microsoft word jrmc_articletemplate.docx all work in jrmc is licensed under cc by-nc volume 3, issue 3 (2020) journal of regional medical campuses call for submissions paula m. termuhlen, md, editor-in-chief as we continue to work with our institutions and local communities to survive and thrive during the covid-19 pandemic, our editorial board invites you to submit your experiences. you will see manuscripts on this topic spread through this issue and upcoming issues of jrmc. in addition, we are curious about how you highlight and share research on your campus. do you have a research symposium? what kind of work do you display and how is the program formatted? short 1-2 manuscripts on this topic with the following sections are being requested: • description of type and themes of research that are presented • who are the presenters and your target audience? • what is the format? (e.g. posters, oral presentations, 2-minute thesis, etc) • how do you recognize excellence? • lessons learned (especially during the pandemic) • future plans thank you for your support of the jrmc! we look forward to learning more about what you do and how you do it! what is your level of confidence in performing each of the following entrustable professional activities (epas)? epa-1 gather a history and perform a physical examination: not at slightly somewhat very all confident confident confident confident confident □ □ □ □ □ epa-2 prioritize a differential diagnosis following a clinical encounter: not at slightly somewhat very all confident confident confident confident confident □ □ □ □ □ epa-3 recommend and interpret common diagnostic and screening tests: not at slightly somewhat very all confident confident confident confident confident □ □ □ □ □ epa-4 enter and discuss orders and prescriptions: not at slightly somewhat very all confident confident confident confident confident □ □ □ □ □ epa-5 document a clinical encounter in the patient record: not at slightly somewhat very all confident confident confident confident confident □ □ □ □ □ epa-6 provide an oral presentation of a clinical encounter: not at slightly somewhat very all confident confident confident confident confident □ □ □ □ □ epa-7 form clinical questions and retrieve evidence to advance patient care: not at slightly somewhat very all confident confident confident confident confident □ □ □ □ □ epa-8 give or receive a patient handover to transition care responsibility: not at slightly somewhat very all confident confident confident confident confident □ □ □ □ □ epa-9 collaborate as a member of an inter-professional team: not at slightly somewhat very all confident confident confident confident confident □ □ □ □ □ epa-10 recognize a patient requiring urgent or emergent care and initiate evaluation and management: not at slightly somewhat very all confident confident confident confident confident □ □ □ □ □ epa-11 obtain informed consent for tests and/or procedures: not at slightly somewhat very all confident confident confident confident confident □ □ □ □ □ epa-12 perform general procedures of a physician: not at slightly somewhat very all confident confident confident confident confident □ □ □ □ □ epa-13 identify system failures and contribute to a culture of safety and improvement: not at slightly somewhat very all confident confident confident confident confident □ □ □ □ □ microsoft word service-learningarticle.docx published by university of minnesota libraries publishing service-learning: best-practices to cultivate engagement between learners and communities experiences from two regional medical campuses heather cassidy, md; erik wallace, md; amy smith, phd z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc heather cassidy, md; director for community engagement, university of colorado school of medicine colorado springs branch, heather.cassidy@cuanschutz.edu erik wallace, md; associate dean for colorado springs branch, university of colorado school of medicine, erik.wallace@cuanschutz.edu amy smith, phd; senior educational consultant, department of education, lehigh valley health network, university of south florida morsani college of medicine, amy_b.smith@lvhn.org all work in jrmc is licensed under cc by-nc volume 2, issue 3 (2019) journal of regional medical campuses abstract service-learning: best-practices to cultivate engagement between learners and communities experiences from two regional medical campuses heather cassidy, md; erik wallace, md; amy smith, phd topic: although the liaison committee on medical education (lcme) now lists a specific standard for service-learning, only 15-25% of american medical schools reported having service-learning components in their curriculum in 2015. evidence suggests that when students engage in service-learning curricula in partnership with community organizations there are benefits to students, partner organizations, and the well-being of the community. students develop a more nuanced view of physician leadership, sustain higher levels of civism including commitment to underserved populations and serving in leadership and/or collaborative capacities in their future communities, and may have lower levels of burnout. partner organizations and communities can recognize economic benefits, increased productivity, and intercultural exchange. well-designed service-learning aligned with community interests can be a curricular tool that cultivates engagement between learners and their communities. regional medical campuses (rmcs) are uniquely positioned to implement impactful service-learning opportunities for students; however, rmcs face different opportunities and challenges for implementation and success based on their different resources and curricular structures. short description: we will summarize the new lcme standard for service-learning including the definition of service-learning as service to the community in activities responding to community-identified concerns and involving both student preparation and reflection. a review of the literature on service-learning in undergraduate medical education with an emphasis on best-practices will be presented. we will then provide detailed outlines of two service-learning curricula developed and deployed at two different regional medical campuses which employ a block model and a longitudinal integrated clerkship model during the clinical years. participants will use the provided curricular models as a lens for analyzing the strengths, opportunities, and obstacles to implementing or optimizing service-learning at their own regional medical campus. participants will develop an action plan to identify next steps at their regional medical campus. four questions that were posed to/considered by session participants: 1) what are the most compelling opportunities to develop service-learning curricula at your institution? 2) if you have a service-learning curriculum, what obstacles have you encountered? if you do not yet have a service-learning curriculum, what obstacles to you anticipate in developing a service-learning curriculum at your institution? 3) what are your obstacles and opportunities for assessing learner outcomes in your current or future service-learning curriculum? 4) how could you go about assessing outcomes for your community-based service-learning partners? three take home points from our session: 1) a new lcme standard encourages integration of service-learning curricula in medical education. service-learning is an educational experience involving medical students’ service to the community in activities responding to communityidentified concerns and involving student preparation and reflection. 2) service-learning is distinct from community-service and volunteerism in that it is anchored in curricular goals and objectives and mandates learner assessment. 3) appropriate learner assessment and assessment of meaningful outcomes for community partners requires future consideration and investigation. microsoft word negotiatingclinicalsitesarticle.docx published by university of minnesota libraries publishing negotiating clinical sites in the community playing the game james b. alexander, md z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc james b. alexander, md; professor of surgery, associate dean, atlantic health system regional campus, sidney kimmel medical college at thomas jefferson university all work in jrmc is licensed under cc by-nc volume 2, issue 3 (2019) journal of regional medical campuses abstract negotiating clinical sites in the community playing the game james b. alexander, md topic: sites for clinical instruction are increasingly in demand. regional campus deans seek to provide high-quality clinical instruction by embedding medical students in practices in their local communities. however, these same clinical sites may be sought for use by other learners from other, competing programs. as the demand for sites increases, regional campus deans may find themselves vieing with other educational programs for instructional opportunities in the same communities and among the same clinical faculty. much to the dismay of deans, this can easily become a “sellers’ market”, in which local community clinicians may make clinical training opportunities available in return for favorable considerations from programs and schools. local politics and economics are in play, resulting in substantial challenges to achieving curricular objectives. regional campus deans have finite resources. in order to secure the high-quality opportunities they need from local community clinicians, they need to seek strategic solutions that satisfy both the interests of prospective faculty and their own curricular objectives. deans need to understand the perspective of community physicians. deans must understand how the interests of faculty can either coincide or conflict with the interests of the medical school. deans also need to understand how differing strategies can yield either favorable or unfavorable educational outcomes for their students and their programs. successful strategies must achieve a win-win, whereby the goals of regional deans and their curricular objectives can be achieved while fulfilling the aims of local community faculty. short description: this highly interactive session explored the dynamics at work. participants had the opportunity to play roles as regional campus deans or clinical preceptors. deans are awarded students with their attendant tuition dollars. students require clinical training in all core disciplines within an academic year. clinicians seek to optimize their practices while negotiating favorable considerations from the deans in return for training opportunities. successful deans achieve recognition and acquire increased resources. successful clinicians receive support from the medical schools and are perceived favorably in their communities. their practices thrive. on the other hand, unsuccessful deans and/or faculty may experience deleterious consequences. alternative strategies yield different outcomes for students, deans, and clinicians. reflections of participants and observers at the end of the exercise provide deeper understandings of the interplay of forces, tensions, and strategies. four questions that were posed to/considered by session participants: 1) what strategies can be used by regional campus deans to obtain clinical training opportunities with community physicians? 2) what are the salient motivations of clinical preceptors in the community as they take on the training of medical students in their practices? 3) are there common values or goals that can serve as win-win opportunities for training medical students with community preceptors? doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 3 abstract three take home points from our session: 1) negotiating clinical sites for training medical students in the community is complex. nonetheless, some salient issues can be realistically portrayed in a game format. the resulting scenarios can yield meaningful insights into the forces at work in these transactions. 2) alternate strategies for securing clinical training sites can be adopted by regional campus deans. the available sites and resulting educational outcomes will vary depending on the strategies chosen. 3) the interactions of regional campus deans and community clinical faculty may yield unanticipated educational outcomes. these outcomes can have substantial impact on both students and the learning environments in which they train. microsoft word covid66article.docx published by university of minnesota libraries publishing covid 66: are we too old for this? william j. crump, m.d. doi: https://doi.org/10.24926/jrmc.v3i1.3190 journal of regional medical campuses, vol. 3, issue 1 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc william j. crump, m.d., associate dean, university of louisville school of medicine trover campus at baptist health madisonville. all work in jrmc is licensed under cc by-nc volume 3, issue 1 (2020) journal of regional medical campuses perspectives covid 66: are we too old for this? william j. crump, m.d. as i drove in to make weekend rounds at our hospital, i noticed a buzzard circling above. it gave me pause. well, i thought, at least it’s just one buzzard. this whole social distancing thing has shaken me to my core. as i passed my 65th birthday and watched all the subspecialists around me retire, i really had to stop and think what i would do if i no longer saw patients. then, i realized that at 65 our hospital bylaws said i could stop taking hospital night call. fewer nighttime awakenings seemed like a good idea after 22 years of 24 /7 call backing up our residents’ deliveries, but it slowly dawned on me that if i stopped taking night call and with younger faculty now available, it didn’t seem reasonable for me to do daytime deliveries and ask them to do those at night. with that, a part of me that had been so integral stopped as well. i still oversee prenatal care with the residents but have stopped doing deliveries. life was less complicated, and i felt more rested and able to give my daytime work my full attention. and then this confounded virus. initially the cdc said that high-risk groups were older age and underlying conditions. i heard this 3 times from the same nih official in the same day. then somehow over the next few days their recommendations changed from “and” to “or”. suddenly, those of us with gray hair and perhaps some wisdom to share become at risk by doing what we’ve done every day for almost 40 years. as we wait to see if the plague strikes our small regional hospital, disappointment is the reigning theme. i was scheduled to receive a national medical education award for our campus at the meeting in my hometown of savannah. family could attend, and it seemed like a nice inflection point in my career. on the same weekend i could see my granddaughter play soccer in a tournament that is worthy of her olympic development team skills. i could visit with the family and walk through the cathedral, the squares downtown, and all of the places that made me who i am. meeting canceled, travel advisory for anyone my age, trip canceled, and disappointment. as we all struggle to decide what parts of medical education should still continue and whether we could possibly have any resident or medical student conferences with 6 feet between each learner, it suddenly dawned on me that i may be at risk in my own hospital. i provide medical support for our inpatient geriatric behavioral health unit. what should i do the next time i’m called about a patient with fever and a cough? i could do a lot of the evaluation by video, but i’m just old-fashioned enough to need auscultation to help me make decisions. although i used telemedicine auscultation 25 years ago with nasa, there’s no quick way to set it up in our small hospital. then there’s the experience i had this morning, when a woman just a few years older than i was admitted for worsening dementia and some verbal aggression. as i examined her, she ruminated with wild eyes on who would put her in such a place and asked me every few seconds how she could get out. no verbal reassurance worked, but when i just held her hand and told her how much we cared and how her family had entrusted her to our care, she visibly relaxed. there is no way we could have gotten to that first step of healing by video. for those of us over 60 but still in good health and thrilled every day to see patients and interact with learners, what do we do? there are no clear guidelines. as i often do, i harken back to my mentor, dr. gayle stephens, who was one of the founding fathers of family medicine. paraphrasing the central tenet of his philosophy: the definition of a family doctor is one who cannot ignore any issue brought to him by his patient. i am going to find a way to get through this without losing who i am. buzzards be damned. microsoft word steppinguptotheplatearticle.docx published by university of minnesota libraries publishing stepping up to the plate: an unexpected leadership opportunity during the covid-19 pandemic sarah fisher, m.d., william j. crump, m.d journal of regional medical campuses, vol. 3, issue 3 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc sarah fisher, m.d., clinical instructor, regional affiliate in obstetrics, gynecology, and women’s health, university of louisville school of medicine trover campus at baptist health madisonville william j. crump, m.d., associate dean, university of louisville school of medicine trover campus at baptist health madisonville. all work in jrmc is licensed under cc by-nc volume 3, issue 3 (2020) journal of regional medical campuses stepping up to the plate: an unexpected leadership opportunity during the covid-19 pandemic sarah fisher, m.d., william j. crump, m.d. abstract a regional campus graduate communicates in this piece her experience during the initial period of the covid-19 pandemic. her words highlight the importance of the “sense of place” that is the unifying theme of this rural regional campus.1 she worked 3 years in our college rural scholar program and ultimately wrote the best summary of the community aspect of this experience.2 she then completed our prematriculation and preclinical programs, and graduated from our clinical campus in 2015. after that she completed an ob/gyn residency at geisenger and returned home to practice, where she serves as a key faculty for our clerkship as a newly graduated ob/gyn resident, i was fortunate to be able to come back to the hospital in my hometown as my first attending job. this is the same hospital where i spent the last two years of medical school and hosts all of the memories that made me fall in love with obstetrics and gynecology as a student. this is the hospital where i say hello to the nurses who i’ve known my whole life as i pass by while seeing patients. this is the hospital where i remember making “rounds” with my dad at age 5. returning to practice in madisonville has been a pleasure, but it has not always been sunshine. aside from all the pleasures, working in my hometown rural hospital has had its own difficulties. i love having known my general surgeons since they were my attendings in medical school, but every time i operate, i wonder if i’m good enough to be in the operating room next to them. i enjoy seeing smiling faces walking in to work and saying hello to the nurses who taught me to put in a foley catheter, but i hope they don’t think i’m too young to take care of their patients. i am proud to be a female physician, but i fear that when administrators look at me, they see an outspoken “dumb blonde” female physician. being a new attending just out of residency is challenging as we overcome imposter syndrome, eventually realizing that all of those years in residency did in fact teach us a thing or two. now throw in covid-19. in my first year out from residency, i had no idea that a worldwide pandemic would turn my own world upside down. in february, my biggest concerns were upcoming oral boards, teaching medical students, and making sure that i didn’t kill a patient. then came march 2020. suddenly, i worried if i was safe around my patients – or if they were safe around me. did i carry the virus? would i infect my patients? my surgery patients didn’t understand cancelling their hysterectomies, sobbing on the phone; i can see how their “elective” surgery doesn’t seem elective to them. i was not trained how to handle this and “pandemic 101” was certainly not part of the residency curriculum. the most dramatic change that i experienced was my role as a physician. not only was i voyaging into the world of telemedicine, but i was also making big decisions about our labor and delivery unit. with my 2 partners, we decided how we would handle a covid-19 patient in labor and during delivery, advocated for fit testing for all of our staff, and urged all to wear n95 masks during the second stage of labor and during delivery to protect ourselves. we reviewed guidelines as they came from the cdc and sought the expert opinions of our maternal-fetal medicine colleagues. i streamlined a policy for mother and baby bonding after delivery for covid-19 patients following updated guidelines set forward by the cdc. however, this was not a one-woman show; i collaborated with my ob partners, labor and delivery nursing staff, neonatology specialists, nicu nursing staff, and infection control. during these round table discussions where all voices were encouraged to express concerns, more than once our labor and delivery nurse manager asked, “dr. fisher, what do you think?” i realized that as a rural physician, i was being turned to for advice and guidance on how to handle this unprecedented pandemic. it didn’t matter that i was green and had virtually no experience under my belt. i was still viewed as a leader. while i felt the weight of this pandemic, i have been reminded of the vital role of the rural physician. this is not just from a patient care perspective but also from a process and policy standpoint. we are viewed as the leaders of healthcare in our communities and that responsibility should not be taken lightly. in times when our staff and patients need an advocate, we are responsible for stepping up to the plate and answering the call. not only do we comb through every cdc guideline and expert opinion to provide the very best care for our patients, we also are involved with developing and modifying policies to keep our staff and journal of regional medical campuses, vol. 3, issue 3 patients safe. being a leader is not about the loudest voice but rather encouraging every voice to be heard. the notion of mutual respect for each person’s role in the solution led to exemplary teamwork which resulted in the best possible patient care and experience for our obstetrical patients and their newborns. i initially thought i needed experience to make a difference; really all i needed was a heart. while my rural hospital may not have initially sought a green female doctor to answer their call for a leader, i feel lucky to serve my community in a unique way. references 1. crump wj, fricker s, barnett d. a sense of place: rural training at a regional medical school campus. j rur health. january 2004; 20(1): 80-84. doi: 10.1111/j.1748-0361.2004.tb00011.x. 2. crump wj, fisher sm, fricker rs. community service as learning laboratory: a report of six years of a rural community-academic partnership. j kentucky med assoc. 2014; 122: 131-136. microsoft word integrated residency.docx published by university of minnesota libraries publishing integrated residency helps retain students in a regional campus residency program david l. bramm, md; paula clawson doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 1, issue 4 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc david l. bramm md; dr. bramm retired from his family medicine practice in 2015 and is now the director of the rural medicine program at the uab school of medicine, huntsville regional medical campus in huntsville, alabama. paula clawson; ms. clawson is the rural medicine program administrator at the uab school of medicine, huntsville regional medical campus in huntsville, alabama. david l. bramm md; davidbramm@uabmc.edu, uab school of medicine, huntsville regional medical campus, 301 governors drive sw, huntsville al 35801 (office): 256-551-4609 (mobile): 256-508-2189 (fax): 256-551-4451 all work in jrmc is licensed under cc by-nc volume 1, issue 4 (2018) journal of regional medical campuses original report integrated residency helps retain students in a regional campus residency program david l. bramm, md; paula clawson abstract the family medicine integrated residency (ir) at the uab school of medicine, huntsville regional medicine campus is designed to attract rural students and to fully prepare them for family medicine residency. it also provides a recruiting method for the residency to retain in-state medical school graduates. the 2017-18 pilot year had 5 fourth year medical students enrolled and they all matched in the huntsville residency. keywords: integrated residency. regional campus residency. rural medical students. alternative residency models. since 2005, only 32.2% of the uab huntsville family medicine residency has been filled with graduates of alabama medical schools.1 this is concerning because in alabama, 74.7% of physicians who do both their undergraduate and graduate medical training in-state set up practice in alabama.2 this residency program accepts 12 interns per year. it is housed in the huntsville regional medical campus of the uab school of medicine (hrmc). the hrmc teaches clinical skills to a cohort of third and fourth year students, approximately 35 in each class. included in these classes are a special track of rural medicine program (rmp) students who grew up in rural alabama, expressed an interest in rural family medicine, and have been exposed to a special rural curriculum. even rmp students, who would seem likely to train in-state, tend to go elsewhere for residency. the entire uab medical school graduates about 175 medical students annually. additionally, 72 students graduate from the university of south alabama college of medicine. though it would seem that the huntsville residency could attract a majority of its intern class from in-state graduates, that has not been the case as of late. it is hard to quantify why in-state students do not choose the huntsville residency. perhaps the reason is the successful recruiting the program does at the regional and national level; rmp students may see this as an opportunity to spread their wings outside of alabama before returning home to set up practice (to date, 96% of the rmp graduates set up practice in alabama3). in an effort to increase in-state intern numbers and to further cement rmp students in alabama, the family medicine residency and rmp launched an integrated residency (ir) in 2017-18. the ir combines the requirements of fourth year medical school with intern experiences. although ir students are not obligated to choose the huntsville family medicine residency, all of the ir students matched in this residency in its pilot year. the ir is fashioned after a similar program at the university of missouri school of medicine. the missouri program has operated since 1992 and every participant has chosen to match into their residency.4 the integrated residency is open to hrmc students from rural alabama. the rural background requirement is because the funding source is specific to creating rural physicians for alabama. it is well documented that students most likely to enter rural family medicine are those who were raised in a rural area, intend rural practice, intend primary care, and participate in a rural program.5 applications are submitted in the spring of the third year with the interview and selection process duplicating the regular residency selection process. selected ir students are notified in may and may begin some ir activities that fit in their schedule prior to the fourth year, which starts in late june. irs engage in a more rigorous fourth year schedule, which includes a pulmonary medicine/critical care rotation designed specifically for ir students, a family medicine acting internship in uab’s huntsville family medicine clinic and required rotations in normal fourth year elective offerings of anesthesia, nephrology, emergency medicine, and cardiology. the fourth-year specialty preceptors in huntsville are community preceptors which were informed of the integrated residency goals. these preceptors expressed enthusiasm for working with students whom they expected to stay in huntsville for residency. even with these required rotations, students have time to take some additional electives of their choosing. these students had an acting internship in rural family medicine in the third year, and we hope to add a fourth rural rotation for ir students. