EXCHANGING IDEAS AND EXPECTATIONS Extern/preceptor Orientation FIRST HAND/FREE HAND Community-based Curriculum A MULTIPLE REALITY Quotations and Photography PROGRAM PEOPLE Rural Extern Advisory Committee Lakes Area Regional Medical Program, Inc. Acknowledgements Design Richard Macakanja Photography Hugo Unger Editorial Janet Gelsinger Anthony Zerbo, Jr. (a> 4-7 Contents PRELUDE TO AN INNERVIEW Introduction , REGIONAL ALTERNATIVES Externship Strategy Regional Map THE RURAL EXTERN PERSPECTIVE Program Profile Externs by Discipline EXCHANGING IDEAS AND EXPECTATIONS Extern/preceptor Orientation FIRST HAND/FREE HAND Community-based Curriculum A MULTIPLE REALITY Quotations and Photography PROGRAM PEOPLE Rural Extern Advisory Committee Lakes Area Regional Medical Program, Inc. Acknowledgements Design Richard Macakanja Photography Hugo Unger Editorial Janet Gelsinger Anthony Zerbo, Jr. (m> Prelude To An Innerview An overview of rural life in America can produce the concepts of existing patterns and evolving trends. These concepts provide the framework of an ‘inner- view’ which will localize the scopes of premise, problems, and alternatives for action. The Lakes Area Regional Medical Program, Inc. is based upon this concept — that regions differ; that regional needs differ; and that solutions to those needs must be. developed within a regional context. Modern communications and transportation have produced a mobile society, urban and rural alike. Radio, television, newspapers, automobiles, super highways, and airplanes are serving to reduce rural- urban differences in health attitudes and needs. Yet the availability of resources and facilities for health services in rural communities remains dispropor- tionate and fundamentally inadequate. The social, technological and industrial changes affecting the society as a whole produce the underly- ing problems in adjusting to the health care needs of rural communities. Population shifts to urban, subur- ban, and rural fringe areas have resulted in a decline in the number of farm families; a growing 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 recognized: Rural regions are often economically depressed, geographically isolated, and sporadically populated. These represent major obstacles to the adequate delivery of compehensive health care to the rural citizen. Regional Alternatives Predominantly rural, the Lakes Area Region encompasses Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara and Wyoming Counties in western New York, and Erie and McKean Counties in northwestern Pennsylvania. A health care manpower survey, conducted in 1967, revealed that several of these counties had a distribution of approximately 1 physician per 1,000 population. However, priorities were not directed toward obtaining a ‘doctor for every town’. These communities delineated their problem as a shortage in health professionals, citing the specific need for nurses, physicians, physical therapists, occupational therapists, medical technologists, social workers and dental hygenists. This inclusive strategy is representative of the ex- panded needs of rural health care delivery. Based upon this concept of a more comprehensive need, the region developed its own alternative, the Rural Extern Program — a community oriented program whose primary purpose is to increase the availability of a// health professionals throughout the Lakes Area Region. its primary method is to expose health science students to health care delivery within the liv- ing context of the rural community. NIAGARA COUNTY LOCKPORT NIAGARA FALLS. BATAVIA GENESEE COUNTY WARSAY. e ERIE COUNTY, N.Y. WYOMING COUNTY @OUNKIRK CATTARAUGUS COUNTY ALLEGANY CHAUTAUQUA COUNTY COUNTY : e e SALAMANCA e a JAMESTOWN OLEAN WELLS. ULE ERSE COUNTY, PA. e BRADFORD McKEAN COUNTY, PA. The Rural Extern Perspective Initiated in 1970, the Rural Extern Program was an experimental program designed to place health science students within the rural health community so that they might formulate realistic knowledge of the problems and the potentialities of rural life and health care practices. Emphasis was placed upon ex- perience, involvement, and interaction. From its onset, the Program’s major goal has been simply stated: To increase the availability of all health professionals in the rural areas of western New York and northwestern Pennsylvania. Short term objectives of the Program include: (1 To expose health science students to the nature of rural health needs and the scope of health care delivery in rural communities. C1 To broaden the understanding of community physicians and health professionals concerning the goals and needs of health science students. C1 To provide a variety of educational experiences as a stimulus. for communication among ©&x- terns in both the same and different disciplines in an interdisciplinary ‘team’ approach to health care delivery