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original report additionally, the ir student must attend at least 50% of family medicine resident didactic sessions, at least 50% of the campus’ m & m conferences and grand rounds, and work 36 half-days in the family medicine clinic under the tutelage of a senior resident mentor. the clinic work allows the ir student to become familiar with those in the patient panel they will assume when the mentor graduates. students are required to post passing scores in step 2 and be successful in each component of the curriculum. there are periodic reviews of the student to be sure they are fulfilling their obligations. either party (the student or the residency) may back out of the agreement prior to the nrmp match day. the student must complete the eras application and rank their residency choices with nrmp. during this pilot year, all 5 ir students chose not to interview at other programs and chose the huntsville residency as their only program for match. each integrated resident receives a scholarship of $20 000 to reduce medical school debt and are eligible for up to $5000 travel expense for conferences and medical mission trips. different institutions handle this scholarship differently and offer varying amounts, but at missouri 21 out of 23 integrated residents said they would have applied to the program even if the scholarship was nonexistent.4 in the 2018 match, 9 of the 12 huntsville interns (75%) are from in-state medical schools. it is impossible to know if any of the ir students would have chosen other residencies if not for this program. we know through conversation with rmp graduates from 2017 that 2 of those who matched out-of-state into family medicine would have chosen huntsville if the ir had been available to them. references 1. date on file. university of alabama school of medicine family medicine residency huntsville. 2. 2017 state physician workforce date report, aamc. nov 2017. alabama profile: aamc.org/download/484510/data/albamaprofile.pdf 3. data on file. university of alabama school of medicine rural medicine program. 4. ringdahl e, kruse rl, lindbloom ej, zweig sc. the university of missouri integrated residency: evaluating a 4-year curriculum. fam med. 2009;41(7):476-480. microsoft word considerationforselectionarticle.docx published by university of minnesota libraries publishing considerations for selecting applicants to rural medicine programs david l bramm, md faap doi: https://doi.org/10.24926/jrmc.v4i4x.4284 journal of regional medical campuses, vol. 4, issue 4 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc david bramm is the director of the rural medicine program for the university of alabama school of medicine, huntsville regional medical campus, huntsville, al. all work in jrmc is licensed under cc by-nc volume 4, issue 4 (2021) journal of regional medical campuses perspectives considerations for selecting applicants to rural medicine programs david l bramm, md faap abstract the selection of medical students destined for rural practice is important to help provide access to care for the 20% of the us population who live in rural america. knowing which medical school applicants will go into rural practice is an inexact science, although the objective predictive characteristics of future rural doctors are well known and evident in the literature. the role of rural program directors is to identify which applicants will likely choose a fm residency, done primarily by identifying which rural predictive characteristics the applicants possess. admissions committee members are not expected to determine the likely practice locations of rural applicants and need only have the responsibility of determining which applicants should become physicians. the selection of medical students destined for rural practice is important to help provide access to care for the 20% of the us population who live in rural america. by 2030, there will be 25% fewer rural physicians practicing medicine.1 knowing which medical school applicants will go into rural practice is an inexact science, although the objective predictive characteristics of future rural doctors are well known and evident in the literature. admissions committees have the responsibility of determining which applicants should become physicians, but it is unclear if they should be charged with determining the likely practice locations of rural applicants. the reasons for the shortage of rural physicians include what is lacking in rural living professional support, opportunities for spousal employment, urban amenities, and quality schools. on the other hand, factors such as societal orientation, lack of interest in research, suitable rural role models, and rural family ties are important predictors of future rural practice.2 additionally, early exposure to medically underserved areas affects future practice locations.3 furthermore, we are producing fewer primary care physicians because of enhanced opportunities for urban centric fellowships in “primary care” specialties. approximately 48% of pediatricians and 80% of internal medicine residents become subspecialists.4,5,6 the converse is true of family medicine doctors; over 90% provide primary care. family physicians only constitute 15% of the primary care workforce yet they provide 42% of the care rendered in rural areas.7 it is rare that subspecialists choose rural practice, thus emphasis must be placed on admitting students who will choose family medicine. programs whose goal is to provide physicians to rural sites must be mindful of these facts. therefore, the initial task of rural program directors is to identify which applicants will likely choose a fm residency, done primarily by identifying which rural predictive characteristics the applicants possess. the role of the admissions committee is to not impede this process, but rather, more importantly to determine which applicants are suitable for medical school. this is no different from the role of admissions committees for the incoming class at large; they are under no obligation to determine what practice locations non-rural applicants might choose. there is no data that suggest an interview has any usefulness is predicting ultimate rural practice.8 knowledge of the factors related to the selection of rural family medicine by students is specialized and medical school interview committees do not necessarily realize this. in the seminal paper by parlier, et.al. it was noted that, “rural upbringing, positive rural exposure, preparation for rural life and medicine, partner receptivity to rural living, financial incentives, integration into rural communities and good work-life balance influence recruitment and retention”. the author cited no evidence in 113 references that the medical school interview added any predictive benefit.9 additionally, factors such as use of concrete language on an application may be unimpressive to an interviewer but has positive journal of regional medical campuses, vol. 4, issue 4 perspectives predictive value for future rural practice. lack of undergraduate research, an idealized view of rural living, the desire to make a difference in a community and having extended family in a very rural part of the state are salient factors that interviewers may not fully grasp or uniformly explore. this knowledge gap threatens to encourage the interviewers to use “feelings” or “impressions” for student selection, which is anathema–unscientific and often sadly erroneous. even the definition of rural may not be accurately known by admissions committees.10,11 the us census bureau defines rural as any population, housing, or territory not in an urban area.12 in alabama we define rural as living in a town less than 50 000 that is not in the footprint of a larger urban area. the large western states have quite remote places more properly deemed frontier. at the university of alabama birmingham school of medicine, the responsibility for screening rural applicants lies with the rural program directors who have knowledge of both the practice of rural medicine and the literature related to the topic. this knowledge allows the broadest evaluation of rural applicants because there are students who are technically rural who manifest few characteristics predicting rural practice and some from the rural fringe who have a compelling rural sense of place. additionally, mentees may be well known to program directors who recognize prized intangibles no interviewer is able to discern. the strongest predictor, rural upbringing, is not the only important factor associated with the choice of rural practice.13 personal interests are rarely predictive unless compellingly rural, like 4h, ffa, and/or animal husbandry, but the reverse may not be true; a truly rural student may well enjoy golf, tennis, or soccer. these activities are related more to opportunity than geography. when the author practiced in a rural mississippi town of 1 400, the other doctors in the two-county area included: an amateur astronomer with a home observatory. an expert in gourmet food and italian opera (who had a stunning record collection). a scratch golfer who had done post-doctoral training at the lahey clinic. a light plane pilot who had been an engineer in a previous career. the common factor was that all of these doctors were originally from rural mississippi, had family there and were desirous of broad scopes of practice, but their passions could be well construed as urban-centric. dr. john wheat published a paper showing that (alabama) rural medical scholars who chose family medicine had activities revealing a humanitarian personality and a commitment to rural underserved communities as well as plans to specialize in fm (urban shadowing had negative predictive value).14 our data shows that the rural applicant most likely to pursue rural fm has only shadowed rural physicians, lacks urban research, uses concrete speech, does not interview well, and is from a town less than 25 000. other predictive elements are community college attendance, extended family in rural alabama, and lifelong rural residence. it is the obligation of all medical schools and particularly those with missions to produce rural physicians for their states to examine their admission apparatus to ensure that the process is data driven and does not unwittingly exclude qualified rural applicants by judging them through inappropriate and irrelevant measures. references 1. skinner l, staiger do, auerbach di, buerhaus pi. implications of an aging rural physician workforce. n engl j med. 2019;381:299-301. doi:10.1056/nejmp1900808 2. mitra g, gowans m, wright b, brenneis f, scott i. predictors of rural family medicine practice in canada. canadian family physician. 2018;64(8):588-596. 3. tavernier la, connor pd, gates d, wan jy. does exposure to medically underserved areas during training influence eventual choice of practice location? med educ. 2003;37(4):299-304. doi:10.1046/j.13652923.2003.01472.x 4. what does the pediatric residency match data look like? medical school headquarters. 2018. accessed july 19, 2021. https://medicalschoolhq.net/ss-48-what-doesthe-pediatric-residency-match-data-look-like 5. macy ml, leslie lk, turner a, freed gl. growth and changes in the pediatric medical subspecialty workforce pipeline. pediatr res. 2021;89:1297–1303. https://doi.org/10.1038/s41390-020-01311-7 journal of regional medical campuses, vol. 4, issue 4 perspectives 6. internal medicine residency match results virtually unchanged from last year. american college of physicians. 2014. accessed july 19, 2021. https://www.acponline.org/acpnewsroom/internal-medicine-residencymatch-results-virtually-unchanged-from-lastyear 7. about rural health care. national rural health association. accessed july 20, 2021. https://www.ruralhealthweb.org/aboutnrha/about-rural-health-care 8. hyer jl. rural origins and choosing family medicine predict rural practice. the robert graham center; 2007. policy paper 49. 9. parlier ab, galvin sl, thach s, kruidenier d, fagan eb. the road to rural primary care: a narrative review of factors that help develop, recruit, and retain rural primary care physicians. acad med. 2018;93(1):130140. doi:10.1097/acm.0000000000001839. 10. coburn, ae. issue brief #2: choosing rural definitions: implications for health policy. rural policy research institute health panel; 2007. 11. ray ra, young l, lindsay db. the influences of background on beginning medical students’ perceptions of rural medical practice. bmc medical education. 2015;15:58. doi10.1186/s12909-015-0339-9. 12. brooks rg, walsh m, mardon re, lewis m, clawson a. the roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of the literature. acad med. 2002;77(8):790-8. doi: 10.1097/00001888-200208000-00008. 13. how does the census bureau define rural? united states census bureau. accessed july 29, 2021. https://www.google.com/search?q=us+census +definition+of+rural&rlz=1c1gceb_enus898u s904&oq=us+census+definition+of+rural&aqs =chrome..69i57j0i22i30.7720j1j7&sourceid=ch rome&ie=utf-8 14. avery dm jr, wheat jr, leeper jd, mcknight jt, ballard bg, chen j. admission factors predicting family medicine specialty choice: a literature review and exploratory study among students in the rural medical scholars program. j rural health. 2012;28(2):128-36. doi: 10.1111/j.1748-0361.2011.00382.x microsoft word windows to the soul article.docx published by university of minnesota libraries publishing windows to the soul: “now close your eyes.” william j. crump, md. journal of regional medical campuses, vol. 1, issue 2 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc william j. crump, md., associate dean, university of louisville school of medicine trover campus at baptist health madisonville. corresponding author: william j. crump, md, associate dean, university of louisville school of medicine trover campus at baptist health madisonville, 200 clinic drive, 3rd north madisonville, ky 42071, v: 270.824.3515 f: 270.824.3560 e: bill.crump@bhsi.com all work in jrmc is licensed under cc by-nc volume 1, issue 2 (2018) journal of regional medical campuses reflective humanities windows to the soul: “now close your eyes.” william j. crump, md. abstract a regional campus dean reflects on his recent acquisition of a new clinical responsibility as medical support to an inpatient behavioral health unit. having taught the neurological exam to students for almost 35 years, this experience caused him to pause and consider a new perspective on teaching the routine exam. the author has no conflict of interest to report, and irb approval for treatment of human subjects and treatment of animal subjects is not applicable. riding up in the staff elevator that still smells like somebody's breakfast, i am checking my email on my phone to get the day started. the door opens on the sixth floor and i stride across the brown tiles that meet the light blue walls that lead into the inpatient psychiatry unit. i touch my badge to the wall sensor that magically opens the first door, and then step in between the locked doors. i have learned to wait until the door behind me clicks to touch the next wall sensor to open the second door. when i first started doing this two years ago, this eight second delay tremendously irritated me. i learned to look through the glass into the geriatric side of our unit to make sure that a patient was not right up against the door, but the delay was still irritating. then, in the middle of a mindfulness discussion with my medical students, it occurred to me what a gift it was to have those few seconds for silent reflection before i enter the chaos. after this classic re-frame, i now cherish those few seconds. my morning schedule is tight. i need to see the two or three new patients and review lab on several others before sit down rounds with staff at 9 am. many of the patients i see are unable to give me a coherent story or have already been sedated by the time i arrive. i have learned to do the detailed neurological exam that is required of a medical consultant in an inpatient psychiatry unit before taking much history. then if the patient is alert enough during the exam, i can get them to tell me their story. this presents an ideal opportunity to evaluate the patient uncontaminated by the previous “i-patient” created by someone else in the chart.1,2 as i go through the routine exam that i've been doing for nearly 40 years, some remarkable moments occur. the patient sits on the side of the hospital bed that is bolted firmly to the floor, as is the only stool in the room, all of which are dark brown plastic. all fixtures are curved, with nothing in the room that could support a ligature of any kind. testing cranial nerve one with an alcohol prep brings some rich nonverbals from alcoholics and reveals the traditional anosmia shown by many patients with alzheimer's disease. testing visual fields by having the patient look at my nose and count my fingers in the periphery results in the patient looking directly at me. the overwhelming sadness of profound depression and the absolute wildness of psychosis are revealed in this mutual gaze and seems to make us both uncomfortable. extraocular muscle testing is interesting in those with dementia. most are completely unable to follow my finger, but if i move my head like a dancing crane they continue to look me right in the eye as i go through the movements. testing masseter function by having the patient “bite down hard” also brings a look of sadness to both of our faces when many teeth are missing. protrusion and movement of the tongue usually goes pretty well, except for the patients who are actively hallucinating. this seems to journal of regional medical campuses, vol. 1, issue 2 reflective humanities trigger some deep response that almost always results in the patient communicating with the unseen figure in the room with us. the request, “now give me a big smile,” results in a remarkable dichotomy. some deeply depressed patients “put on a happy face” for those few seconds that is strikingly incongruous. others cannot make those muscles complete the task, and i have learned to say, “i know that’s hard to do now.” testing sensation on the face is perhaps the most telling. my standard is saying, "i'm going to touch your face lightly, and i want you to close your eyes and tell me whether it feels right or left." i am constantly surprised that almost all of the patients with dementia respond correctly. but there is a group of patients, most of whom are young women, that pause and seriously consider whether they can actually do this. despite my best nonverbal efforts to connect with all of my patients at some level, their deep suspicion simply will not allow them to close their eyes. some try to comply for a few seconds but are extremely uncomfortable and become agitated. when i hear their tragic stories later, i understand the looks on their faces. i have learned that having a chaperone in the room actually adds to their discomfort, although with some patients i still require this. muscle strength testing generally goes pretty easily. however, some patients with dementia have great difficulty deciding what to do when i ask them to press against my hands. quite a few with schizophrenia will simply leave their arms and legs wherever they last were when i moved my hands. surprisingly, attempting reflexes with a small reflex hammer is generally not interpreted as threatening by even the most delusional patient. palpation of the neck is usually not a problem, but some of the same young women pull away after a few seconds. i have learned to say very quickly, "that's fine, we don't need to do that part now." i was trained that correct auscultation requires the chest piece to be touching the skin and not to be through clothes where unusual, adventitious sounds can arise. surprisingly, slipping the chest piece of the stethoscope inside the hospital gown or shirt to listen in the front to the heart has never been perceived as threatening by anyone. however, the challenge comes when i want to listen to the chest posteriorly. i am very clear saying, "now i'm going to go around behind you and listen to your lungs." regardless of gender or hospital unit, i next ask for permission to lift the shirt or gown to place the chest piece on the posterior chest. on this unit, this results in a bit of hesitation in patients regardless of gender. almost universally, i later discover their stories of abuse which are usually sexual and from when they were children. again, i have learned to agree quickly to listen through the gown if that makes the patient more comfortable. i guess that does not make me a bad doctor. abdominal exams usually go easily and for these patients a gu and breast exam are not indicated at this interaction. i must admit that it is always surprising how many adult patients in this unit are so ticklish that it is difficult to do a complete abdominal exam. i wonder if that is some kind of predictor of significant mental health issues. i hope not. for the patients where rapport has been developed in this reversal of the routine pediatric exam, i seek an opening, "so tell me why you think you're here." responses are rich and devastating at the same time. i have had a patient tell me that they are worried that they cannot die3, and another who explained that her absolute hate of her teenage children is driven by the fact that her "rotten kids" were fathered by her father.4 there have been times that i wished i had not sought an opening, like the time that the patient described the devils in the room and their individual plans for me. or, the large twenty-something man who promptly pushed his face close to mine and said, “why the f--do you think i’m here?” next in my routine, i take a chance. i say, "you know, i ask all new patients, is your faith important to you?" this is not unusual for me to ask in my office, but with patients so vulnerable it always gives me pause.3 however, despite the crazy things that we have already discussed, this journal of regional medical campuses, vol. 1, issue 2 reflective humanities almost always brings a moment of peace mixed with genuine interest to the patient's face. some explain that they are atheists and we discuss that a bit. many in this bible belt area say, “well i just don't go to church anymore.” this gives us an opportunity to talk about the difference between faith and religion, and far too many talk about the guilt that their former religious practice has engendered. with the delusional, hyper religious patient, this can be almost comical. i have had a request for an exorcist consultation. but it is always time well spent. i do not usually offer to pray with these patients, but i do make it clear to them that our chaplain will and will see them at their request. it is remarkable how many of these patients have a bible borrowed from us when i return to their room during their stay. we have not had a patient ask for a torah or qur’an yet, but we have a plan. so, i finish my notes, go back to the double doors, and during the pause between the two i reflect on the human misery i have just shared and perhaps re-interpreted for the patient. i am also struck that almost all said, “thank you,” when i told them we were finished. then, back across the brown tile, past the blue walls and into the elevator. when the door opens on the main floor, it almost feels like i am stepping onto another continent. i head over to our classroom, thinking about how i will teach the next group of students how to do a neuro exam, as i have done for almost 35 years. it is with a different perspective that i say: “first, begin with testing the cranial nerves.” references 1. verghese a. culture shock patient as icon, icon as patient. n engl j med. 2008;359 (26):2748-2751. doi: 10.1056/nejmp0807461. 2. chi j, verghese a. clinical education and the electronic health record: the flipped patient. jama. 2014;312(22): 2331-2332. doi: 10.1001/jama.2014.12820. 3. crump wj. but doc, what if i can’t die? ky acad fam phys j. 2017;88(winter):18. 4. crump, wj. those kids are rotten. submitted to the ky acad fam phys j. 2018. article published by university of minnesota libraries publishing a preclinical course to develop clinical reasoning skills of first-year medical students alan johns, md, med, raymond christensen, md doi: https://doi.org/10.24926/jrmc.v1i1.1003 journal of regional medical campuses, vol. 1, issue 1 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc https://doi.org/10.24926/jrmc.v1i1.1003 https://pubs.lib.umn.edu/index.php/jrmc/index alan johns, md, med department of family medicine and community health university of minnesota medical school, duluth raymond christensen, md department of family medicine and community health university of minnesota medial school, duluth corresponding author: alan johns, md, med. medical school duluth 1035 university drive duluth, mn 55812 office: 218-726-8874 fax: 218-726-6235 e-mail: ajohns1@d.umn.edu all work in jrmc is licensed under cc by-nc volume 1, issue 1 (2018) journal of regional medical campuses original report a preclinical course to develop clinical reasoning skills of first-year medical students alan johns, md, med raymond christensen, md abstract background and objectives: clinical reasoning is developed sometime during medical school training. when and how this knowledge is attained is less clear. this study looks at clinical reasoning development after initiation of a rural experiential course for first-year medical students at the university of minnesota medical school, duluth (regional) campus. methods: the rural medical scholars program course (rmsp) was developed to create a longitudinal rural family medicine experience for first and second-year students at the university of minnesota medical school duluth. sixtythree first year medical students participated in this required course and their clinical reasoning levels were measured using the diagnostic thinking inventory (dti). the dti was given to the medical students after one year of participation in the rmsp course. a previous cohort before the rmsp course was developed was used as a control. a literature search was used for comparison to other schools that measured the dti in their students. results: student diagnostic thinking performance as measured by the dti after one year of the rural medical scholars program course significantly increased when compared to a previous cohort of first-year students who did not take the rmsp course. when compared to previously published dti data, students after one year of rmsp had clinical reasoning levels of second through fourth-year students from other schools. conclusions: the addition of a rural experiential course with family medicine preceptors significantly increased clinical reasoning levels of first-year medical students. financial support: none conflicts of interests: no conflicts to report keywords: clinical reasoning; family medicine; experimental learning setup “the wild raggedness of the room was the soul and symbol of doc vickerson; it was more exciting than the flat-faced stack of shoeboxes in the new york bazaar: it was the lure to questioning and adventure for martin arrowsmith.”1 martin arrowsmith is the medical student in sinclair lewis’ 1905 pulitzer prize winning novel arrowsmith and doc vickerson his minnesota small-town mentor. using minnesota rural physicians as mentors in the 21st century is the basis of an experiential first-year course at the university of minnesota medical school, duluth campus. https://creativecommons.org/licenses/by-nc/4.0/legalcode doi: https://doi.org/10.24926/jrmc.v1i1.1003 journal of regional medical campuses, vol. 1, issue 1 article clinical reasoning skills developed during medical school are represented as a competency in several domains by the aamc.2 teaching of clinical reasoning is both informal and formal in the clinical years. gay and colleagues3 described a formal curriculum for fourth-year medical students but there was no assessment of learning. development of these skills has been measured by the diagnostic thinking inventory in the clinical clerkship years by several authors.4,5,6,7,8 this study reports the positive effect of a rural experiential course on the clinical reasoning skill levels of first-year medical students as measured by the dti. methods setting and participants the rural medical scholars program (rmsp) course was initiated in the 2010-2011 school year at the university of minnesota medical school duluth. our regional campus has a record of success in training rural family physicians over the past forty years.9 to maintain and build on this success, an experiential, longitudinal rural experience was created as a required course in the 2010-2011 school year. this course consists of students spending five one-week periods with a rural family physician. course learning objectives are numerous and include: developing history and physical examination skills, understanding principles of longitudinal care in the community, using reflective practice and feedback, assessment of rural communities, exploring interprofessional relationships, demonstrating professionalism, and patient-centered care. students are encouraged to see patients before preceptors to allow time for development of assessments and plans. evaluation of each student includes submitted history and physicals, progress notes, completed interprofessional signature lists and reflection essays. these elements are assembled in a portfolio and reviewed a faculty advisor. clinical reasoning performance of the rmsp students was measured with the diagnostic thinking inventory (dti).4 the dti is composed of two parts, knowledge structure and flexibility of thinking. the dti has been used to measure diagnostic reasoning in medical students and residents worldwide.5.6.7,8 sixty-three first-year medical students participated in the required rmsp course in the 2011-2012 school year. the dti was completed by 58 of these students three months after the course. the results were compared to a control group of first-year students who took the dti in 2010 before the rmsp course was developed. the control group had nine half-day visits with urban and rural preceptors compared to five weeks in the rmsp group. the dti was given during the same month of the year to both the control and rmsp study group and was administered by the same administrative assistant. the control and rmsp groups of students had similar academic statistics entering medical school (table 1). table 1 matriculating year gpa bcpm of gpa mcat total 2009 3.62 3.52 28.7 2011 3.63 3.54 29.2 ethical approval the university of minnesota institutional review board approved this study. results fifty-four (of 63) students completed the diagnostic thinking inventory three months after completing the rmsp course in the spring of 2013. the rmsp students scored at a mean level of 168.9. when compared to 55 (of 63) non-rmsp students in 2010, the study group had a statistically increased total dti score and in the components of structure and flexibility. (table 2). when compared to previously published studies, our study group’s total dit was comparable to more advanced students from other schools (table 3). https://doi.org/10.24926/jrmc.v1i1.1003 doi: https://doi.org/10.24926/jrmc.v1i1.1003 journal of regional medical campuses, vol. 1, issue 1 article table 2 year dti structure dti flexibility mean dti total standard deviation total 2013 n=54 81.0* 87.9* 168.9* 8.49 2010 n=55 74.2 82.4 156.6 9.36 *p< 0.05, student’s t-test table 3 school medical student year dti total u. of levuen, belgium5 fourth-year 168 u. of brasilia, brazil6 third-year 169 mayne medical school, australia7 second-year 158 johns hopkins8 second-year 165 minnesota duluth with rmsp without rmsp after first-year 2013 2010 169 157 discussion first-year medical students were shown to statistically increase their diagnostic reasoning skills after completing a required longitudinal experiential rural course. the mechanism for this improvement on first glance would seem to be related to time-on-task and the nature of the rmsp experience. time-on-task would be an obvious explanation for improved performance but educational literature is mixed on this theory. karwett reviewed 50 years of k12 studies and found inconsistent and modest effects of increasing time in the curriculum.10 he found studies that had increased engaged time showed increased learning but studies with increased nonengaged time actually decreased learning. similarly, beattie and colleagues found learning is related to the difficulty of the task and the engagement of the learner.11 their work looked at the role of self-efficacy and learning. if a task was static and unchallenging then a student’s self-efficacy was not developed. a student would feel bored and determine “anyone can learn this.” repeated interesting and challenging tasks energize and increase self-efficacy which then energizes the student’s learning. we feel the nature of the rmsp student experience contributes to increased diagnostic reasoning skills. the benefit of experiential learning has its origins in https://doi.org/10.24926/jrmc.v1i1.1003 doi: https://doi.org/10.24926/jrmc.v1i1.1003 journal of regional medical campuses, vol. 1, issue 1 article the works of david kolb.12 his theory of experiential learning explains how adult learners use educational experiences to develop and retain knowledge. in essence, his model starts with concrete experiences; progresses to observations and reflections of those experiences by students and faculty, then students develop new models of reasoning. the final stage is testing the new models with another concrete experience. by repeating this reflective process thorough numerous experiences, a student will attain not only experience but also knowledge. the rmsp course has all of these elements. a student will see a patient in the rural office or hospital (concrete experience). he/she will then reflect on that experience both verbally with their preceptor and in written form with their preceptor and other course faculty. based on oral and written feedback the student will create a slightly or significantly changed model of reasoning and test their reasoning when they see their next patient. bowen describes this process of promoting diagnostic reasoning in medical students and residents.13 she feels key elements of the process are students diagnosing patients under the guidance of teachers who bring knowledge, context, and experience. again, the rmsp course has all these elements; students, patients and knowledgeable family physicians. strengths and limitations the strength of the study is in a clearly defined and validated instrument, the diagnostic thinking inventory. although the control group was medical students from three years prior, the regional campus medical students are very similar from year to year when measured in both academic and demographic terms. a limitation of the study revolves around timeon-task in that the rmsp group had more patient contact hours. our discussion of time-on-task in the previous section addresses the potential mitigation of these increased contact hours. conclusions first-year medical students at the university of minnesota medical school, duluth regional campus developed significantly increased diagnostic thinking skills after participating in a longitudinal required rural experience. this finding is supported by educational literature related to strategies in promoting experiential learning. bibliography 1. lewis s. arrowsmith. new york, ny: harcourt brace & company;1925. 9 2. englander r, cameron t, ballard aj, dodge j, bull j, aschenbrener ca. toward a common taxonomy of competency domains for the health professions and competencies for physicians. acad med. 2013;88(8):1088-1094. doi: 10.1097/acm.0b013e31829a3b2b [doi]. 3. gay s, bartlett m, mckinley r. teaching clinical reasoning to medical students. the clinical teacher. 2013;10(5):308-312. doi: 10.1111/tct.12043. 4. bortage g, grant j, marsden p. quantitative assessment of diagnostic ability. medical education. 1990;(24):413-425. 5. beullens j, struyf e, van damme b. diagnostic ability in relation to clinical seminars and extendedmatching questions examinations. med educ. 2006;40(12):1173-1179. 6. sobral dt. appraisal of medical students' diagnostic ability in relation to their learning achievement and self-confidence as a learner. med teach. 2000;22(1):5963. 7. groves m, o'rourke p, alexander h. the association between student characteristics and the development of clinical reasoning in a graduate-entry, pbl medical programme. med teach. 2003;25(6):626-631. 8. windish dm, price eg, clever sl, magaziner jl, thomas pa. teaching medical students the important connection between communication and clinical reasoning. jgim: journal of general internal medicine. 2005;20(12):1108-1113. 9. fuglestad a, prunuske j, regal r, hunter c, boulger j, prunuske a. rural family medicine outcomes at the university of minnesota medical school duluth. fam med 2017;49(5):388-393 https://doi.org/10.24926/jrmc.v1i1.1003 doi: https://doi.org/10.24926/jrmc.v1i1.1003 journal of regional medical campuses, vol. 1, issue 1 article 10. karweit n., time-on-task reconsidered: synthesis of research on time and learning. educational leadership. 1984;41(8):32-59. 11. beattie, s., fakehy, m. and woodman, t., 2014. examining the moderating effects of time on task and task complexity on the within person self-efficacy and performance relationship. psychology of sport and exercise, 2014;16(6):605-610. 12. miettinen r. the concept of experiential learning and john dewey's theory of reflective thought and action. international journal of lifelong education. 2000;19(1):54-72. doi:10.1080/026013700293458. 13. bowen, j. educational strategies to promote clinical diagnostic reasoning. nejm. 2006; 355(21):2217-2225. doi:10.1056/nejmra054782 https://doi.org/10.24926/jrmc.v1i1.1003 microsoft word implementationofaclinicalarticle.docx published by university of minnesota libraries publishing implementation of a clinician and academic researcher-led funding program to stimulate research in a regional medical campus mathieu bélanger, phd; michel h. landry, md doi: https://doi.org/10.24926/jrmc.v2i5.2137 journal of regional medical campuses, vol. 2, issue 5 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc mathieu bélanger, phd; centre de formation médicale du nouveau-brunswick, moncton, new brunswick; department of family and emergency medicine, université de sherbrooke, sherbrooke, quebec; vitalité health network, new brunswick. michel h. landry, md; centre de formation médicale du nouveau-brunswick, moncton, new brunswick; department of family and emergency medicine, université de sherbrooke, sherbrooke, quebec; vitalité health network, new brunswick. all work in jrmc is licensed under cc by-nc volume 2, issue 5 (2019) journal of regional medical campuses original reports implementation of a clinician and academic researcher-led funding program to stimulate research in a regional medical campus mathieu bélanger, phd; michel h. landry, md abstract introduction: fostering locally initiated clinical research, with physicians as lead investigators, can be challenging for a regional medical campus (rmc) or any site involved in distributed medical education (dme). exposing students to research and to clinically relevant research is an important accreditation criterion. we discuss an initiative implemented to stimulate the development of clinical research activities within the main hospital affiliated with our rmc. methods: the duo research grant program was launched in march 2018. it offers research grants worth up to can$25 000. proposals have to be submitted by 2 co-principal investigators, including one academic researcher and one clinician involved in medical education through our rmc. projects need to address a clinical practice or medical education issue. results: twelve projects were submitted in the first 2 funding rounds of the duo research grant program. eight of the 12 proposals received funding (67% success rate) and have already directly exposed medical students and residents to clinical research. they have also led to presentations at conferences and submission of external grant proposals. conclusions: with a cost of can$100 000 per year, the duo research grant program appears to be an effective strategy for fostering meaningful collaborations between clinicians and researchers, for exposing our medical students to more clinical research, and for favoring the development of our clinicians’ academic profiles. introduction among criteria for accreditation of medical programs is the requirement that they provide opportunities for medical student participation in research.1 distributed medical education (dme) sites, especially regional medical campuses (rmc), are commonly established in regions where there are little research activities. when rmc set up adjacent to other universities, the research activities carried out in these institutions may not originally include medical research.2 it can therefore be challenging for dme sites that are based away from large-scale, research-intensive academic health centers to offer exposure to clinical research.3 nevertheless, recent paradigm shifts are calling for more clinical research involving physicians and patients.4 these include the desire to move from experience-based to evidence-based practice in medicine5 and the adoption of a national strategy for patient-oriented research by the canadian institutes of health research (cihr).6 researchers are therefore more incentivized to move away from purely fundamental work and to engage in research that has a greater potential to impact patient care. another inducement for collaborations between clinicians and researchers is the demonstration that combining these 2 professions in the development of research projects leads to sustainable alliances and produces impactful results.7 aiming to expose students from our rmc to more clinical research, we developed a research funding program designed to foster clinician-researcher collaborations. funding for this program came from an exhaustive revision of our existing rmc’s budget to align with the identified priority to develop research capacity. the main goal of the research grant program was to encourage meaningful collaborations between clinicians and researchers. other research grant program objectives included favoring the development of our clinicians’ academic and research profiles and creating opportunities to expose our students to research during their clinical rotations in our affiliated hospitals. methods setting: our rmc, the centre de formation médicale du nouveaubrunswick (cfmnb), is located in moncton, new brunswick. established in 2006, the cfmnb is the product of a partnership between the université de sherbrooke’s faculty of medicine, the université de moncton, and the government of new brunswick. through this consortium of partners, the université de sherbrooke offers its entire 4-year medical program to 24 francophone students from new brunswick per year in their home province. the université de moncton provides the infrastructure required to host the academic journal of regional medical campuses, vol. 2, issue 5 original reports program and the government of new brunswick funds most of the initiative. the main hospital affiliated with our rmc is the dr. georges-l.-dumont university hospital centre in which 202 of the 236 (86%) physicians are involved in the training of medical students or residents. the new research grant program: we launched the duo research grant program in march 2018. the duo program encourages collaborations between clinicians and academic researchers by offering up to can$25 000 per project over 2 years. eligibility criteria are twofold: 1) co-principal investigators must include at least one local academic researcher and one clinician involved in teaching or clinical supervision of medical students or residents in our university health center (hence the name “duo”), and 2) proposals must focus on a clinical practice or medical education issue or need. the first eligibility criterion positions the academic researcher and the clinician on equal footing in terms of project leadership. this criterion favors the development of projects that are relevant from a clinical perspective and for which there is engagement of a scientist with the necessary methodological training and time commitment (i.e., “conducting research” is part of their job description) to pursue the research project. the requirement that projects be co-led also has the effect of genuinely engaging clinicians in the research process, thereby contributing to the enhancement of their scholarly abilities. the funding program does not allow financially supporting investigators. the threshold of can$25 000 per grant was established following consultations with researchers, clinicians, academic leaders, and research funding organizations. a consensus formed around this benchmark amount for several reasons: 1) it was considered adequate to attract academic researchers, 2) it represented a noteworthy grant to document in a cv for clinicians aiming to build their academic profiles, 3) it represented an amount sufficient to support several types of research projects, and 4) it could be perceived as enough for external granting agencies to consider funding follow-up studies building on duosupported projects. annually, the first call for proposals for the duo research grant program occurs in the fall and is followed by a series of reminders with a submission deadline of late february. along with a simple registration form, applicants need to submit their cvs, a 2-page description of their project, up to 2 pages describing the roles of each team member, a budget, justifications for the budget, and a work plan with timelines. components of this application package are meant to be sufficient to enable a clear and concise description of the research plan without requiring the investment of an inordinate amount of time and energy to produce. the format and length of the application package also allows for an effective and efficient review process. an external evaluation committee reviews projects submitted within the 2 weeks following the deadline date, such that funds are transferred to successful research teams by the end of march. the rapid peer-review process contributes to maintaining the momentum built at the stage of preparing the grant proposal. still, the review process employs a rigorous approach, involving at least 3 reviewers per grant and a discussion at the level of review committee, akin to the process employed by the cihr.8 the peer review committee is made of individuals with experience in clinical research, which are recommended by the research support offices of the cfmnb, the université de moncton and the dr. georgesl.-dumont university hospital centre. as much as possible, we aim for the committee to be representative of all pillars of research recognised by cihr. the evaluation of proposals takes into account 4 main criteria: scientific merit (i.e. empirical support for objectives, and appropriateness of methods), feasibility (i.e. realistic timeline, sufficient infrastructure, and adequate funding), expertise (i.e. team has necessary expertise and experience, roles and responsibilities of team members are clearly established, relevant and meaningful), and impact (i.e. potential to impact the system or patients, likelihood to be published and to lead to external funding). results we have now completed 2 rounds of duo research grant competitions. the clinical and research communities responded by submitting 6 grant proposals in each of the 2 funding rounds. funds were available to support 4 projects per competition, for a success rate of 67%. the projects supported are in the areas of oncology (n=3), neurology (n=2), cardiovascular health, inter-professional education within primary healthcare, and nephrology. for 7 of the 8 projects funded, this success represented the clinicians’ first peer-reviewed research grant as a principal investigator. all successful projects received can$25 000 over 2 years. the funds have been used to support research activities including the collection of data and acquisition of samples. several research assistants, graduate students, and postdoctoral fellows have received salary funding through the duo research grant program. an impact of the first year of this funding program has been that 2 postdoctoral fellows, 4 graduate students, 8 residents in family medicine, 3 students in medicine, and 5 students in other health sciences programs were directly exposed to research activities. furthermore, the first year of funding has already led to 5 conference presentations and at least 2 external grant submissions. journal of regional medical campuses, vol. 2, issue 5 original reports discussion with an investment of can$100 000 per year, we were able to establish a research grant program favoring the development of research activities within our university health center. at this current funding level, the program is supporting the ongoing operation of at least 8 academic research projects within the university health center at any given time. this represents a substantial uptake of scholarly research within this center. in time, we hope to increase our capacity to fund more projects. this will be facilitated by the contribution of our partners, including the vitalité health network (our regional health authority), which has recognized the benefit of the duo research grant program and invested can$50 000 in it for the next funding cycle. discussions are also ongoing with the university hospital center’s foundation, our partner universities and the hospital’s council of physicians to identify how they could contribute to it. the increase in research activities within our university health center provides more opportunities for exposing our medical students to research. it also contributes to building both the academic and research profiles of physicians in our rmc and in our center. the research that we support will also eventually lead to improvements in health care and in the overall health of our patients and populations. we hope that this program marks the beginning of more partnerships between academic and clinical researchers. so far, implementation of the duo research grant program appears to be an effective strategy for fostering meaningful collaborations between clinicians and researchers, for better exposing our medical students to clinical research, and for favoring the development of our clinicians’ academic profiles. references 1. association of american medical colleges and the american medical, association. functions and structure of a medical school: standards for accreditation of medical education programs leading to the md degree. liaison comm med educ. 2017:35. 2. toomey p, lovato cy, hanlon n, poole g, bates j. impact of a regional distributed medical education program on an underserved community: perceptions of community leaders. acad med. 2013;88(6):811818. doi:10.1097/acm.0b013e318290f9c7 3. topps m, strasser r. when a community hospital becomes an academic health centre. can j rural med. 2010;15(1):19-26. 4. castonguay lg, youn sj, xiao h, muran jc, barber jp. building clinicians-researchers partnerships: lessons from diverse natural settings and practice-oriented initiatives. psychother res. 2015;25(1):166-184. doi:10.1080/10503307.2014.973923 5. hummers-pradier e, scheidt-nave c, martin h, heinemann s, kochen mm, himmel w. simply no time? barriers to gps’ participation in primary health care research. fam pract. 2008;25(2):105-112. doi:10.1093/fampra/cmn015 6. strategy for patient-oriented research. canadian institutes of health research. http://www.cihrirsc.gc.ca/e/41204.html. published 2019. accessed july 15, 2019. 7. blevins d, farmer ms, edlund c, sullivan g, kirchner jae. collaborative research between clinicians and researchers: a multiple case study of implementation. implement sci. 2010;5(1):1-9. doi:10.1186/1748-5908-5-76 8. peer review: policies and procedures. canadian institutes of health research. http://www.cihrirsc.gc.ca/e/39414.html. published 2017. accessed july 4, 2019. microsoft word narrativefeedbackinfacultyarticle.docx published by university of minnesota libraries publishing narrative feedback in faculty development ralitsa akins, md, phd doi: https://doi.org/10.24926/jrmc.v2i2.1220 journal of regional medical campuses, vol. 2, issue 2 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc ralitsa akins, md, phd; provost, des moines university corresponding author: ralitsa_akins@yahoo.com; 515-271-1505 all work in jrmc is licensed under cc by-nc volume , issue 6 (2019) journal of regional medical campuses original reports narrative feedback in faculty development ralitsa akins, md, phd; provost, des moines university abstract research on faculty development and its generalizability is lagging compared to other areas of research in medical education. providing feedback has been identified as a skill in need of improvement for medical educators, both in the classroom and at the clinical bedside. surprisingly, little has been published on faculty skills in providing feedback during faculty development sessions, and more specifically, providing narrative feedback. an irb-approved study analyzed the outcomes of 73 faculty development sessions conducted within one academic year. a qualitative study of the narrative portion of end-of-session evaluations examined type and scope of narrative feedback provided to presenters about their presentation skills as well as about the perceived quality and usefulness of the faculty development sessions. the findings from this study suggest that further and more in-depth professional development in providing feedback is warranted, preferably early in faculty's professional development. introduction research on faculty development and its generalizability is lagging compared to other areas of research in medical education.9 providing feedback has been identified as a skill in need of improvement for medical educators, both in the classroom and at the clinical bedside.12,14 surprisingly, little has been published on faculty skills in providing feedback during faculty development sessions, and more specifically, providing narrative feedback aiming to guide improvement of presenters’ skills or session organization. in general, faculty development includes activities used to assist faculty in their roles as teachers, researchers, clinicians, administrators, and leaders.3 traditionally, needs assessment utilizing surveys or focus groups have been used to determine the needs for faculty development.10 it has been suggested that in creating faculty development sessions, the session “developers” use the processes of negotiation, construction, and attuning of knowledge to actively interact with the environment and respond to faculty development needs.1 the need for improved faculty development involving teaching, communication, and practice behaviors is well documented.5,15 objective structured teaching evaluations (ostes) have been used to assess teaching and assessment skills, and to provide feedback to faculty participating in professional development programs.6 while the role of medical teachers in giving feedback to learners has been more extensively explored,4 little is known about whether teachers use the same conceptual principles in providing feedback related to faculty development. providing peer review in teaching has been a challenging task, and peer-review evaluations may be difficult to implement.11 materials and methods an irb-approved study (wsu no.16228, 2017) examined the outcomes of faculty development sessions to explore the skills of faculty in providing narrative feedback as assessed by the narrative portion of faculty development end-of-session evaluations. seventy-three faculty development sessions were conducted on 4 campuses of one medical school during one academic year. three hundred and three individuals attended one or more sessions and provided end-of-session evaluations that included narrative portions about: 1) the attributes of the presenter(s), and 2) the perceived usefulness of the professional development offerings. the narratives from the evaluations were analyzed with the help of qualitative software (nvivo professional 11.x64 by qsr). cluster analysis, frequency queries, and tree map analysis were performed. a word cloud was created to visually demonstrate the narrative word frequencies. results often participants provided one-word narrative feedback, where the words "great", "good", and "helpful" were the top 3 choices used, as visualized in the word cloud (figure 1). figure 1. word cloud presenting a visual of the most frequent word choices in providing narrative feedback in faculty development session evaluations doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports this finding was also demonstrated in the narrative tree map analysis of the total of 1006 distinctive words found in the narratives from the feedback notes. these words were used with varied frequencies, and showed specific patterns of use, as shown on figure 2. figure 2. clustering of feedback narratives although separate fields were available in the session feedback form to provide responses about the quality of the session and the characteristics of the presenter(s), session participants mixed the types of feedback they were asked to provide in the 2 separate fields. for example, comments about the presenter’s attributes would be written in the field asking about session usefulness: “loved presenter’s teaching style and approach.” “presenter was very organized.” “was very responsive to the needs of the faculty.” vice versa, comments about the session’s usefulness would be found in the field asking about presenter’s attributes, as demonstrated in the following comments: “both the lecture and the workshop were excellent.” “too much information squeezed into 1 ½ hours. perhaps one well-developed program per section of talk would suffice.” “this session was great! practical, informative, and great discussion.” useful feedback that could aid future session or presenter skills improvement were seen less often than expected. many feedback narratives consisted of description of feelings (e.g., "loved it", “impressed”) or writing "thank you". examples of comments that did not guide to the specific activity that the participants appreciated included, “great job!”, “great session”, “very good!”, “well done!” and “great work!”