in a rural or semi-rural primary care setting. This unique, eight-week interchange between students, professionals and communities is based upon a relationship of mutual incentive and benefit. Financial support has come from the rural health professionals, agencies, hospitals, social services, businesses, private corporations and such organizations as the Appalachian Regional Commis- sion. These facets of the community have contributed toward student stipends, often providing free room and board. A weekly stipend of $100 was granted to each student participant by the Lakes Area Regional Medical Program, Inc., subject to slight reduction if the community was able to provide room and board. The progress of the Rural Extern Program can be readily recorded by its rapid growth. The 1970 summer program was a joint venture developed by the Student American Medica! Association, the Ap- palachian Regional Commission, and the Lakes Area Regional Medical Program, Inc. A group of nine medical, dental, and nursing students were placed with twelve preceptors in three counties of western New York: Allegany, Cattaraugus and Chautauqua. in 1971, the program expanded to include twenty-two students, fifteen preceptors and eleven locations. In 1972 it was comprised of thirty-four students, thirty- one preceptors, and thirteen locations. In 1973, fifty- five students worked with over one hundred precep- tors in every county of the Lakes Area Region as well as in Livingston County, New York. This rapid growth in numbers is paralleled by an in- crease in represented disciplines. The Rural Extern ° Program has included students of Medicine, Den- tistry, Pharmacy, Nursing, Physical Therapy, Oc- cupational Therapy, Medical Technology, Dietetics, Hospital Administration, Podiatry and Social Work. As the visibility of the Program expands, it is ex- pected that the scope of student participation will continue to widen. Rural Extern Program 1970-1973 Externs by Discipline 1970 1971 1972 1973 Discipline No. % No. % No. % No. % Medicine 7 77.8 12 54.6 12 35.3 16 29.1 Dentistry 4 11-4 1 4.6 2 5.9 4 7.3 Pharmacy 0 0.0 1 4.6 5 14.7 13 23.6 Nursing 4 11.1 3 13.6 4 11.8 8 14.6 Physical Therapy 0 0.0 4 18.2 7 20.6 6 10.9 Medical Technology 0 0.0 0 0.0 1 2.9 3 5.5 Dietetics 0 0.0 0 0.0 0 0.0 1 #18 Hospital Administration 0 0.0 0 0.0 1 2.9 3 5.5 Podiatry 0 0.0 0. 0.0 1 2.9 1 1.8 Social Work 0 0.0 0 0.0 1 2.9 o 0.0 Occupational Therapy 0 0.0 1 46 o 60.0 o 0.0 as ana 5H 100.1 Exchanging Ideas And Expectations The pursuit of prevention and health maintenance directly depends upon the increased use and coor- dination of the ‘full range’ of health related professionals. The delivery of health care in rural areas will have to be developed through teams of health professionals, in an interdisciplinary collabora- tion. This concept is the very axis of the Rural Extern Program. Students in various health disciplines are able to develop an understanding of the competen- cies outside their disciplines by actually participating in team practice and by experiencing the complex- ities involved in the delegation of responsibility. This interdisciplinary interaction begins with a general orientation meeting for the preceptors and externs at the onset of the program when ideas and expec- tations can be exchanged and expanded. This orientation marks the beginning of an explora- tion for the students in which they can experience the full range of existing health services — solo practice, partnerships, group practice, hospitals, health departments, nursing homes, clinics and extended care facilities. The Program’s flexibility allows for the realistic exposure and evaluation of rural health care delivery as it actually exists. Debriefing sessions are interdispersed throughout the eight weeks to allow for the verbalization of the student/preceptor inter- pretations of their individual experiences. This con- tinual dialogue is integral to the Program’s dynamic learning process. It is the start of individual and group confrontations that will serve to construct expectations into well-founded, well-experienced attitudes. First Hand / Free Hand The primary prerequisite for acceptance into the program is student interest in rural. health, primary care, and family or community medicine... The process of selecting appropriate preceptors who will plan and be responsible for community-oriented ex- ternships is based upon their enthusiasm for teaching and their willingness to arrange a variety of health care experiences for the students. These dispositions combine to structure an innovative and varied curriculum relevant to the circumstances presented by each particular location and conducive to the in- terests and needs of each student. It is this. ‘free hand’ flexibility that enables first hand experience to become productive. The diversity of the extern experience is highly