. session participants also used the opportunity to provide feedback outside of the areas of interest (presenter’s attributes and session usefulness), writing about unmet needs and expectations: “we need more support for coordination of course meetings and timelines.” “i’m still concerned about information overload for faculty and students.” “i didn’t get specific directions or parking information fyi.” the skills of faculty attending professional development sessions in providing feedback about session usefulness and presenter skills varied vastly between session attendees as related to usability of provided feedback and ability to focus answers on the questions asked. narrative comments made it evident that there could be a possible disconnect between the goals of the requested feedback (e.g. goal to improve the session usefulness and presenter skills) and the nature of the written comments (exploring unmet needs and describing feelings and offering non-specific comments such as “great job!”). overall, narrative feedback suggested that faculty preferred small group, interactive sessions. faculty were appreciative of the opportunity to participate in professional development sessions, as demonstrated in the comment, “thank you for these very well organized sessions – great information, great food, great colleagues.” discussion faculty’s skills have been shown to improve after a participation in a faculty development program.2 in one study, faculty-novices to peer evaluations in teaching benefited from structured training on providing frame-ofreference feedback when assessing a performance at the workplace.8 another study showed that greater agreements between ratings from novices and experts were documented upon completion of focused hands-on training, placing the process of assessment and feedback beyond the teacherlearner framework, and within providing feedback-to-peers realm. both performance-dimension training, and frame-ofreference training positively influenced faculty’s approach in providing feedback.7 therefore, introducing faculty development sessions on providing peer-to-peer feedback early in the professional development program could improve the usefulness of the participants’ comments which will better aid improvement of future sessions and presenters’ skills. participants in the faculty development sessions included in this study confirmed the perceived usefulness of the faculty development offerings and/or the perceptions that their skills improved: “they challenged me to reframe the way i was thinking about things and it helped me fill in a few ‘gaps’ that i was unable to ‘articulate’ prior to the session.” doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports “this didactic was relevant to what i needed training on. this will be helpful now/tomorrow. it is helpful to learn by role playing and the “workshop teaching style.” “thank you – i learned things and i will try to incorporate them.” giving feedback to the participants in a faculty development activity (e.g. sending the results from an end-of-session satisfaction survey back to the session participants) has been perceived to enhance future participation as well as the credibility of the people/institution conducting the activity/survey. feedback provided back to the participants is known as a “reciprocal” feedback, and it entails sending to the participants a summary of the findings. importantly, reciprocal feedback could enhance future participation, future feedback reliability, and serve as an incentive to participate in change.13 reciprocal feedback was a concept used for the sessions in this study. the office organizing the faculty development sessions provided summary of the received feedback and what actions were taken, if any, back to the session participants. for example, if questions were asked during a session that were not immediately answered, the session organizers and the presenters provided additional information and responses in a follow-up communication to the session participants. in addition, all narratives, as originally written by the session participants, were sent as a collated document back to the presenter(s) to aid future improvement. while the narratives were provided by session participants in an anonymous way, some comments clearly identified the writers and were redacted to delete a person’s or department’s name, as applicable. in turn, session participants and presenters offered spontaneous, unsolicited follow-up feedback that they valued the opportunity to review the outcomes and appreciated the actions taken to respond to participants’ needs. conclusion this study was conducted within 4 campuses of one institution over one academic year, and this may limit the study’s generalizability. the study suggested that faculty in medical educational programs would need focused skills development in providing narrative feedback early in their professional careers to include providing meaningful feedback to peers and in faculty development sessions. more studies including multiple institutions could lead to a better understanding of the needs in faculty development about narrative feedback. references 1. baker, l., leslie, k., panisko, d., walsh, a., wong, a. stubbs, b., & mylopoulos, m. (2018). exploring faculty developers’ experiences to inform our understanding of competence in faculty development. academic medicine, vol. 93(2): 265273. 2. branch, w. t. jr., frankel, r., gracey, c. f., haidet, p. m., weissmann, p. f., cantey, p., mitchell, g. a., & inui, t. s., (2009). a good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. academic medicine 84(1):117-125. 3. centra j.a. (1978). types of faculty development programs. j higher educ (49)151–162. 4. cote, l. & bordage, g. (2012). content and conceptual frameworks of preceptor feedback related to residents' educational needs. academic medicine 87(9):1274-1281. 5. darosa, d. a., skeff, k. friedland, j. a., coburn, m. cox, s. pollart, s. o'connell, m. & smith, s. barriers to effective teaching. academic medicine 86(4):453459. 6. julian, k., appelle, n., o'sullivan, p., morrison, e.h., & wamsley, m. (2012). the impact of an objective structured teaching evaluation on faculty teaching skills. teach learn med. 24(1):3-7. 7. kogan, j.r., conforti, l.n., bernabeo, e., iobst, w., & holmboe, e. (2015). how faculty members experience workplace-based assessment rater training: a qualitative study. med educ. 49(7):692708. 8. newman, l. r., brodsky, d., jones, r. n., schwartzstein, r. m., atkins, k. m., & roberts, d. h. (2016). frame-of-reference training: establishing reliable assessment of teaching effectiveness. journal of continuing education in the health professions 36(3):206-210. 9. o'sullivan, p.s., & irby, d.m. (2011). reframing research on faculty development. acad med. 86(4):421-8. 10. pololi, l. h., dennis, k., winn, g. m., & mitchell, j. (2003). a needs assessment of medical school faculty: caring for the caretakers. journal of continuing education in the health professions 23(1):21-29. 11. strafford, k., tartaglia, k., mahan, j., nagel, r., verbeck, n., & davis, j. (2016). description and evaluation of peer review of teaching in an integrated medical school curriculum. obstetrics & gynecology 128 supplement 1:52s-53s, october 2016. 12. telio s., ajjawi, r., & redehr, g. (2015). the “educational alliance” as a framework for reconceptualizing feedback in medical education. academic medicine (90): 609-614. 13. watson, r.a. (2015). reciprocal feedback: closing the loop on postactivity surveys. journal of continuing education in the health professions 35(4):284-285. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports 14. weinstein, d. f. (2015). untying the gordian knot. academic medicine 90(5): 559-61. 15. wilkes, m. s., hoffman, j. r., usatine, r. & baillie, s. (2006). an innovative program to augment community preceptors' practice and teaching skills. academic medicine 81(4):332-341. microsoft word influenceofdistributedarticle.docx published by university of minnesota libraries publishing influence of distributed medical education on pre-clerkship elective use and utility joshua yu, bsc; andrew p. costa, phd; aaron jones, phd doi: https://doi.org/10.24926/jrmc.v4i1.3447 journal of regional medical campuses, vol. 4, issue 1 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc joshua yu, bsc; michael g. degroote school of medicine, waterloo regional campus; mcmaster university andrew p. costa, phd; michael g. degroote school of medicine, waterloo regional campus; mcmaster university; department of health research methods, evidence, and impact; mcmaster university aaron jones, phd; michael g. degroote school of medicine, waterloo regional campus; mcmaster university; department of health research methods, evidence, and impact; mcmaster university all work in jrmc is licensed under cc by-nc volume 4, issue 1 (2021) journal of regional medical campuses original reports influence of distributed medical education on pre-clerkship elective use and utility joshua yu, bsc; andrew p. costa, phd; aaron jones, phd abstract purpose to explore differences in optional pre-clerkship elective (opce) use and utility between main and regional campuses at mcmaster university’s michael g. degroote school of medicine, in 4 main areas: ease of access to opces, volume and breadth of opces, helpfulness in choosing future specialties, and utility for clerkship preparation. methods an anonymous and voluntary survey was distributed in early 2020 to mcmaster university michael g. degroote school of medicine’s medical students across all 3 years of study. data were analyzed for any significant differences between main and regional campuses, and post-hoc sensitivity analyses were used to account for non-response and self-selection bias. results regional campus students felt significantly less frustration around opce availability (2.88 vs 4.16, p<0.001, scale 1(least) – 5(most)) and significantly greater ease of opce scheduling than students at the main campus (3.50 vs 2.24, p<0.001, scale 1(least) – 5(most)). regional campus students explored significantly fewer specialties (5.19 vs 6.19, p = 0.049) and there was no significant difference in the total number of opce hours undertaken, nor hours spent with a single specialty. overall, students in both campuses endorsed pressure to take opces and mixed benefits of opces for clerkship preparation. students also found opces to be an important part of choosing a specialty independent of campus. conclusion regional medical campuses at mcmaster university offer generally equal opportunities for opce volume and breadth as main campuses, but with significantly lower barriers and frustrations around scheduling and availabilities. conflicts of interest there are no conflicts of interest to report. introduction medical education in canada is a continually evolving landscape. with a growing impetus to introduce new strategies in medical education to better service the needs of the population, there is also increased recognition of the stresses and pressures of physician training and selection of an eventual specialty.1–3 at mcmaster university’s michael g. degroote school of medicine, one approach has been a focus on early clinical exposure. while early mandatory preclerkship clinical experiences exist, they are limited mainly to an 18-hour family medicine experience. instead, pre-clerks are encouraged to pursue optional pre-clerkship electives (opces), optional clinical experiences with physicians or other healthcare professionals that often form the bulk of early clinical exposure. students choose and schedule opces on their own time, depending on preceptor and specialty availabilities, with no hard limit on the number of opces that can be done. opces can range from simple observerships and shadowing to more experiential hands-on learning, depending on student comfort levels and preceptor preferences. as such, opces can be a valuable opportunity to practice newly acquired knowledge and skills, and to explore different careers within medicine beyond family medicine,4–6 especially within mcmaster’s accelerated 3 year program. similar elective opportunities in other institutions have demonstrated the benefit of structured, hands-on preclerkship electives in developing early clinical skills, comfort with inpatient environments, and readiness for clerkship.4–6 in addition to an emphasis on opces, mcmaster is part of a growing number of medical schools utilizing distributed medical education (dme). in canada alone, more than a third of medical schools already distribute their programs. mcmaster uses a ‘hub and spoke’ dme model, with its main campus located in the city of hamilton, near large academic journal of regional medical campuses, vol. 4, issue 1 original reports teaching hospitals. its regional campuses are in the regions of waterloo and niagara, separate from large urban teaching hospitals, and host a much smaller number of students per year. a growing literature supports the dme model. medical training placed apart from traditional urban academic centers puts learners in unique environments and can offer closer contact with preceptors, more hands-on experience, and exposure to clinical cases.3,7–9 establishing more communitybased campuses expands the otherwise limited clinical capacity for learners, with the relatively small regional class sizes reducing competition to secure clinical experience opportunities for regional students.8,10,11 moreover, dme promotes retention and recruitment of physicians to host communities, helping address the disparity between locations of practice and underserved populations.10,12–14 with dme however, the degree of accessibility and variety of specialties offered for opces at each campus is inevitably different, and whether the benefits of dme translate to the use and utility of opces has not been previously studied. we thus aimed to explore differences in opce use and utility between main and regional campuses at mcmaster with respect to 4 main areas: ease of access to opces, volume and breadth of opces, helpfulness in choosing future specialties, and utility for clerkship preparation. our objective was to shed light on whether dme provides a different and noninferior learning experience through opces. we hypothesized that students at regional campuses would have easier access to opces. methods survey distribution we conducted a cross-sectional study using data from a survey provided to medical students in all 3 years of study at mcmaster university (table 1). the survey was an anonymous and voluntary online google form, and was distributed to all students at the waterloo regional campus through email on february 11, 2020. the survey was further distributed to all students at the hamilton and niagara campuses on march 10, 2020 via facebook. the survey was closed april 10, and participant responses were anonymized with no personal information stored. this study was approved by the hamilton integrated research ethics board (#11096-c). data management and analyses data were visualized and analyzed using r 3.6.3, with a significance level of 0.05. descriptive statistics for regional and main campus results were generated using r software. mann–whitney–wilcoxon tests were applied to assess for significant differences between campuses. a post-hoc sensitivity analysis was performed to account for nonresponse and self-selection. in this analysis, participant data were weighted by campus and class year to match the distribution of the general population of medical students at mcmaster. results from the sensitivity analysis were doi: https://doi.org/10.24926/jrmc.v4i1.3447 compared to the original analysis, with results significant in both analyses being considered robust. table 1. questions used on the survey. questions are abbreviated into short form within the results section. results aggregate results a total of 149 students participated in the survey, which corresponds to a response rate of 24%: most respondents were from hamilton campus students in the class of 2022 (table 2). overall, students perceived opces to be an important experience when deciding a specialty; however, when compared to clerkship experiences, students found opces to be slightly less important. students did not have strong opinions on whether opces contributed to clerkship readiness, nor on the ease of opce scheduling. however, students felt strong frustration with opce availability, along with a high pressure to take opces (figure 1a). the median total time participating in opces was 40 hours, the median number of specialties explored was 5, and the median maximum time spent with one specialty was 12 hours (table 2). sensitivity analysis corroborated all aggregate results (table s1). table 2. sample characteristics (n=149) and aggregated opce volume and breadth results. doi: https://doi.org/10.24926/jrmc.v4i1.3447 journal of regional medical campuses, vol. 4, issue 1 original reports figure 1. aggregate answers to survey questions. a) distributions of likert-scale question responses (%). b) distributions of opce volume and breadth (%). dotted lines represent the median. stratified by campus primary analysis found that students in the regional campuses felt significantly less pressure to take opces than hamilton (3.20 vs 3.67, p = 0.017, scale 1 (least) – 5 (most)), significantly less frustration around opce availability (2.88 vs 4.16, p<0.001), and significantly greater ease of opce scheduling (3.50 vs 2.24, p<0.001). there were no significant differences in the total opce hours between campuses, or maximum time spent with one specialty. however, regional campus students explored significantly less specialties than hamilton (5.19 vs 6.19, p = 0.049) (figure 2). subsequent sensitivity analysis corroborated all findings with one exception: regional campuses did not feel significantly less pressure to take opces (p = 0.059) with the weighted data (figures s1, s2). figure 2. differences between main and regional campus distributions. significant differences between group distributions were determined by mann–whitney–wilcoxon tests. a) boxplots of likert-scale question distributions stratified by regional campus. b) violinplots of opce volume and breadth stratified by campus. medians, interquartile ranges, and whiskers are presented using boxplots. each boxplot lies within a coloured distribution, with the width of the shaded area estimating the proportion of data located there. *p < 0.05, **p < 0.01, ***p < 0.001, ****p < 0.0001. discussion we report that regional campuses felt significantly less pressure to do opces, significantly less frustration around opce availability, and significantly greater ease of opce scheduling than students at the main campus. moreover, regional campuses offered generally equal opportunities for opce volume and breadth as main campuses, suggesting a noninferior experience at regional campuses. our findings help to characterize the impact of dme on opces and support the benefits of dme in canada previously reported in the literature. our findings corroborate with the benefits of dme in the literature, such as greater clinical capacity and lower competition at regional sites.3,7–9 smaller regional class sizes at mcmaster reduce the administrative burden on regional staff and the relative oversaturation of learners at the main traditional campus. however, while regional differences in frustration and scheduling were considered robust, our sensitivity analysis cast some doubt on the finding of less pressure at regional sites. despite lower geographic access to large teaching hospitals, regional campuses did not show significant differences in total opce hours or maximum hours spent with one specialty. independent of campus, students also found opces important for considering specialties—though not as important as clerkship—reaffirming the benefits of early clinical exposure, especially in the condensed 3 year program provided by mcmaster. while regional campuses did report significantly fewer specialties explored, the absolute differences between medians was by one less specialty. however, students in the main campus likely have greater access to opces in specialized tertiary care, that may be rarer in the outside community.10 students reported mixed utility of opces for clerkship preparation independent of campus, in contrast to prior studies.4–6 this discrepancy is likely from the greater heterogeneity of opces at mcmaster, in contrast with the more structured experiences in the literature. opces at mcmaster are not uniform and standardized; preceptors may be from any specialty, and learners may be exposed to a a b a b journal of regional medical campuses, vol. 4, issue 1 original reports broad spectrum of experiences subject to situational factors present at the clinical placement. the lack of standardized structure in mcmaster’s opces is a limitation of the generalizability of our results to programs with differently structured opces. limitations due to our study design being a voluntary survey, weaknesses of our study include potential non-response bias and selection bias. our sample had unequal representation among campuses and student years, particularly among the graduating year and students in the niagara campus, which may skew our primary analysis. therefore, a post-hoc sensitivity analysis was performed to determine the robustness of our initial assessment, by weighting our sample by campus and year. the results of the primary analysis were generally consistent with our sensitivity analysis, suggesting that our results are robust. future studies can build on this work by better optimizing the distribution strategy for surveys, in order to better capture underrepresented groups within the cohort and gain a greater sample size. adding variables such as gender and age to the survey can strengthen the robustness of results and including postal code data would also help to identify student groups residing someplace other than the community of their assigned campus. additionally, knowing how many opces were taken outside of the geographical area of a student’s assigned campus should be queried. we recommended that the administration of this survey be repeated in the future to ensure longitudinal follow-up of the included cohort and assess the outcomes of opces on specialty selection. conclusion although students overall reported mixed helpfulness of opces for clerkship preparation, regional students found opces easier to schedule and with less frustration around availability. in addition, regional campuses generally had equal opportunities for opce volume and breadth as main campus students, though with slightly less variety of specialties, suggesting a noninferior experience at regional campuses. overall, our data increase our understanding of the impact of dme and further contribute to the accumulating evidence of its benefits on medical education. acknowledgements the authors would like to kindly thank the following individuals for their support and guidance in assisting with this project: graham campbell, dr. sharon bal, dr. kathleen nolan, dr. jason profetto, and jenny zhu. doi: https://doi.org/10.24926/jrmc.v4i1.3447 appendix table s1. sensitivity analysis of aggregate responses. unweighted and weighted median and spread (q1 – q3) of survey questions were compared. figure s1. sensitivity analysis of likert-scale question results by campus. wider, coloured boxplots represent unweighted data, and internal thin red boxplots represent weighted data. unweighted and weighted mann–whitney–wilcoxon tests were compared and any differences in results (significant vs not significant) were noted. figure s2. sensitivity analysis of opce volume and breadth results by campus. wider, coloured boxplots represent unweighted data, and internal thin red boxplots represent weighted data. unweighted and weighted mann–whitney– wilcoxon tests were compared and any differences in results (significant vs not significant) are annotated. references 1. hill mr, goicochea s, merlo lj. in their own words: stressors facing medical students in the millennial doi: https://doi.org/10.24926/jrmc.v4i1.3447 journal of regional medical campuses, vol. 4, issue 1 original reports generation. med educ online. 2018;23(1). doi:10.1080/10872981.2018.1530558 2. o’rourke m, hammond s, o’flynn s, boylan g. the medical student stress profile: a tool for stress audit in medical training. med educ. 2010;44(10):10271037. doi:10.1111/j.1365-2923.2010.03734.x 3. ellaway r, bates j. distributed medical education in canada. can med educ j. 2018;9(1):e1-e5. 4. connor dm, conlon pj, o’brien bc, chou cl. improving clerkship preparedness: a hospital medicine elective for pre-clerkship students. med educ online. 2017;22(1). doi:10.1080/10872981.2017.1307082 5. johnson ak, scott cs. relationship between early clinical exposure and first-year students’ attitudes toward medical education. acad med. 1998;73(4):430–2. doi: 10.1097/00001888199804000-00018 6. penciner r. emergency medicine preclerkship observerships: evaluation of a structured experience. can j emerg med. 2009;11(3):235-239. doi:10.1017/s1481803500011258 7. cameron p, mann k. results of a survey of distributed medical education activities at canadian faculties of medicine. assoc fac med can. published online 2006. 8. de villiers m, van schalkwyk s, blitz j, et al. decentralised training for medical students: a scoping review. bmc med educ. 2017;17(1):196. doi:10.1186/s12909-017-1050-9 9. lovato cy, hsu hch, bates j, casiro o, towle a, snadden d. the regional medical campus model and rural family medicine practice in british columbia: a retrospective longitudinal cohort study. cmaj open. 2019;7(2):e415-e420. doi:10.9778/cmajo.20180205 10. grand’maison p, alexiadis-brown p, konkin j, bates j. distributed medical education: training future physicians for the community, in the community and with the community. assoc fac med can. published online 2018:14-15. 11. couper id, worley ps. meeting the challenges of training more medical students: lessons from flinders university’s distributed medical education program. med j aust. 2010;193(1):34-36. doi:10.5694/j.1326-5377.2010.tb03738.x 12. saxena a, lawrence k, desanghere l, et al. challenges, success factors and pitfalls: implementation of distributed medical education. med educ. 2018;52(11):1167-1177. doi:10.1111/medu.13715 13. lovato c, bates j, hanlon n, snadden d. evaluating distributed medical education: what are the community’s expectations? med educ. 2009;43(5):457-461. doi:10.1111/j.13652923.2009.03357.x 14. hogenbirk jc, robinson dr, hill me, et al. the economic contribution of the northern ontario school of medicine to communities participating in distributed medical education. can j rural med. 2015;20(1):25-. microsoft word do rural longitudinal article.docx published by university of minnesota libraries publishing independent-academic vs. university-based surgical residency. does rural medical training impact residency match? bennett j. maki, bs; karen c. riley, bs; raymond christensen, md; kirby clark, md; paula m. termuhlen, md doi: https://doi.org/10.24926/jrmc.v4i3.3621 journal of regional medical campuses, vol. 4, issue 3 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc bennett j. maki, bs; university of minnesota medical school, united states karen c. riley, bs; university of minnesota medical school, united states raymond christensen, md; medical school duluth campus, university of minnesota, united states kirby clark, md; department of family medicine and community health, university of minnesota, united states paula m. termuhlen, md; medical school duluth campus, university of minnesota, united states corresponding author: bennett j. maki 610 hovland lane duluth, mn, 55811 cell: 218-393-3531 makix327@umn.edu all work in jrmc is licensed under cc by-nc volume 4, issue 3 (2021) journal of regional medical campuses original reports independent-academic vs. universitybased surgical residency. does rural medical training impact residency match? bennett j. maki, bs; karen c. riley, bs; raymond christensen, md; kirby clark, md; paula m. termuhlen, md abstract purpose: rural general surgery experiences during medical school appear to have influenced the decision of prospective general and orthopedic surgery applicants to pursue residency programs that provide rural surgery opportunities. this is an analysis of a single cohort, rural-focused, longitudinal integrated clerkship to determine if there is an association between type of residency program applicants match with and completion of a rural-focused longitudinal integrated clerkships, as well as how rural clerkships affect practice size and location. methods: an institutional database of de-identified, self-reported data was reviewed to identify rural-focused longitudinal integrated clerkship alumni who matched into a surgical residency program. findings: of the 75 alumni who chose a surgical residency program, forty (53.3%) matched into a university-affiliated residency program, and 32 (42.6%) matched into an independent-academic program. there was no association between type of residency program and completion of a rural-focused longitudinal integrated clerkship. conclusions: a rural-focused longitudinal integrated clerkship can help increase the rural physician workforce within both the state and region of the sponsoring institution. to facilitate heightened interest in rural general surgery, these types of programs should continue to be promoted. introduction: at the national level, it is anticipated that there will be a substantial shortage of rural general surgeons by the year 2025.1-3 recruitment of general surgeons to these communities can be challenging due to a number of factors such as limited opportunities for spouses, fewer amenities and a heavy workload. factors such as having a rural background and interests, as well as completing rural clerkships have been described as influencing the choice to practice rural general surgery. 4-8 previous exploration of the rural physician associate program (rpap) cohort from the university of minnesota has found that practicing surgeons who had rural training in a longitudinal integrated clerkship (lic) during medical school were more likely to practice in a rural community, validating this assumption within minnesota.4,8 surgical clerkships on longitudinal rotations, such as rpap, have developed a variety of experiences, mimicking the medical student rural experience, as a way of introducing and nurturing interest in rural general surgery practice.4,5,8 rpap is a 9-month, community-based lic founded in 1971 at the university of minnesota. the first program of its kind, it was developed to encourage students to practice primary care in rural areas across the state of minnesota. since the program’s inception over 1 500 students have participated of which 40% practice rural areas, 65% practice in minnesota, and 69% are in primary care.1 rpap students spend 9 months of doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports the year 3 of medical school located in rural communities throughout minnesota supervised by a local primary care preceptor. all core clerkship experiences take place in the community in a longitudinal fashion. students live and work side-byside with community members. rural communities in minnesota have benefited from this shared experience by inspiring students to return to practice in a rural setting after having been immersed in the experience as a student. the university of minnesota medical school’s strong rural curriculum fortified through both the regional campus in duluth and the rpap program increases the likelihood that its graduates will practice in rural communities.4,9-10 rural communities can be thought of as areas with lower population densities and population. important characteristics of rural areas include lower cost of living, aging population, and proximity to natural resources. for this paper, we defined rural cities as those with a population of less than 50 000. we further designated small rural as < 20 000 residents, large rural as >20 000 and <50 000 residents, and metropolitan as >50 000 residents. as more students have rural experiences in medical school, it appears that they have started to seek rural general surgery experiences in residency. residency programs that promote rural surgery vary in type and location. there are currently limited studies of how lics, such as rpap or other rural-focused medical school programs, may impact students’ interest and decision in choosing a residency program. given the challenges of recruiting general surgeons and surgical subspecialists to rural areas, we sought to examine how the rpap lic affected surgeons' match in general surgery and orthopedic residency programs, as well as type and location of permanent practice. methods: institutional review board exemption was granted for this study. retrospective, de-identified, self-reported data from the rpap office regarding alumni who matched into a surgical residency (general surgery and orthopedics, n = 75) from 1971 through 2014. data from 2014-2020 has not been added to this deidentified data pool since some of these graduates are still in training. the type of residency (independent-academic vs. university-affiliated), as well as the last known area of practice, was reviewed for possible associations with completion of the rpap longitudinal integrated clerkship. independentacademic is defined as a community program without university ties, whereas university-affiliated encompasses all programs that are part of a university residency or have ties to it. results: of the 75 rpap alumni who chose a surgical residency, including both general surgery and orthopedic surgery, 40 (53.3%) matched into a university-affiliated residency program, 32 (42.6%) matched into an independent-academic program, and 3 (4%) matched into a military program. when looking specifically at general surgeon alumni (n=60), 26 (43%) matched into a university-affiliated residency program, 31 (51%) matched into an independentacademic program, and 3 (5%) matched into a military program. a comparison of proportions utilizing chisquared testing revealed no statistical difference when looking at general surgery and orthopedic surgery versus general surgery alone in the domains of university-affiliated and independent-academic residency programs (p = 0.35 and p = 0.25, respectively). this suggests that there is no correlation between rpap and type of surgical residency. using the self-reported data, a breakdown of general surgery and orthopedic alumni by last known practicing states (figure 1), as well as distribution of last known practice community sizes (tables 1, 2). for general surgeons, 27 were practicing in mn, 9 were practicing in the neighboring states of iowa, north dakota, south dakota, and wisconsin (figure 1). the distribution of alumni who matched into general surgery (n=60) shows that 21 (35%) were practicing in a rural setting, 21 (35%) were practicing in a metropolitan setting, and 18 (30%) did not identify what size community they were practicing in (table 1). there is an equal distribution of alumni who were practicing general surgery in either a rural or metropolitan setting. as previously mentioned, of the nearly 1 500 students who have completed the rpap lic nearly 40% practiced in rural areas. of those who matched into general surgery and reported where they were practicing, half (50%) were practicing in a doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports rural setting; 10 percentage points greater than the collective group of all rpap alumni. of note, there is an appreciable number of alumni who did not identify their community’s population size, which could affect the distribution between rural and metropolitan practice. for orthopedic surgeons, 8 were practicing in mn (figure 1). the distribution of alumni who matched into orthopedic surgery (n=15) shows that 7 (47%) were practicing in a rural setting, 5 (33%) were practicing in a metropolitan setting, and 3 (20%) did not identify where they were practicing (table 2). there is a higher distribution of alumni who were practicing orthopedic surgery in a rural than metropolitan setting. it is worth noting that this group is considerably smaller when compared to general surgery. collectively, the data highlights a higher proportion of the aggregate rpap alumni, who matched into either general or orthopedic surgery, were practicing in a rural setting (48%) than a metropolitan setting (37%). furthermore, nearly three-quarters were practicing in minnesota (71%). this data seems to suggest that those individuals who completed the rpap lic are more likely to practice in minnesota, and in rural settings. however, it is also important to note that 21 (28%) individuals of the aggregate did not identify what size community they were practicing in. this missing data could have a significant impact on the distribution of practice locations if it were skewed towards either rural or metropolitan settings. table 1: community size distribution of rpap alumni (1971-2014) practicing general surgery. populations of each community are defined as small rural = < 20 000; large rural = 20 000 50 000; metropolitan = > 50 000. unknown alumni did not have a current location of practice. table 2: community size distribution of rpap alumni (1971-2014) practicing orthopedic surgery. populations of each community are defined as small rural = < 20 000; large rural = 20 000 50 000; metropolitan = > 50 000. unknown alumni did not have a current location of practice. figure 1: rpap alumni cohort (1971-2014) last known state of practice. black box general surgery, maroon box orthopedic surgery discussion: this paper serves to investigate how educational experiences, specifically the rpap longitudinal integrated clerkship, impact residency or career placement in a single public land-grant institution located in the midwest. this cohort of rpap alumni suggests that there is not a correlation between the type of residency program an individual will choose; however, students that complete this educational doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports experience are likely to practice within the state of minnesota as well as in rural areas. building on prior studies from the rpap cohort ,4-5,7 this study serves to promote further investigation and discussion around outcomes of rural focused programs on medical student career development. rpap historically has had higher rates of alumni who practice rural medicine when compared to those who did not participate in the lic.4 with an increasing and aging population, the demand for physicians overall continues to increase as workforce shortages are expected throughout the country by the year 2030.11 the ohio state university has studied the demand for general surgeons using population-based modeling and have identified an overall general surgery workforce shortage between 4 917 and 7 047 in the year 2050. this is despite increasing medical school enrollment, graduate medical education programs, and new accredited medical schools.12 historically, rpap students have not chosen community or independent-academic residency programs over universityaffiliated programs. this may be due to personal and future practice interest. it may also be related to a desire to remain in the region for training and the options available. other factors may be at play such as spouse’s occupation, family preference or other unknown aspects, yet lic programs such as rpap have been one avenue to increase interest through increased exposure, handson experience, and increased responsibility. students in rpap are able to formally experience what the life of a general surgeon can be like as well as explore the field of surgery with one or a few providers. the symbiotic relationship of primary care physicians with surgeons in rural settings is seen and experienced by rpap students, highlighting the interdependence. lics have been critical in providing the opportunity for students to experience and learn about a rural community. this type of experience is critical towards sparking an interest and nurturing it with the hope of enticing new physicians to practice and live in a rural area. meta-analysis has shown that third and fourth year students participating in rpap, or rpap like experience, appear to be the most influential in impacting choice of rural practice; there is reproduced data supporting that this may be more important than choosing students from rural upbringings alone.8 rural practice experience later on in medical education in the later years of medical school and in residency increase rural retention by 4 times, but meta-analysis has shown this may range from 1 to 19 times more impactful; this has been studied across the united states and in european countries.8 additionally, immersion into a rural setting for urban raised students in third year clerkships has a positive impact on interest in future practice within a rural setting. the university of louisville has been sending urban students for 4 to 6 week rural, surgical immersion rotations which has yielded a positive impact on perception of rural practice quality of life, work-life balance, comfort of living, comfort of support, and patient motivation.13 thus, it remains important that rpap and these rural experiences be promoted to students interested in the field of general surgery and other needed rural specialties. lastly, rural general surgery residency programs have been steadily increasing in recent years to accommodate the growing demand of rural surgeons, yet students must have interest in surgery in order to increase resident numbers. it is unclear how rural residency programs and tracks may impact future students who gain their core clerkship experiences at schools which use the lic model. specific to rpap, this will be an interesting topic to explore as more general surgery programs with formal rural experiences come online. in the few years these programs have been open, they have been competitive and drawn strong applicants.4,7 limitations: comparison was not made to other longitudinal programs or traditional clerkships. data was from a self-reported, de-identified study without recent follow-up. the data set being analyzed is 6 years old, and it is not able to take into account how increasing numbers of rural residency training programs, including the recently established one at the university of minnesota, may impact candidates preference in training programs.7 we did not assess the number of longitudinal clerkship students who applied into rural surgery, but who did not get placement, nor were we able to discern their exact thought process in choosing independent vs. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports university affiliated programs. minnesota has 3 general surgery residencies and 2 orthopedic surgery residencies. in general surgery, hennepin county medical center has an independent-academic general surgery training program. mayo clinic has one university affiliated general surgery and one orthopedic program. university of minnesota has one university affiliated general surgery residency with a rural training track option and one orthopedic surgery residency. of those who answered the survey 13 completed a general surgery residency (10 independent-academic; 3 academic) and 8 completed an orthopedic surgery residency (7 independentacademic and 1 academic) in minnesota. data from residents currently in training may also change the results of the data we have recorded. additionally, there is about one-third of data from alumni surveyed that is incomplete which may be quite impactful if those residents did not practice in rural, midwestern locations. lastly, it is not possible to completely discern if rpap, rural training experiences, or both have the most significant impact on residents’ choices. another interesting question that our data set is unable to answer is whether individuals were from the states they currently practice in and how this compares to other states retention rates. overall, we know that over 70% of university of minnesota medical school graduates come from minnesota given the public land-grant charge of the university to produce physician workforce conclusion: this study has demonstrated that rural focused experiences in a single institution can help to increase the rural physician workforce in state and within a region. while the rpap program at the university of minnesota medical school has made a difference in choice of practice setting for its graduates, it does not appear to influence the match process of residency in either general surgery or orthopedic surgery. this suggests that exposure to rural practice in medical school can be nurtured with a variety of residency experiences. as rural-training tracks in residencies expand, additional research into the influence of those experiences and other programs like rpap in medical school on the development of rural surgeons is warranted. references 1. dill mj, salsberg es. the complexities of physician supply and demand: projections through 2025. aacm; 2008:1-94. available at: http://www.innovationlabs.com/pa_future/1/b ackground_docs/aamc%20complexities%20o f%20physician%20demand,%202008.pdf accessed july 13, 2020. 2. mann s. research shows shortage of more than 100,000 doctors by 2030. aamc. https://www.aamc.org/newsinsights/research-shows-shortage-more100000-doctors-2030. published march 14, 2017. accessed july 13, 2020. 3. minnesota department of health. overview of the physician workforce 2019. mdh; 2020;150. available at: https://www.health.state.mn.us/data/workfor ce/phy/docs/cbphys.pdf. accessed 13 july 2020. 4. skube sj, thorndal n, boulger jg, et al. outcomes and influences of rural-focused integrated clerkship programs in general surgery. am j surg. 2020;219(2):355-358. doi:10.1016/j.amjsurg.2019.11.040. 5. brooks kd, acton rd, hemesath k, schmitz cc. surgical skills acquisition: performance of students trained in a rural longitudinal integrated clerkship and those from a traditional block clerkship on a standardized examination using simulated patients. j surg educ. 2014;71(2):246-253. doi:10.1016/j.jsurg.2013.08.008 6. jarman bt, cogbill th, mathiason ma, et al. factors correlated with surgery resident choice to practice general surgery in a rural area. j surg educ. 2009;66(6):319-324. doi:10.1016/j.surg.2009.06.03 7. mercier pj, skube sj, leonard sl, et al. creating a rural surgery track and a review of rural surgery training programs. j surg educ. 2019;76(2):459-468. doi:10.1016/j.jsurg.2018.09.004 doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports 8. holst j. increasing rural recruitment and retention through rural exposure during undergraduate training: an integrative review. int j environ res public health. 2020;17(17):6423. published 2020 sep 3. doi:10.3390/ijerph17176423 9. medical school university of minnesota. about. https://med.umn.edu/mdstudents/individualized-pathways/ruralphysician-associate-program-rpap/about. published march 17, 2018. accessed july 13, 2020. 10. zink t, center b, finstad d, et al. efforts to graduate more primary care physicians and physicians who will practice in rural areas: examining outcomes from the university of minnesota-duluth and the rural physician associate program. acad med. 2010;85(4):599604. doi:10.1097/acm.0b013e3181d2b537. 11. zhang, x., lin, d., pforsich, h. et al. physician workforce in the united states of america: forecasting nationwide shortages. hum resour health 18, 8 (2020). https://doi.org/10.1186/s12960-020-0448-3 12. ellison ec, pawlik tm, way dp, satiani b, williams te. ten-year reassessment of the shortage of general surgeons: increases in graduation numbers of general surgery residents are insufficient to meet the future demand for general surgeons. surgery. 2018;164(4):726-732. doi:10.1016/j.surg.2018.04.042 13. crump am, jeter k, mullins s, shadoan a, ziegler c, crump wj. rural medicine realities: the impact of immersion on urban-based medical students. j rural health. 2019;35(1):42-48. doi:10.1111/jrh.12244 article published by university of minnesota libraries publishing promoting physician/attorney collaboration on behalf of older individuals: the contribution of medical school regional campuses gregory turner, ed.d., m.b.a., m.p.h., marshall b. kapp doi: https://doi.org/10.24926/jrmc.v1i1.1000 journal of regional medical campuses, vol. 1, issue 1 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc https://doi.org/10.24926/jrmc.v1i1.1000 https://pubs.lib.umn.edu/index.php/jrmc/index gregory turner, ed.d., m.b.a., m.p.h. associate professor and associate dean for faculty development, florida state university college of medicine marshall b. kapp, j.d., m.p.h. professor and director, center for innovative collaboration in medicine and law florida state university college of medicine and college of law all work in jrmc is licensed under cc by-nc volume 1, issue 1 (2018) journal of regional medical campuses original report promoting physician/attorney collaboration on behalf of older individuals: the contribution of medical school regional campuses gregory turner, ed.d., m.b.a., m.p.h. marshall b. kapp, j.d., m.p.h. abstract there are many situations in which an older person needs the services of both an attorney and a physician and communication and collaboration between members of those two professions would be highly advantageous to the older patient/client’s well-being. unfortunately, the record of physician/attorney interprofessional collaboration on behalf of the shared older patient/client in such circumstances too often is deficient and needs to be improved. this article reports on a project designed to maximize the synergistic value of physicians as patient advocates and attorneys as problem solvers when the two professions work together. the project consisted of several components, culminating in the availability of a continuing education toolkit for these two helping professions that identifies and aims to overcome an array of potential impediments inhibiting effective physician/attorney collaboration in the aging arena. one project component featured here focuses on the contribution of the florida state university college of medicine’s regional campuses in carrying out the described project. financial support: this project was supported by retirement research foundation grant #2015-121 to the florida state university research foundation, inc. human subjects: this project was approved and reapproved by the florida state university human subjects committee, hsc no. 2017.20466. keywords: interprofessional collaboration; older persons; attorneys; faculty development; continuing medical education introduction there are many situations in which an older person needs the services of both an attorney and a physician and communication and collaboration between members of those two professions would be highly advantageous to the older patient/client’s wellbeing. physicians and medical records they generate may be sought by attorneys in various legal contexts as sources of evidence regarding the physician’s firsthand observations of the older patient/client’s symptoms and behaviors, clinical diagnoses, and treatments offered and dispensed. in addition to the fact-provider role, the physician also may be solicited to provide an expert opinion about some facet of an older person’s health or health care that is being or might become disputed in a legal proceeding or other context. conversely, a physician, in the course of evaluating or treating an older patient, may identify particular needs and issues for which the advice or representation of a legal professional might be beneficial or even essential to the patient. unfortunately, the record of physician/attorney interprofessional collaboration on behalf of the shared older patient/client in such circumstances too https://creativecommons.org/licenses/by-nc/4.0/legalcode doi: https://doi.org/10.24926/jrmc.v1i1.1000 journal of regional medical campuses, vol. 1, issue 1 article often is deficient and needs to be improved. the chasm between the ideal and the actual is lamentable, but not surprising. while there are many benefits to the increased collaboration between lawyers and physicians, it is important to acknowledge that there are differences in the professions, which pose challenges for these collaborations to occur and thrive. these differences, which are deep-seated and emanate from many sources, include education, training, and socialization. there are also differences in the language, customs, values and definitions of roles that can impact effective interactions. the variations in role are very broad, including views of role in society and roles in relation to clients/patients.1 (p. 214) this project was designed to maximize the synergistic value of physicians as patient advocates and attorneys as problem solvers when the two professions work together.2 the project consisted of several components, culminating in the availability of a continuing education toolkit3 for these two helping professions that identifies and aims to overcome an array of potential impediments inhibiting effective physician/attorney collaboration in the aging arena. one of the most important components of this project significantly involved the contribution of florida state university college of medicine’s regional campuses. robust faculty development for community faculty among the resources available for the fsu college of medicine’s multi-campus educational program, the most important are the more than 2,000 local physicians across florida who provide both their time and their patients. figure 1. regional campus sites of florida state college of medicine core faculty play important educational leadership roles within their own departments and units, and they also play important institutional roles as the experts and leaders of the educational mission. within their own disciplines, they serve as important role models, mentors, and resources for educational practice, both formally and informally. indeed, the success or failure of the program will depend largely on the level and quality of community faculty cooperation. it is essential that a comprehensive program of faculty development is established. the overwhelming majority of fsu com communitybased clinical teachers are practicing clinicians, mostly physicians, who receive limited financial remuneration for their clinical teaching role. our clinician educators are a widely diverse group of practitioners. theoretical frameworks informing the project the concept of knowledge translation4 offers an important framework for designing effective continuing medical and legal education. knowledge translation recognizes that successful practice change requires more than just learning something new to improve care or services. educational interventions that are responsive to point-of-service concerns (e.g., https://doi.org/10.24926/jrmc.v1i1.1000 doi: https://doi.org/10.24926/jrmc.v1i1.1000 journal of regional medical campuses, vol. 1, issue 1 article time constraints and office processes) increase the likelihood of practice change. the second theory which informed this project is the normalization process theory (npt).5 this theory focuses on explicating the legitimacy of an intervention and the role of opinion leaders. npt is concerned with understanding trust and interpersonal relationships within social networks as they impact innovations. describing the organization and action of work performed, it proposes that for a complex intervention to become part of everyday practice, the following mechanisms need to be considered: (1) coherence (‘what is the work?’); (2) cognitive participation (‘who does the work?’); (3) collective action (‘how does the work get done?’); and (4) reflexive monitoring (‘how is the work understood and enacted?’). identifying areas of potential interprofessional collaboration and competencies a project advisory board composed of florida legal and medical experts with significant practical and academic experience and expertise in geriatrics and gerontology was assembled, with several members representing relevant state organizations. through an in-person meeting, supplemented by subsequent conference calls and several electronic exchanges of written materials, as well as informal consultation by advisory board organizational representatives with some of their key organizational members, the advisory board and project staff compiled and prioritized a list of key factual situations meeting two criteria. first, situations identified were those that arise frequently within professional relationships between older individuals and their physicians and attorneys. second, enumerated situations involve problems or issues that require, or at least ought to have, the involvement of both medical and legal professionals for the older patient/client to attain an optimum outcome.6 the most important situations believed by project participants to merit potential physician/attorney collaboration on behalf of older patients/clients are those raising issues about the following: decisional capacity, elder mistreatment, self-neglect, medical payment, family relationships, and confidentiality. connected to the issue identification exercise, project staff and the advisory board also