ex- tensive. In addition to having contacts with all hospital departments, both preceptors and externs go into the community and experience the many aspects of health care delivery in rural, semi-rural, and small urban areas. Externs are exposed to the practices in medical and dental offices, public health offices, social service agencies, nursing homes, community pharmacies, family practice centers, physicians’ home visits, and the home-based activities of the Visiting Nurses Association and the public health nurses. In addition to this broad exposure to the rural health care system, students are able to contribute to health care delivery and to obtain valuable clinica! experience. Many function as ‘physician assistants’, 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 logs 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 problems were surfaced and progress was recorded. All of these written or verbal impressions represent the realities behind the Rural Extern Program. Itis 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. rt “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. | hope that | 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 hospital staff. This working together as a team is definitely the trend of the future.” “| met with the migrant workers in the clinic during the evening. | 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. | 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 the patient presented to the students. | am sure that this will continue and stimulate many of the physicians long out of training to do some independent study for these presentations. “Today | 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, | have been learning how to read EKGs. Several of the doctors have given me books on the subject. | 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.” den erence eR Ng “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. | found this very unusual. tn 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.” The general directions of the Rural Extern Program are coordinated by a Program Director who is a member of the Lakes Area Regional Medical Program, Inc. The Director works closely with an Ad- visory Committee consisting of representatives from each of the health sciences schools at the State University of New York at Buffalo, past and present 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 The Rural Extern Program Advisory Committee is an extension of regional imperative, whereby needs are defined: alternatives are delineated; and action is determined, directed and continued. They are the people who shape the program and, together with the student and preceptor participants, they are the im- petus that moves local need into local initiative. parameters in program development. Rural Externship Advisory Committee — 1973 G. Donald Bissell, D.D.S. Clinical Associate Professor School of Dentistry — S.U.N.Y.A.B. Rath Building — Room 285 95 Franklin Street Buffalo, New York 14202 John Coulter, Assistant Dean School of Pharmacy — S.U.N.Y.A.B. 118 Health Sciences Building Buffalo, New York 14214 Thomas Cummiskey, M.D. Assistant Dean, School of Medicine S.U.N.Y.A.B. Buffalo, New York 14214 Martin Gerowitz Comprehensive Health Planning Council of Western New York, Inc. Genesee Building, Suite 300 Buffalo, New York 14202 Ernest R. Haynes, M.D., Director (moved) Family Practice Center 840 Humboldt Parkway Buffalo, New York 14211 Bert S. Klein, D.P.M. 16 West 6th Street Jamestown, New York 14701 Murray Marsh, Administrator W.C.A. Hospital 207 Foote Avenue . Jamestown, New York 14701 Advisory Committee Chairman Mary Mogan, R.N., M.P.H., (moved) Director of Nurses New York State Health Department Regional Office 584 Delaware Avenue Buffalo, New York 14202 J. Warren Perry, Ph.D., Dean School of Health Related Professions 19 Diefendorf Annex — S.U.N.Y.A.B. Buffalo, New York 14214 Martha Reddout, R.D., M.P.H. Department of Nutrition S.U.C.A.B. 1300 Elmwood Avenue Buffalo, New York 14222 Jeanette Spero, Ph.D., M.P.H. Chairman, School of Nursing S.U.N.Y.A.B. Health Sciences Building —- Room 121 Buffalo, New York 14214 Patricia Stopen, R.N., M.S. Public Health Administrator Wyoming County Health Department 400 North Main Street Warsaw, New York 14569 H. Gregory Thorsell, M.D. 21.Porter Avenue _ Jamestown, New York 14701 Duncan C. Wormer, M.D. Wormer Medical Center Main Street Portville, New York 14770 *The student component of the Advisory Committee varies each year. Participants on the 1973 Committee included: Dorothy Ackerman David Breen John Frischolz Barry Kilbourne Sara Lane Lakes Area Regional Medical Program, Inc. John R.F. Ingallt, M.D. Reverend Cosmas Girard, OFM, Ph.D. executive director Chairman, Regional Advisory Group LARMP, Inc. . ken ow y : ENE William Crage Robert J. Beebee Rural Extern Rural Extern program director—1973 program director—1974