discussed specific interprofessional competencies that physicians and attorneys should possess and be able to practice in providing their services to older persons. this discussion was consistent with the general modern movement in professional education to emphasize the development of actual, demonstrable practice abilities on the part of learners, and the cultivation of legal competencies for physicians ought to be an important part of that movement.7 in addition to the advisory board consultation process, a review of the quite limited literature regarding physician/attorney collaboration in practice was conducted. two forms of interprofessional collaboration appear to be in place presently. first, several formal written agreements have been negotiated between bar associations and medical associations at the state or local level. these agreements almost invariably focus on the respective rights, interests, and responsibilities of attorneys and physicians when they have worked together on a particular case.8 the current project sought to move beyond these self-interested, professional-focused agreements toward an enhanced consumer-centered direction, concentrating less on concerns of professional courtesy and decorum and more on fostering and improving interprofessional collaboration in ways that mainly benefit the mutual patient/client of the physician and attorney. the other, more recently-evolved extant collaborative development revolves around the proliferation of medical-legal partnership (mlp) programs throughout the united states. this service delivery model integrates legal assistance into a medical care delivery setting or system.9 in early 2017, the national center for medical-legal partnership reported programs in its network at 294 health centers in 41 states, as well as dozens in various legal entities.10 some of these programs target their provision of interprofessional services specifically on older persons.11 the current project aimed to expand on these formal programs based in organizations or https://doi.org/10.24926/jrmc.v1i1.1000 doi: https://doi.org/10.24926/jrmc.v1i1.1000 journal of regional medical campuses, vol. 1, issue 1 article institutions to encourage consumer-centered interprofessional collaboration and cooperation at the level of individual, independent physicians and attorneys, as well as those who work in organizations or institutions that might participate in a formal medical-legal partnership. educational toolkit the project produced an educational module for physicians and attorneys. this module could be presented by a physician or attorney facilitator to live audiences, in a (flexible) two-hour block, of physicians, attorneys, or—ideally—a mixture of the two professions. live presentation builds in opportunities for robust audience interaction. additionally, the module has been posted on the website of the florida state university college of medicine office of faculty development and access is available to individual physicians and attorneys who wish to use it in a selfdirected manner, deriving their own responses to questions posed in the module. substantively, the module beings with a brief introduction explaining the rationale for an educational module encouraging physician-attorney collaboration on behalf of older individuals and setting out overall learning objectives. the introduction is followed by seven case scenarios, each raising several of the different issues identified earlier as important by the project advisory board. after each case, the module presents the key issues or challenges facing the older person and the actors responsible for the older person’s well-being, opportunities for interprofessional collaboration in addressing the key issues or challenges, potential impediments inhibiting physicians and attorneys from taking advantage of the interprofessional opportunities, and organizational and written resources to assist medical and legal professionals in their own practices when similar issues are presented. for each case study, after the learner has had the chance to review the key issues, opportunities, and impediments, the learner is asked two overarching  regional campuses are located in daytona beach, fort pierce, orlando, pensacola, sarasota, and tallahassee. questions. first, “how you would address the impediments in order to maximize the interprofessional collaborative opportunities if you were the older person’s attorney or physician?” then, “how would interprofessional collaboration potentially improve the older person’s medical or legal experience or outcome?” additionally, a facilitator’s guide was created for this project. this guide fleshes out in detail, for each of the seven cases created for the educational module, the main opportunities for, obstacles to, and resources to aid in interprofessional physicianattorney collaboration on behalf of older individuals. regional campus field testing and feedback one of the project co-directors and co-authors (mbk) field tested the educational module developed by utilizing it as the centerpiece of a faculty development workshop conducted live at four regional campuses of the florida state university college of medicine. faculty development plays a particularly important role at the florida state university college of medicine, given its model of clinical education in which third and fourth-year medical students are distributed among six regional campuses across the state and are educated primarily by clinical educators who are actively engaged in patient care within their respective communities.12 marketing and outreach to participants – early planning and wide dissemination key to the successful implementation of the program was the cooperation and assistance of the college’s regional campuses. planning and marketing activities were coordinated through each of the regional campus sites. wide dissemination of information about the program began 6 – 8 weeks prior to each workshop. announcements and reminders were sent clinician educators on a bi-weekly schedule (appendix 1). publicizing this faculty development workshop to local elder law attorneys was unique and required special attention. a spreadsheet was created with https://doi.org/10.24926/jrmc.v1i1.1000 doi: https://doi.org/10.24926/jrmc.v1i1.1000 journal of regional medical campuses, vol. 1, issue 1 article names and email addresses of members of the florida bar elder law section who practice in each of the campus vicinities. the four faculty development workshops, conducted during 2017, were attended by 45 members of the college of medicine’s communitybased faculty. consistent with the interprofessional collaboration theme of this project, attorneys identified as elder law practitioners in the respective regional campus communities were invited; a total of 24 attorneys attended the four workshops. discussions emanating from the case studies in the educational module at each of the workshops were honest and lively, but collegial. specific points of emphasis differed among participants somewhat from one workshop to another, but common themes that were discussed at each of the workshops included, among others: pervasive presumptive distrust between physicians and attorneys; communication barriers; medical and legal private practitioner time constraints impinging on collaboration; confidentiality obstacles to sharing patient/client information between professionals; the sometimes disruptive role of family members; lack of good knowledge among physicians and attorneys about available assistive community resources; and financial constraints of older individuals, which especially deter them from retaining and involving legal counsel on their own behalf. workshop participants provided feedback to the authors both informally afterwards and formally through preand post-workshop survey and evaluation instruments. based on this feedback, minor revisions were made to the educational module. a copy of the facilitator’s guide was sent to each workshop participant. conclusion to “solve complex issues effectively …, it is imperative for our professions [medicine and law] not just to cooperate, but also to collaborate.”13(p. 319) benefits of interprofessional collaboration are likely to include enhanced health and well-being for the patient/client and increased satisfaction for the professionals. nonetheless, as has been noted, serious barriers to physicians and attorneys working as trusted colleagues with a mutual interest (in the patient/client good), rather than as adversaries, exist. the project described here sought to identify and help to address some of the most vexing of these impediments, with particular emphasis on maximizing resultant benefit to older individuals whose optimal well-being is jeopardized when legal and medical practitioners fail to work together on behalf of their shared patient/client. the involvement of the college of medicine’s regional campuses in providing opportunities to meaningfully field test the educational module developed was essential to the success of this project. the formal and informal feedback of clinical faculty who actually care for older patients regularly in situations that could benefit from interprofessional collaboration helped to practically ground and refine the educational module. moreover, the regional campus’ cooperation in this project provided an excellent chance for the college of medicine to initiate or enhance ties with the legal communities surrounding their respective locations, thus laying or strengthening the foundation for future productive interactions. references 1.trubek lg, zabawa b, galowitz. transformations in health law practice: the intersections of changes in health care and legal workplaces. ind health law rev 2015;12:183-226. 2. scott c. doctors as advocates, lawyers as healers. j pub law & pol’y 2008;29:331-399. 3.toolkit is available at http://mediaproduction.med.fsu.edu/mdjd/playmodul e/story_html5.html. 4. estabrooks ca, thompson ds, lovely j & hofmeyer a. a guide to knowledge translation theory. j continuing educ in the health professions 2006; 26:25–36. 5. murray a, treweek s, pope c, macfarlane a. ballini l, dowrick c, finch t, kennedy a, mair f, o’donnell c, ong bn, rapley t, rogers a, & may c. normalization process theory: a framework for developing, https://doi.org/10.24926/jrmc.v1i1.1000 http://mediaproduction.med.fsu.edu/mdjd/playmodule/story_html5.html http://mediaproduction.med.fsu.edu/mdjd/playmodule/story_html5.html doi: https://doi.org/10.24926/jrmc.v1i1.1000 journal of regional medical campuses, vol. 1, issue 1 article evaluating and implementing complex interventions. bmc med 2010; 8:63. 6. kapp mb, taite sm, turner g. medical-legal partnerships: six situations in which elder law attorneys and physicians caring for older patients need each other. bifocal: j amer bar assn commission on l & aging 2016 (july-aug.);37:115-118. 7. kapp mb, campbell a. interprofessional education for future physicians: including legal competencies. med sci educator 2013;23:566-569. 8. north carolina bar association medico-legal liaison committee. medico-legal guidelines. sept. 2014. available at http://www.ncmedsoc.org/wpcontent/uploads/2013/06/medico-legal-guidelines2014.pdf. 9. lawton e, sandel m. investing in legal prevention: connecting access to civil justice and healthcare through medical-legal partnerships. j legal med 2014;35:29-39. 10. national center for medical-legal partnership. http://medical-legalpartnership.org/ (last accessed sept. 26, 2017). 11. newman j. miami’s medical-legal partnership: preparing lawyers and physicians for holistic practice. ind health l rev 2012;9:471-483. 12.http://med.fsu.edu/index.cfm?page=comaboutus. educationalprogram. 13. morton l, taras h, reznik v. encouraging physician-attorney collaboration through more explicit professional standards. j pub law & pol’y 2008;29:317-330. https://doi.org/10.24926/jrmc.v1i1.1000 http://www.ncmedsoc.org/wp-content/uploads/2013/06/medico-legal-guidelines-2014.pdf http://www.ncmedsoc.org/wp-content/uploads/2013/06/medico-legal-guidelines-2014.pdf http://www.ncmedsoc.org/wp-content/uploads/2013/06/medico-legal-guidelines-2014.pdf http://medical-legalpartnership.org/ http://med.fsu.edu/index.cfm?page=comaboutus.educationalprogram http://med.fsu.edu/index.cfm?page=comaboutus.educationalprogram doi: https://doi.org/10.24926/jrmc.v1i1.1000 journal of regional medical campuses, vol. 1, issue 1 article appendix 1: promoting physician/attorney collaboration on behalf of older individuals flyer https://doi.org/10.24926/jrmc.v1i1.1000 microsoft word strategies to integrate article.docx published by university of minnesota libraries publishing strategies to integrate community engagement in medical student education sonal chandratre md, corina norrbom md, christopher scott zeman md, amy prunuske phd doi: https://doi.org/10.24926/jrmc.v4i2.3600 journal of regional medical campuses, vol. 4, issue 2 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc sonal chandratre, md; pediatric endocrinology, assistant professor of pediatrics, 1medical college of wisconsin-central wisconsin regional campus, site course director, foundations of clinical medicine, founding director specialty longitudinal integrated clinical experience, founding director acting internships, founding director medical writing elective 1900 westwood drive, suite 3166, wausau, wi 54401 work: 715-870-0900 2ascension saint michael’s hospital, 824 illinois ave, stevens point, wi 54481 phone: (715) 342-7655 email: sonal.chandratre@ascension.org corina norrbom, md; assistant professor co-director, physician in the community medical college of wisconsin-central wisconsin 715-881-1816 cnorrbom@mcw.edu christopher scott zeman, md; 318 geralds court, wausau, wi 54401 719-313-7534 czeman@mcw.edu amy prunuske, phd; associate professor medical college of wisconsin – central wisconsin 1900 westwood drive, suite 3161 wausau, wi 54401 715-870-0905 aprunuske@mcw.edu corresponding author: sonal chandratre, md ascension saint michael’s hospital, 824 illinois ave, stevens point, wi 54481 phone: (715) 342-7655 email: sonal.chandratre@ascension.org all work in jrmc is licensed under cc by-nc volume 4, issue 2 (2021) journal of regional medical campuses perspectives strategies to integrate community engagement in medical student education sonal chandratre md, corina norrbom md, christopher scott zeman md, amy prunuske phd abstract engaging medical students in the community during medical education can facilitate the development of the competencies necessary to be a successful community-centered physician. though health care is essential to health, it is a relatively weak health determinant. improving health and achieving health equity requires broader approaches that address social, economic, and environmental factors that influence health. to successfully improve the health of the community, medical student trainees need to learn about community issues from a diverse set of community perspectives. the value of community engagement in medical education to address society’s health challenges is particularly relevant for regional medical campuses that often have missions to serve their local communities. in this article, we share 12 tips for successfully integrating community engagement into medical student education. these tips are based on the literature and the authors’ experiences developing and implementing a community-engagement scholarship program for medical students at a new regional medical campus that incorporates a community engaged scholarly project. introduction all medical schools in north america are required to ensure that their medical education program provides sufficient opportunities for medical students to participate in service-learning and community service activities.1 integrating community engagement with medical student learning can connect students with marginalized and underserved populations and strives to improve community health and reduce health inequities.2 community engagement is reported to impact future physicians by increasing their awareness of community health needs and deepening their understanding of the perspectives of vulnerable and marginalized populations.3 according to the aamc (association of american medical colleges), the united states will see a shortage of up to 122 000 physicians by 2032, with rural and underserved areas experiencing this shortage more acutely.4 therefore, it is essential that medical schools, particularly those with a focus on addressing physician shortages, are training physicians oriented toward their community’s needs. thus, with a) the need for medical schools to offer activities involving community engagement, b) evidence in the literature showing the importance of community engagement in community health and medical student education, and c) growing need for physicians dedicated to understanding and providing exigencies of the community, the authors share 12 tips for successfully integrating community engagement into medical student education using a program that incorporates a community-engaged scholarly project. medical college of wisconsin central wisconsin campus is known for its 3-year longitudinal integrated curriculum with a research pathway of the “physician in the community”. as part of this “physician in the community” course, students participate in a 2-year course and complete a scholarly project. as part of the project, student’s progression is tracked from journal of regional medical campuses, vol. 4, issue 2 perspectives connecting, consulting, being involved, actively collaborating, and empowering or sharing results back with the community. see figure 1. community engagement tool. tip 1. identify community concerns that impact health. encourage students to explore local public health data to identify changing health trends and emerging priorities.5 online local public health databases are becoming increasingly available and can be utilized to compare local with state and national data to identify health inequities and regional differences.6 students can discuss and review local health department priorities and community improvement plans. often these priorities are established in collaboration with the community and incorporate broader definitions of health, highlighting the need to address challenges such as food insecurity or access to high quality childcare in order to build a healthier community. tip 2. build relationships with diverse professionals. students and faculty can look to partner with teachers, public health officers, law enforcement, nurses, and pastors. students can attend community events and volunteer with organizations to build relationships. making connections with a wide variety of individuals sharpens essential networking skills and will lead to a better understanding of the community and its challenges. collaborative engagement between diverse professionals enhances meaningful partnerships and leads to insights about the system and increases collective impact.7 the ability of medical students to effectively build trusting relationships will be paramount to having a successful career in medicine. tip 3. the project should meet the student’s goals. students will be more motivated to work on a community-engaged project if it connects with their own interests and builds on their previous experiences and professional goals. examples of student goals may include developing leadership skills, learning more about the perspectives of a particular population, or addressing an issue with personal relevance. learning to recognize the skills and knowledge one wishes to develop is an important step in a student's professional development.8 medical students should share their goals with community partners to identify mutually reinforcing activities for their engagement. course directors can structure assignments to create opportunities for reflection and identification of student-derived personal goals. tip 4. find out and determine what works. students should learn to use the scientific and grey literature to identify evidence-based practices that address the community-identified concern. this includes identifying the goals and activities of similar programs and evaluating how they fit with your community’s goals. students can also benefit from understanding public health and education theories like the socioecological model that suggests health is impacted at 5 levels by public policy, community, institutional, interpersonal, and intrapersonal factors.9 once an intervention has been adopted, outcomes should be tracked to determine effectiveness in the current context since there can be important variables that differ between communities. tip 5. collaborate in project design with community partners. the students should discuss with community partners the metrics that are currently being tracked and determine if there are additional outcomes that should be measured. the faculty should discuss with the community partners what ethical assurances or letters of approval are needed. community health educators, community review boards, or focus groups with the target population can assist in project design in order to maximize the likelihood that the community members will choose to engage in the project. memorandums of understanding or a written protocol can be used to document proposed program activities. it is important that all partners have a clear understanding about how responsibilities will be divided and shared while being flexible to iterate based on outcomes.10 tip 6. foster equitable inclusion of community participants. healthy inequities have grown out of lack of inclusion. there is an increasing need to identify strategies that journal of regional medical campuses, vol. 4, issue 2 perspectives successfully engage a diverse set of participants. it is important to understand the motivations and concerns of the population and what incentives might be valued. in addition, one of the benefits to students participating in these projects is to get proximate to the problems and to different perspectives. it is important to understand relevant historical trauma11 and to learn about local history and existing power structures from multiple lenses. tip 7. encourage students to support each other’s efforts. students can build their collaboration skills by helping to recruit additional students to participate in program activities. faculty and community members can facilitate synergy between projects. different students may offer different skill sets and more junior students can support sustainability while more senior students can provide near-peer mentoring.12 engaging with peer projects will broaden students’ exposure to other important community concerns. tip 8. garner and share resources in an equitable manner. the university can provide resources to support programming through space, technology, or supplies and students can assist with grant writing or fund raising. by paying community members for their contributions rather than assuming that they will volunteer, can help support equity. community members should be included in decisions about how these resources will be allocated.13 multiple community partners can work together to identify and allocate resources and personnel. tip 9. analyze, interpret, and disseminate results back to the community. medical students and community members should partner in how they interpret and disseminate data. balance commitment, power, trust, and respect. faculty must encourage bidirectional communication. all final products (posters, papers, talks) should be reviewed by community members and, if feasible, presented in local community forums or co-presented with community members. by disseminating the final outcomes back to the partner organizations, this increases the likelihood of the projects driving change in the community. tip 10. provide students with opportunities to reflect on their experiences. students are often discouraged with the lack of “results” that may come from their community-engaged projects. their involvement in a community project may be a small but very important part of a much larger process of the plan-do-study-act quality improvement cycle.14 qualitative data does not always feel as “real” as quantitative data but may play a key role in understanding why and how an intervention is working. faculty should help students understand that personal growth often comes from engaging in the process and an understanding of what was learned from failures as well as successes. faculty can highlight student progress along the community engagement continuum moving from unidirectional outreach to achieving successful collaboration and shared leadership (figure 1).15 tip 11. develop a sustainability plan to have continued community impact requires regularly fostering existing relationships and recruiting additional partners to ensure sustainability of the projects. these long-term relationships can be supported by educational experiences rather than if students participate in volunteer experiences. the long-term partnership is between the institution and community organization rather than the student and community mentor to ensure that the project is not a single occurring event. tip 12. identify how policies impact the community outcomes. students should aim to understand how institutional, local, state, and national policies are affecting potential project outcomes and health equity in the community. students should be encouraged to find opportunities to be part of critical conversations between community stakeholders and policymakers. it is important for them to learn that their advocacy as students and future advocacy as a physician may significantly impact the health of their patients and the health of the community in which they serve. conclusion journal of regional medical campuses, vol. 4, issue 2 perspectives community-based learning experiences have a positive impact on both the community and the learner. service in response to community-identified concerns will help strengthen the relationship between the community and the medical students. scholarly activity of medical students in collaboration with community mentors can help identify impactful policies and interventions. student projects may also have a potential for sustainability and growth as students become practicing physicians serving in the same or similar communities. including community engagement in medical student education gives medical students hands-on opportunities to learn about public health and to work on something they feel passionate about. assessing community needs broadens knowledge and helps students gain a better understanding of existing health inequities and disparities in the community. students gain a better grasp on the impact of social determinants of health and the importance of thinking beyond clinic walls to improve the health of the community.16 students also develop partnership skills for addressing complex, community problems. furthermore, taking the lead in community-based projects will help students sharpen their leadership qualities and give them an opportunity to work in a team. limitations of community engagement partnerships with community members may come with multiple logistic challenges in terms of scheduling. in our experience, community partners are overall very eager to collaborate with medical students. balancing community expectations and student learning objectives can be demanding given the full medical school curriculum. students may perceive community engagement as an additional workload if it is not well integrated. can these tips actually work? lastly, we would like to share the personal experience of how these tips helped one of our students in engaging in the community for his scholarly project. student reflection: “knowing that stable income and employment play a significant role in determining health, my communityengaged project was the development of a job skills workshop. after successfully completing the workshop, community members with a history of incarceration or substance abuse are guaranteed a job interview with a local manufacturer. the program has a hire rate of over 90% and since 2017, over 100 graduates have been given the opportunity for a stable source of income and a network of support. by building relationships with diverse professionals from the manufacturing industry, state and federal government, and local faith communities, we were able to leverage community resources to provide training and develop a network of support for involved participants. we were challenged to find what works; often by noting what didn’t. each new workshop cycle offered opportunities to tweak programming or find new community partners to provide optimal support to our graduates. only through collaboration with local partners were we able to develop a sustainability plan. i am grateful for the community leaders who stepped forward to lead this program after my departure. i am honored to have been part of a community-engaged project that directly impacts the health of my community. i am proud of the project graduates, our collaborative team, and my fellow students who continue to make projects like ours a reality.” figure 1. community engagement tool references 1. liaison committee on medical education (2020) standards, publications, & notification forms. https://lcme.org/publications/. accessed january 16, 2021. 2. meurer, ln, young, sa, meurer, jr, johnson, sl, gilbert, ia and diehr, s. the urban and journal of regional medical campuses, vol. 4, issue 2 perspectives community health pathway. american journal of preventive medicine 2011; 41 (4): s228–36. https://doi.org/10.1016/j.amepre.2011.06.005. 3. dharamsi, s, espinoza, n, cramer, c, amin, m, bainbridge, l and poole, g. nurturing social responsibility through community servicelearning: lessons learned from a pilot project. med teach 2010; 32 (11): 905–11. https://doi.org/10.3109/01421590903434169. 4. aamc (2020) workforce studies data and analysis. https://www.aamc.org/data/workforce/reports/. accessed february 13, 2021. 5. university of wisconsin population health institute. (2020) county health rankings & roadmaps. https://www.countyhealthrankings.org. accessed january 17, 2021. 6. marathon county. (2021) pulse. http://www.marathoncountypulse.org. accessed january 17, 2021. 7. national council of nonprofits. (2021). collective impact. https://www.councilofnonprofits.org/tools/collective-impact. accessed january 24, 2021. 8. cutrer, wb, atkinson, hg, friedman, e, deiorio, n, gruppen, ld, dekhtyar, m, and pusic, m. exploring the characteristics and context that allow master adaptive learners to thrive, med teach, 2018; 40:8, 791-796. doi: 10.1080/0142159x.2018.1484560 9. mcleroy, kr, bibeau, d, steckler, a, and glanz, k. an ecological perspective on health promotion programs. health educ q 1988; 15 (4): 351–77. https://doi.org/10.1177/109019818801500401. 10. jackson, kt, burgess, s, toms, f, and cuthbertson, el. community engagement: using feedback loops to empower residents and influence systemic change in culturally diverse communities. gjcpp, 2018; 9(2), 1-21. http://gjcpp.org. accessed 2/13/2021. 11. mohatt, nv, thompson, ab, thai, nd, and tebes, jk. historical trauma as public narrative: a conceptual review of how history impacts present-day health. soc sci med. 2014; 106:128136. doi: 10.1016/j.socscimed.2014.01.043 12. akinla, o, hagan, p, and atiomo, w. a systematic review of the literature describing the outcomes of near-peer mentoring programs for first year medical students. bmc med educ 2018; 18, 98. https://doi.org/10.1186/s12909-018-1195-1 13. wilkins, consuelo h. md, msci; alberti, philip m. phd shifting academic health centers from a culture of community service to community engagement and integration, academic medicine: 2019; 94 (6) 763-767. doi: 10.1097/acm.0000000000002711 14. institute for healthcare improvement. (2021). science of improvement: testing changes. http://www.ihi.org/resources/pages/howtoimpro ve/scienceofimprovementtestingchanges.aspx. accessed 2/13/2021. 15. aamc. (2021). community engaged research and resources. https://www.aamc.org/what-we do/mission-areas/medical-research/health equity/community-engagement. accessed 2/13/2021. 16. ktf. (2021). beyond health care: the role of social determinants in promoting health and health equity. https://www.kff.org/racial-equity and-health-policy/issue-brief/beyond-health care-the-role-of-social-determinants-in promoting-health-and-health equity/view/footnotes/#footnote-412056-3. accessed 2/13/2021. microsoft word analyticdecisiongamingarticle.docx published by university of minnesota libraries publishing analytic decision gaming –a tool for crisis response and clinical reasoning morgan decker; jacob l. graham; mark b. stephens, md doi: https://doi.org/10.24926/jrmc.v4i1.3447 journal of regional medical campuses, vol. 4, issue 1 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc morgan decker ms4, class of 2021 penn state college of medicine university park, pa, u.s.a mdecker@pennstatehealth.psu.edu jacob l. graham college of information sciences & technology the pennsylvania state university university park, pa, u.s.a. jgraham@ist.psu.edu mark b. stephens, md professor of family and community medicine professor of humanities penn state college of medicine university park, pa mstephens3@pennstatehealth.psu.edu all work in jrmc is licensed under cc by-nc volume 4, issue 1 (2021) journal of regional medical campuses original report analytic decision gaming –a tool for crisis response and clinical reasoning morgan decker; jacob l. graham; mark b. stephens, md introduction the covid-19 pandemic has created unprecedented changes in how organizations plan for and deliver medical education and patient care. as a result of the pandemic, medical schools and healthcare delivery systems were forced to pivot quickly to find best practices to sustain or promote healthy outcomes for patients and provide productive educational opportunities for medical students. while the specifics of the coronavirus outbreak may have been unforeseen a year ago, the principles of pandemic planning and outbreak modeling have been present for decades. at the penn state college of medicine, university park regional campus, we have used a simulated outbreak as part of our core orientation for medical students to promote teamwork, critical thinking, and public health awareness while simultaneously familiarizing students with the geography, ethnography, and resources available in the local community. decision-making, pandemic planning and critical thinking historical models of decision-making focus on how people “should reason” to conform to accepted norms of rationality and utility.2 such dichotomous, binary reasoning has shifted towards a revised heuristic-analytic theory of reasoning.10 this theory proposes that judgment and reasoning are facilitated by individual mental models (singularity) that couple with heuristic processes to contextualize situations to meet immediate goals (relevance). in the context of applying decision-making to pandemic planning and crisis response, the national incident management system (nims) was developed. the cornerstone of nims is the incident command system (ics), which promotes procedural interoperability across all levels of incident response.3 despite this framework, nuanced emergency situations inevitably dictate that not all exigencies can be adequately addressed. health systems and individual providers find themselves developing and deploying improvised, moment-to-moment methodologies to address complex and multidimensional crisis situations.4 a specific example of this in the current covid pandemic was the early struggle that a majority of health systems faced to ensure adequate personal protective equipment for providers and staff. recent studies evaluating hospital preparedness and adherence to nims principles suggest that medical facilities lack a gold standard for measuring and evaluating readiness, particularly with regard to command, communications and information management.5 steady increases in emerging threats, such as the recent covid-19 outbreak, provide ample motivation to develop new methods of preparing the next generation of crisis responders.7 at the pennsylvania state university, faculty use scenariobased activities in the form of an analytic decision game (adg) as pedagogy for engaging, educating, and training medical students as critical thinkers. the adg is an adapted tactical game that creates a virtual crisis requiring participants to engage in scenario management as roleplayers. adg scenarios vary by subject and audience and are readily adaptable to a wide variety of crisis responses. for the past 3 years, students from the penn state college of medicine university park campus have participated in the adg epicentre scenario. this scenario tests community preparation and resilience after a widespread and monthslong epidemic. the epicentre construct was specifically selected to introduce students to the demographics and resource infrastructure of the local community, taking place in a rural setting matching the area surrounding the penn state campus. epicentre commences with several, similar patient cases of a non-specific viral illness that escalate to a county-wide epidemic. during the facilitated exercise, students collaborate to address an ever-expanding set of community, security, and health-related issues, engaging in decision-making processes to manage the burgeoning crisis. the decision-making processes of the epicentre exercise are analogous to clinical reasoning skills students develop and employ as physicians.6 crisis response as an introduction to clinical reasoning—what does covid teach us? clinical reasoning is a complex process by which health care providers solicit and collect cues, process information, and assess available data to arrive at a diagnosis. this information is also used to plan and implement strategies to successfully treat the problem (diagnosis). the process loop continues with the evaluation of results in terms of patient outcomes and reflection on action to learn from the process and better inform future practice. to improve clinical reasoning journal of regional medical campuses, vol. 4, issue 1 original report processes, there is keen interest in examining how individuals make decisions under conditions that are high-stakes, timeconstrained, and dynamic. in the late 1960s, daniel kahneman, a psychologist/behavioral economist most well known for his work on the psychology of judgement and decision-making, teamed up with amos tversky, a cognitive and mathematical psychologist, to explore and establish a cognitive basis for common errors in decision-making. to investigate how humans make decisions, tversky and kahneman8 outline 2 systems of intuitive reasoning and extensional reasoning. the former is quick, unstructured, and informal (using heuristicenabled processes), while the latter takes time and effort and is structured and controlled. jonathan evans a well-known cognitive psychologist, developed the heuristic-analytic theory9 that explains mismatches in reasoning due to cognitive bias. heuristic-analytic theory proposes that 2 sequential cognitive processes are at work for any given reasoning task. these include 1) heuristic processes, which draw from prior experience and expectations to aid in the formulation of representative models, and 2) analytic processes, which draw on sense-making techniques to form judgments on these models. heuristic-analytic theory was extended10 to account for the inclusion of hypothetical thinking as a means to broaden the range of considerations beyond those represented by known facts. in 2004, magda osman integrated previously held distinctions between analytic and intuitive reasoning into a single-system model called dynamic graded continuum (dgc).11 this framework represents an alternative model to dual-process theory. the dgc framework proposes that representative reasoning could be viewed as a continuum from implicit to explicit and automatic. recognition primed decision (rpd) and naturalistic decision making (ndm) are 2 other models that describe how experienced practitioners solve complex problems. in the rpd model, experience results in a cognitive catalog of possible actions and the typical course of action is the first one considered. rpd recognizes the value of intuitionenabled analysis in decision making, especially when applied by seasoned practitioners (particularly physicians, military personnel, and emergency responders) who often operate in high-stakes situations. whereas intuition (honed through experience) can help recognize patterns and construct potential response strategies, this may not be appropriate in all situations. in the ndm framework,14 cognitive task analysis encourages decision-makers to develop alternate options and conduct probability estimates to determine the best course of action. this raises the question of how best to train future practitioners (who lack experience) to construct intuitive strategies. one such method is through gaming and simulation. doi: https://doi.org/10.24926/jrmc.v4i1.3447 the present covid-19 pandemic, in particular, provides the opportunity to examine decision-making processes using the previously established adg frameworks. addressing asymmetric threats like covid requires reasoning that is dynamic, adaptable, and tailorable to a wide range of possibilities. clinical reasoning in complex medical cases13 can also be viewed as a series of asymmetric threats. at both the individual level (caring for complex covid patients) and the health systems level (creating an organized response to the covid-19 pandemic), complex reasoning and critical thinking skills are essential. inquiry-based medical education the penn state college of medicine has a long-standing scientifically and clinically rigorous educational tradition with deep foundations in scholarship and humanistic care. penn state recently built on this experience to open a regional campus in university park, pa. this novel program uses transdisciplinary educational strategies to create a flexible and integrated program of study. students learn in an environment that fosters interprofessional team skills, curiosity, and a commitment to the calling of medicine. a number of guiding principles form the basis of this collaborative curriculum. students are engaged from the first day of medical school to contribute in meaningful ways to the health of patients and populations while also working to improve the health system. students are challenged to address the needs of the local community as a scaffold for transferring cognitive and clinical skills to a national and global context. the curriculum features community engagement; inter-professional, team-based care; advocacy and leadership to promote the health of patients and populations; experientially driven learning in biomedical science, clinical science, and health systems science; longitudinal learning relationships; flexible assessment; and a culture of respect and humanistic care. educational experiences are designed to emphasize interprofessional collaboration, critical reasoning, and systems thinking. to do this, the curriculum uses experiential learning and clinical immersion for students to integrate 4 core educational pillars: biomedical sciences, clinical sciences, health systems sciences, and health humanities. the design of the curriculum is based on the best evidence in the science of learning and anchored in a culture of continuous critical reflection, rigorous evaluation, adaptability, and innovation. the educational design embraces opportunities for interprofessional collaboration with educators from other disciplines, a process that gave rise to translating the analytic decision game epicentre to medical education. journal of regional medical campuses, vol. 4, issue 1 original report red teaming and the analytic decision game (adg) the use of hypothetical thinking in problem-solving is not new. red team analysis, a form of alternative analysis has been in use by military planners since the cold war.15 in the 1960s, early military red teamers utilized game-theory techniques to evaluate strategic decisions. red team analytics models the behavior of individuals or groups by emulating their thought processes in order to anticipate probable (adversary) actions. the red cell analytics lab (rcal) on the campus of the pennsylvania state university, has combined the tenets of red teaming with the adg to analyze multiple scenario-based threats. covid-19 adds a layer of urgency and importance to such work. the analytic decision game (adg) was developed as a pedagogy to bridge theory and practice in collegiate classrooms by applying structured and unstructured analytic techniques to solve problems of security and risk (including natural and man-made crises).16 the adg combines the tenets of pbl and experiential learning with analytic techniques, allowing students to experience relevant academic content while simultaneously developing skills in problem-solving, critical thinking, communication, collaboration, and creativity. epicentre: the scenario for many of the medical students at the regional campus of the penn state college of medicine, epicentre was their introduction to rural america. the scenario is set in centre county, where our regional campus is located. the epicentre simulation provides students with topographical county and community maps, a demographic study of the region, a countywide strengths-weaknesses-opportunities-threat (swot) analysis, and a 200-year oral history created from data collected from local resources in centre county. the crisis response exercise was initially developed for security and risk analysis students in the college of information sciences and technology. after collaboration with penn state medical school faculty and recognition of the utility of exercise-based approaches and the parallels between analytic reasoning and clinical reasoning, the scenario was radically adapted for incoming medical students to create the epicentre adg. at the beginning of the exercise, 3 teams are formed corresponding to 3 communities within centre county. students take on leadership roles to guide their respective communities through the constantly evolving public health crisis. as the scenario progresses, it becomes obvious that identified issues cannot be fully resolved during the span of the exercise (a situation often found in the context of clinical decision making in real-life patient care). the timeconstrained nature of the exercise forces students to doi: https://doi.org/10.24926/jrmc.v4i1.3447 prioritize and focus, the same as with real-life crises situations. the epicentre scenario plays out in 4 parts: part-1: welcome to centre county epicentre begins with having the teams get to know their respective communities. in this initial phase, students are put in the role of community leaders of 3 geographically and economically distinct communities. students must identify available resources, assess any immediate threats to health and safety, conduct risk assessments, and identify high-risk populations. part-2: cough and chills and constipation, oh my! students are introduced to their “patient zero.” in this second phase, students within each of the 3 communities interview several simulated patients who present with non-specific complaints. students practice patient history taking skills and are asked to develop a rudimentary differential diagnosis. because this potentially represents the first experience incoming students have with patient interviewing, they are provided with several “how-to” guides on history taking and construction of a differential diagnosis, both of which are foundational components of clinical decision making. each team also has a senior medical student to help guide them as a near-peer educator, particularly with respect to the clinical decisionmaking process. senior students were encouraged to ask helpful questions, help develop an initial problem list, and differential diagnosis supported by positive and negative findings. the entering students are then asked to submit their final formal clinical note with rationale for each differential diagnosis to the faculty for feedback. standardized patients also provide real-time feedback regarding each student’s data gathering and interpersonal communication skills. part-3: houston, we have a problem as the scenario progresses, students continue to see standardized patients with clustered presenting complaints at a higher frequency. they begin to realize that “something is not normal”. students from each community are encouraged to contact neighboring communities to determine patterns of disease presentation, marshal available resources and decide what to do. they are also asked to revisit their differential diagnosis when they receive new information (e.g. public health updates and news briefs) that is provided in a spontaneous and unpredictable manner during the simulation. public health concepts, such as case identification, containment, mitigation, and contact tracing, are emphasized during this phase of the activity. part-4: power in numbers the community teams are encouraged to work together to form a health care coalition. students continue to gather, interpret, and evaluate information so that they apply across the county. this larger group must create an immediate action plan based on cdc recommendations, map and track disease progression, journal of regional medical campuses, vol. 4, issue 1 original report explore state and national level reporting systems, and develop a cooperative plan of action. epicentre: a shared educational model for crisis response to date, there have been 3 iterations of the epicentre activity with arriving first-year medical students. after each, a comprehensive after-action review was conducted. common findings suggest that most students found the introduction to established disaster management protocols from the centers for disease control to be quite helpful. in addition, students appreciated the ability to practice different methods of leadership and collaboration. this is not something the students were expecting during their first week of medical school. retrospectively, students also highlighted the value of epicentre in terms of day-to-day clinical reasoning and problem solving, as well as their understanding of different public health approaches in the context of the covid-19 pandemic—an event that they did not see coming at the time of the initial exercise. the value of the epicentre activity has come into additional focus for students during the covid pandemic. as penn state college of medicine shifted to online coursework, all students (n=152) from the regional and main campus concurrently enrolled in a course on public health and underserved medicine entitled health systems and equity. as part of the course, students discussed the disparate impact of the covid pandemic on vulnerable populations. students from the regional campus mentioned being comfortable with pandemic planning material while students from the main campus reported that this material was completely new for them. other students from the regional campus used their epicentre experience to further expand their public health awareness and brainstorm solutions for healthcare delivery to vulnerable populations. students from the regional campus felt well prepared to address the course learning objectives and outline the nims structure and function. this provides anecdotal evidence that epicentre was useful in helping students develop clinical reasoning skills while also providing a fundamental understanding of public health and pandemic preparedness. conclusion the asymmetric nature of crisis, whether natural or manmade, requires thought processes and analytic strategies that are dynamic, adaptable, and applicable to a wide range of possibilities. the strength of the adg lies in its inherent flexibility. design features are tailored to specific desired learning outcomes. in the case of epicentre 2020, the design of the exercise focused on elements such as building cohesive teams, adult learning theory, covid crisis planning, and covid crisis response. other elements, such as evidencebased reasoning, examining correlation versus causation, and doi: https://doi.org/10.24926/jrmc.v4i1.3447 practicing clinical reasoning skills were included. the activity emphasized principles of active adult learning by linking the evolving pandemic with the creation of a tangible covidresponse plan for the local community. the time-constrained nature of this year’s exercise, coupled with real-life constraints imposed by the pandemic did not allow for the typical post-exercise after-action review. this review allows exercise to highlight areas that may not have been obvious and allows participants to ask specific questions about the exercise design, sequence, or content. the analytic decision game is an interesting pedagogical strategy designed to promote critical thinking in the context of developing clinical reasoning skills. the epicentre adg at the penn state college of medicine has been utilized to promote the development of interprofessional team skills, curiosity, and problem-solving skills in the specific context of disaster preparedness. the covid pandemic emphasizes the real-world applicability of a thoughtfully created clinically relevant analytic decision game. the utility of this particular adg was made particularly evident in the context of the covid-19 pandemic as a tool to help students gain greater insights on the nature and effects of the covid disease on individuals and on society while simultaneously using this information to create a specific public health plan to benefit the local community. acknowledgments we thank all administrators, faculty, and staff of the penn state college of medicine and students who have become members of the epicentre community. references 1. manktelow, k., over, d. and shira, e. (eds.). (2011) the science of reason: a festschrift for jonathon st. b.t. evans. new york: psychology press. doi: 10.4324/9780203847121 2. kneale, w. c., & kneale, m. (1962) the development of logic. oxford university press. doi: 10.2307/2964116 3. annelli, j. f. (2006) the national incident management system: a multi-agency approach to emergency response in the united states of america. revue scientifique et technique-office international des épizooties, 25(1), 223. 4. mendonca, d., beroggi, g. e., & wallace, w. a. (2003, january) evaluating support for improvisation in simulated emergency scenarios. in system sciences, 2003. proceedings of the 36th annual hawaii international conference on (pp. 9-pp). ieee. doi: 10.1109/hicss.2003.1174599 5. jenkins, j. l., kelen, g. d., sauer, l. m., fredericksen, k. a., and mccarthy, m. l. (2009) review of hospital preparedness instruments for national incident doi: https://doi.org/10.24926/jrmc.v4i1.3447 journal of regional medical campuses, vol. 4, issue 1 original report management system compliance. disaster medicine and public health preparedness, 3(s1), s83-s89. doi: 10.1097/dmp.0b013e3181a06c5f 6. trowbridge, r., rencic, j., durning, s.j. (2015). teaching clinical reasoning. american college of physicians. phila, pa. isbn: 9781938921063 7. hall, d., graham, j. and catherman, e. (2015) a survey of tools and resources for the next generation analyst, proceedings spie dss sensing technology and applications conference: next generation analyst iii, baltimore, md. doi: 10.1117/12.2176613 8. tversky, a., kanheman (1974) judgment under uncertainty: heuristics and biases science (washington, d.c.), 185 (1974), pp. 1124-1131. isbn: 9780521240642 9. evans, j. (1984) heuristic and analytic processes in reasoning. british journal of psychology, 75, 451– 468. doi: 10.1111/j.2044-8295.1984.tb01915.x 10. evans, j. (2003) in two minds: dual-process accounts of reasoning. trends in cognitive sciences, 7(10), 454-459. doi: 10.1016/j.tics.2003.08.012 11. osman, m. (2004) an evaluation of dual-process theories of reasoning. psychonomic bulletin review, 11, 988-1010. doi: 10.3758/bf03196730 12. cyber, electronic warfare, and critical infrastructure strategies for national security. summary of remarks, eighth symposium on asymmetric threats to national security, october, 2014. mcclean, virginia. isbn: 9780313016196 13. custers, e. (2013). medical education and cognitive continuum theory: an alternative perspective on medical problem solving and clinical reasoning. academic medicine 88 (8): 1074-1080. doi: 10.1097/acm.0b013e31829a3b10 14. klein, g. (2008) naturalistic decision making. human factors, 50(3), 456-460. doi: 10.1518/001872008x288385 15. zenko, m. (2015) red team, how to succeed by thinking like the enemy. new york, ny: basic books. isbn: 9780465048946 graham, j., & hall, d. (2012) the use of analytic decision game (adg) methods for test and evaluation of hard and soft data fusion systems and education of a new generation of data fusion analysts. pennsylvania state university state college, pa, college of information sciences and technology. microsoft word understandingtheneedsofruralarticle.docx published by university of minnesota libraries publishing understanding the needs of rural preceptors from groups underrepresented in medicine erica sutton md, angelita howard edd mba, ashaki goodman journal of regional medical campuses, vol. 3, issue 3 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc erica sutton md, morehouse school of medicine, atlanta, ga angelita howard edd mba, morehouse school of medicine, atlanta, ga ashaki goodman, morehouse school of medicine, atlanta, ga corresponding author: erica sutton, md associate dean, academic programs and affiliations morehouse school of medicine 720 westview dr. sw atlanta, ga 30310 email: esutton@msm.edu cell: 410-908-0514 all work in jrmc is licensed under cc by-nc volume 3, issue 3 (2020) journal of regional medical campuses understanding the needs of rural preceptors from groups underrepresented in medicine erica sutton md, angelita howard edd mba, ashaki goodman abstract introduction community preceptors are essential in providing sufficient training opportunities for health professional students. recently, focus has been given to the recruitment of community preceptors from groups underrepresented in medicine (uim) for their contributions in training a diverse and culturally competent workforce. the overall goal of this study is to review data collected from uim preceptors and potential preceptors for unique beliefs or values that reveal their motivation for teaching. we hypothesize that community preceptors from groups underrepresented in medicine hold beliefs reflective of high levels of altruism and service. methods this is a retrospective study of interview data collected from uim community preceptors for developing clinical education experiences. we sought to uniquely understand the needs of these preceptors in order to develop our recruitment strategy. each participant agreed to a structured interview and gave or denied permission to have the interview recorded. in the structured interview, community physicians were asked to answer questions about their motivation to precept medical and physician assistant students. they were further asked about their desired compensation, reservations about teaching, and interest in participating in curricular development. results we interviewed 12 community providers: 11 physicians and one advanced practice nurse. participants were from a broad range of specialties: obstetrics/gynecology (3), surgery (3), psychiatry (3), family medicine (1), pediatrics (1), and emergency medicine (1). of the providers interviewed, 10 were from groups underrepresented in medicine. all 10 of the uim participants were physicians. all participants completed the structured interview. the answers provided in the interview were able to be grouped into themes reflecting a recurring set of beliefs and motivations. conclusions uim preceptors hold values reflective of altruism and a willingness to serve in the creation of the future workforce. we have found uim preceptors possess a strong desire for training as educators. further, uim preceptors are incentivized by financial compensation and willing to commit their personal time to advising the medical school. introduction community preceptors are essential in providing sufficient training opportunities for health professional students. given the expansion in class size and creation of regional campuses seen across the country, health professional schools are beholden to the community preceptor to meet their program objectives. recently, focus has been given to the recruitment of community preceptors from groups underrepresented in medicine (uim). organizations such as the society of teachers of family medicine (stfm) are making deliberate efforts at recruiting and developing a pipeline for uim community preceptors. their goals are to foster mentorship, academic leadership, and scholarship among uim community preceptors in order to achieve health equity among the patients they serve and garner the benefits of a diverse workforce for the learners they teach.1 the overall goal of this study is to review data collected from uim preceptors and potential preceptors for unique beliefs or values that reveal their motivation for teaching. we hypothesize that journal of regional medical campuses, vol. 3, issue 3 community preceptors from groups underrepresented in medicine hold beliefs reflective of high levels of altruism and service. the knowledge expected to result from this study will inform medical educators as to why community physicians choose to engage as teachers. this is important to understand in a society where physician workforce shortages promote the training of more doctors, but also create more demands on the time of doctors in practice. methods this is a retrospective study of interview data collected september 2019 through december 2019 from uim community preceptors for the purpose of developing clinical education experiences. participants were identified in one of 3 ways. several participants were approached because they were existing preceptors with morehouse school of medicine (msm). we felt their motivations were important to record because their experience could validate potential barriers, supporting or refuting preconceptions. secondly, we identified community preceptors who specialized in a field where we needed more educational experiences for students. we sought to uniquely understand the needs of these preceptors in order to develop our recruitment strategy. lastly, we approached community physicians who had expressed an interest in learning more about becoming a preceptor. we learned of their interest through direct communication at one of 2 medical society events in the community or through word of mouth. indirect communication came by way of existing preceptors, msm faculty members or msm board members. each participant agreed to a structured interview and gave or denied permission to have the interview recorded. in the structured interview, community physicians were asked to answer questions about their motivation to precept medical and physician assistant students. they were further asked about their desired compensation, reservations about teaching, and interest in participating in curricular development (figure 1). figure 1. focus group questions 1. what concerns do have about teaching medical students in your practice? 2. for those of you who have students, what made you willing to teach a medical student in your practice? 3. what sort of return would make teaching students worth it for you? cme, library access, scribe services, patient referrals, monetary compensation? pay medical society dues? other membership dues? 4. are you receiving enough support from the clerkship director or msm clinical department for your role? what support would you like to see? 5. would you be willing to serve on an advisory board for the columbus expansion group? interviews were recorded electronically or via handwritten notes. recorded interviews were transcribed. the authors [es, ah] read the transcribed interviews and notes to identify themes in the responses. these themes were tabulated and summarized to constitute study findings. some respondents gave more than one answer and both answers were counted. therefore, it was possible to have more answers than participants. the use of this data for publication purposes was reviewed and approved by the morehouse school of medicine irb (https://www.msm.edu/research/hrpp/irb/index.php). results we interviewed 12 community providers11 physicians and one advanced practice nurse. participants were from a broad range of specialties: obstetrics/gynecology (3), surgery (3), psychiatry (3), family medicine (1), pediatrics (1), emergency medicine (1). seven participants were community preceptors for other medical schools in the area, 5 of whom were also existing preceptors with msm. of the providers interviewed, 10 were from groups underrepresented in medicine. all 10 of the uim participants were physicians. in response to the question, what concerns do have about teaching medical students in your practice? participants provided answers along 5 themes (number of responses given containing this theme): concern surrounding the quality of the experience for the students (6), if students would possess the needed procedural skills related to sterile technique (2), added work for the preceptor (2), if students would possess the needed clinical skills such as history taking and performing a physical exam (1), and professionalism related to confidentiality (1) (table 1). journal of regional medical campuses, vol. 3, issue 3 table 1. community preceptor concerns about having a medical student participate in the practice. in response to the question, for those of you who have students, what made you willing to teach a medical student in your practice? participants provided responses along 5 themes: a culture of teaching in the practice (7), a desire to give back (5), a desire to increase the number of local practitioners (2), a practice obligation (1), a desire to ensure the quality of future practitioners (1) (table 2). table 2. reasons given for community preceptors’ willingness to teach in response to the question, what sort of return would make teaching students worth it for you? participants responded along 8 themes: financial compensation via tax credit, monetary payment, loan repayment, payment of membership dues, or funds to support other professional work (10), faculty appointment (6), access to education such as continuing medical education credit or library access (5), access to research opportunities (2), access to scribe services (1), recognition for teaching (1), exposure to new learners (1), and more local practitioners (1) (table 3). table 3. community preceptors’ desired return on investment in response to the questions are you receiving enough support from the clerkship director or msm clinical department for your role? what support would you like to see? participants responded along 3 themes: desired a better understanding of clerkship learning objectives (3), desired a better understanding of student performance/gaps (1), communication is sufficient (1) (table 4). table 4. perceptions of adequacy of institutional support for existing community preceptors in response to the questions would you be willing to serve on an advisory board for the columbus expansion group? participants responded yes (5), no due to time constraints (2), unsure (3) (table 5). 0 2 4 6 8 qu ali ty of … pr oc ed ur al… ad de d w or k cli nic al sk ills pr of es sio na li… table 1. concerns about having a medical student in your practice 0 1 2 3 4 5 6 7 8 teaching in the practice give back < # of local practitioners practice obligation quality of future practitioners table 2: willingness to teach 0 2 4 6 8 10 12 co mp en sa tio n o f… fa cu lty … cm e c re dit re se ar ch … te ac hin g… ne w le ar ne rs table 3: return on investing 0 1 2 3 4 clerkship learning objectives student performance/gaps sufficent communication table 4: institutional support (current preceptors only) journal of regional medical campuses, vol. 3, issue 3 table 5. community preceptors’ willingness to serve on institutional committees discussion morehouse school of medicine is known for its commitment to serving underserved populations and for creating the healthcare workforce who will serve them. because there is a growing need for care in georgia’s rural populations and urban underserved populations, msm has strategically expanded its medical student class size from 60 to 100 students per class over the last 3 years. in addition, msm matriculated its first physician assistant class of 20 students in 2019, with 100% and 50% growth expected in the next 2years. also, in 2019, msm matriculated its first class into the online master’s in biotechnology program and the master’s in public health program welcomed is first class of the executive mph degree. this brings the total mph class size to 54 students, 50% of whom are from georgia. msm’s growth mirrors trends in medical school enrollment among schools nationwide. according to an analysis in brief published by the aamc in 2018, by academic year 2022–2023, medical school enrollment is expected to increase by 36% over 2002–2003 levels.2 morehouse school of medicine, like others, needed to address clerkship site availability to support its growth. the need was most pronounced in primary care specialties. msm ranks above the 90th percentile for placement of trainees in primary care. among msm’s 10-year graduates (2004-2005 through 2008-2009), 86% practice in underserved areas and 73% practice in rural areas.3 yet, the current reality is that available faculty in rural settings is increasingly scarce. rural clinicians are faced with more pressure for revenuegenerating productivity, leaving less time for teaching.4 thus, it became imperative to not only recruit more rural community preceptors, but to also understand what preceptors need to be effective teachers and providers. we sought first to understand barriers to teaching that may exist. when we asked, what concerns do you have about teaching medical students in your practice?, we found the most common concern about teaching was ensuring the quality of the experience for the students. similarly, when existing preceptors were asked, are you receiving enough support from the clerkship director or msm clinical department for your role?, respondents asked for a better understanding of what learners were expected to know and do. these findings highlighted for us the need to further structure and formalize our communication to preceptors about medical education program objectives, course learning objectives and how the students will be assessed and evaluated. we did not find this concern to be uniquely held by uim physicians. we did find that a centrally managed orientation allowed our institution to connect to our preceptors, several of whom had a connection to the school as alumni. leveraging such connections aided us in recruiting uim faculty from the community. schools that are not designated as historically black colleges or universities could similarly benefit from deliberate inclusion of their uim alumni in preceptor recruitment and training activities. our findings related to what made you willing to teach mirror those of related studies. we found our preceptors were largely motivated by a culture supportive of teaching. a survey of 233 canadian preceptors showed that their primary motivator was the enjoyment of having students in their practice (scott).5 this finding persists in the literature across multiple preceptor groups, despite data showing that physician preceptors most often reported a negative impact of medical student interactions on patient flow, work hours, and income.6 we made a unique discovery in the return on investment valued by our preceptors by asking what sort of return would make teaching students worth it for you?. ten out of 12 preceptors found financial compensation a meaningful incentive. in “the community preceptor crisis,” the authors advocate for financial incentive to preceptors if financially feasible.7 the article further mentions the georgia preceptor tax incentive program (gptip) and suggests it could serve as a model of physician compensation for other states.8 in our cohort, 4 out of 5 of our existing preceptors receive some form of financial compensation, either through the tax credit or a stipend supported by msm. to compare these options, we modeled the maximum compensation achievable by each and found that the gptip offered a benefit that was equivalent to or slightly higher than direct taxable payment. while the “joy of teaching” remains a primary motivator for uim community preceptors, our study suggests that open dialogue about financial compensation is welcome and incentivizing. this study is limited by its retrospective methodology, small sample size, and potential selection bias. participants were identified either for having an existing connection to msm or expressing an interest in learning more about such a 0 1 2 3 4 5 6 yes no unsure table 5: advisory board participation journal of regional medical campuses, vol. 3, issue 3 connection. this methodology could have introduced bias into the data in favor of preceptors who held positive views about precepting learners and altruistic attitudes surrounding compensation. our findings suggest that preceptors were in favor of teaching but still contributed barriers and concerns. participants did not appear biased toward altruism and were in fact willing to discuss their desires for compensation. the small sample size is derivative of the small numbers of rural uim physicians who engage in teaching medical students. a better understanding of the needs of this population can inform strategies meant to grow it constituents. future studies could both develop formal strategies to increase the numbers of rural uim preceptors and test if these strategies are effective when implemented by primarily white institutions. conclusions while several studies support the need for more preceptors globally, this study aims to understand the needs of rural preceptors, focusing on those underrepresented in medicine. uim preceptors hold values reflective of altruism and a willingness to serve in the creation of the future workforce. we have found uim preceptors possess a strong desire for training as educators. further, uim preceptors are incentivized by financial compensation and willing to commit their personal time to advising the medical school. it is necessary and vital that we have preceptors from groups underrepresented in medicine who are committed to lifelong learning and teaching; and, that we as an institution are committed to ensuring their success in these educational roles. references 1. walters e. building a diverse academic family medicine workforce: urm initiative focuses on four strategic areas. ann fam med 2020;18(1):87-8. 2. association of american medical colleges. analysis in brief 2018; 18(3). http://www.aamc.org/data/aib, accessed march 16, 2020. 3. association of american medical colleges 2020 missions management tool. website: https://services.aamc.org/dsportal2. accessed march 2, 2020. 4. cox, m, irby d. a new series on medical education. n engl j med 2006; 355:1375-1376. doi: 10.1056/nejme068211. 5. scott i, sazegar p. why community physicians teach students (or not): barriers and opportunities for preceptor recruitment. medical teacher 2006; 28(6): 563-565. doi: 10.1080/01421590600627375. 6. functions and structure of a medical school: standards for accreditation of medical education programs leading to the m.d. degree. available at: http://www.lcme.org/publica tions.htm#standardssection. accessed april 23, 2020. 7. christner j, dallaghan g, et al. the community preceptor crisis: recruiting and retaining community-based faculty to teach medical students—a shared perspective from the alliance for clinical education, teaching and learning in medicine 2016; 28(3):329-336. doi: 10.1080/10401334.2016.1152899. microsoft word medical school campus article.docx published by university of minnesota libraries publishing medical school campus choice: factors influencing a student’s decision to attend a rural regional medical campus brooke fowler, bs, chase brown, bs, and william cathcart-rake, md doi: https://doi.org/10.24926/jrmc.v4i2.3695 journal of regional medical campuses, vol. 4, issue 2 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc brooke fowler, bs; university of kansas school of medicine-salina salina, kansas chase brown, bs; university of kansas school of medicine-salina salina, kansas william cathcart-rake, md; university of kansas school of medicine-salina salina, kansas corresponding author: william cathcart-rake, m.d., clinical professor of medicine, university of kansas school of medicine-salina, 138 north santa fe, salina, kansas 67401; email: wcathcart-rake@kumc.edu all work in jrmc is licensed under cc by-nc volume 4, issue 2 (2021) journal of regional medical campuses original report medical school campus choice: factors influencing a student’s decision to attend a rural regional medical campus brooke fowler, bs, chase brown, bs, and william cathcart-rake, md abstract the factors that influence medical school choice have been the subject of previous reports, but there is a paucity of data regarding the factors influencing a student’s choice between the main campus and a regional medical campus (rmc) in the united states. the authors surveyed current students and graduates of the university of kansas school of medicine (kusm) rural rmc in salina regarding those factors that influenced their decision to attend that campus and their satisfaction with delivery of their medical education and student support services. the authors identified 3 major factors influencing rural campus selection (important or very important in >75% of current students and graduates): small class size, quality of core clinical experiences, and working one-on-one with clinical faculty and residents. salina met student expectations regarding the main reasons for selecting the campus but were disappointed with several other campus aspects, including: research opportunities, interest groups, academic counseling, mental health services, and residency counseling. the survey results provided impetus for optimizing recruitment strategies and improving campus support services. introduction medical school campus selection can be a daunting process for any prospective medical student. while it may be a straightforward decision for the premedical student who is accepted at only one medical school, there may be disappointment and hesitation if it was not their preferred choice. the decision can be challenging for the pre-medical student accepted to more than one school. undoubtedly, multiple factors are considered when deciding on which medical school to attend or on which campus to attend when a school offers more than one campus location. hours of research, self-reflection, and advice seeking may be required, resulting in what one hopes is the best decision regarding school choice. the factors that influence a student’s decision to choose a particular medical school have been addressed previously.1-8 the most common threads in a student’s decision regarding a choice of medical schools in nearly all of these reports were the importance of school reputation and campus location. the decision regarding medical school choice may be just as difficult for those students admitted to a medical school with a main campus (usually in a metropolitan area) and one or more regional (often rural) campuses. which campus should they attend? in a study by graeme jones,9 students attending the university of melbourne in australia were sent a survey to evaluate their concerns about choosing to study at the rural clinical school (rcs) for 18 months of their training. the most commonly cited concerns were quality of teaching and education, transportation and location issues, and student access to patients. family and partner commitments, financial issues, and housing commitments were the most common deterrents cited by those students who did not choose the rcs. in their study of campus choice (main campus versus 2 regional campuses), mihalynuk et al10 from the university of british columbia and the university of northern british columbia in canada also investigated the factors influencing the decision to attend the main metropolitan campus versus a smaller regional campus. the authors noted that the smaller regional campuses emphasized close relationships and educational experiences, while greater access to medical and educational specialists, a journal of regional medical campuses, vol. 4, issue 2 original report greater patient case mix, and the community were features of the larger campus. while education, relationships, and lifestyle were important influences on study-site choice, partner and family exerted even greater influence on campus choice. krahe et al11 surveyed 6 australian universities with rcss and found that the primary driver to attend a rcs was students’ access to patients, although friends and academic reputation were also important considerations. because there is a paucity of data from the united states regarding the factors that influence the decision to attend a main urban campus versus a rural regional medical campus (rmc), the salina rmc of the university of kansas school of medicine (kusm-salina) conducted a survey of current students and graduates regarding the factors that influenced their decision to attend its campus. the primary goal of this study was to identify those factors influencing a student’s decision to select the rural rmc in salina. determining what factors were most important and least important can assist the kusm admissions committee in presenting campus choices to prospective students, as well as in campus assignment decisions. this information may also provide guidance to other medical schools with urban and rural campuses in their recruitment of students and their campus assignment decisions. the secondary goal of this study was to determine the satisfaction of kusm-salina students with the educational program and support services provided once they were on campus. kusm-salina was established as a small rural 4-year rmc in 2011; eight students matriculated on the campus each year from 2011 to 2019. this campus complemented kusm’s urban rmc in wichita and the main campus in kansas city. salina is a community of approximately 50 000 people located in a predominately agricultural region in north-central kansas. the founding mission of kusm-salina is to educate medical students in a rural environment, hoping that many graduates will choose to practice in rural kansas.12 although there are differences in presentation, the curriculum on the kusm-salina campus is identical to that on the kansas city and wichita campuses. the majority of the foundational science lectures during years 1 and 2 are delivered to salina students via live televideo conferencing generated from the main campus, while small group case-based discussions, anatomy labs, and clinical skills labs are facilitated by local faculty. required and elective clinical clerkships during years 3 and 4 are offered in salina, although students have the opportunity to complete clinical work on other campuses. the rural kusm-salina campus is particularly attractive to students from rural communities, and studies have shown that medical students originally from rural areas are more likely to return to such areas and practice medicine.13-18 cathcart-rake recently published a report regarding the dramatic impact the kusm-salina campus has had on the production of primary care physicians who stay in or return to kansas, especially rural kansas.19 students applying to kusm do not list campus choice on their amcas application. prospective students rank their choice of campuses (main campus in kansas city, metropolitan rmc in wichita, first 2 years in kansas city and final 2 years in wichita, or rural rmc in salina) on their supplemental application. the kusm admissions committee initially decides which students are accepted for admission to the medical school and then decides on campus assignment. campus assignment is predominantly based on student preference. methods an invitation to voluntarily and anonymously participate in a 51-question redcap20,21 survey was sent to all 24 current students (classes of 2021, 2022, and 2023, each comprised of eight students) and all 47 graduates of kusm-salina (classes of 2015-2020). the study was conducted during the first weeks that the incoming firstyear medical students (class of 2024) were on campus. although this group could identify factors that influenced their campus choice, they could not accurately reflect on their kusm-salina campus experiences; therefore, they were not invited to participate. the first 8 questions of the survey identified the participants’ current status as either a student or graduate of kusm-salina, interview site for medical school admission, rural background, future medical practice plans, and overall satisfaction with the kusmsalina campus. the next 22 questions used a 5-point likert scale (1 = not important, 2 = slightly important, 3 = moderately important, 4 = important, and 5 = very important) to query factors that may have influenced their decision to attend kusm-salina. then 17 questions (also using the same 5-point likert scale; 1 = very dissatisfied, 2 = dissatisfied, 3 = neutral, 4 = satisfied, and 5 = very satisfied) inquired about satisfaction with the campus. finally, there were 4 open-ended questions: 1) why they did or did not rank salina first among the 3 kusm campuses; 2) what was most gratifying about journal of regional medical campuses, vol. 4, issue 2 original report matriculating to kusm-salina; 3) what was most disappointing about attending kusm-salina; and 4) satisfaction with the kusm curriculum in general. the survey remained open for 3 weeks. reminders to complete the survey were sent to both current students and graduates at approximately weekly intervals. all respondents who replied within the 3 weeks of opening the survey were included in the analysis. univariate statistics were calculated to describe participant responses and achieve our study objective. the university of kansas medical center irb reviewed and approved the study protocol (study00146084). results summary statistics regarding respondents are noted in table 1. fifty-three (20 students and 33 graduates) of the 71 individuals invited to participate in the redcap survey completed the survey, representing an overall response rate of 74.6% (an 83.3% response rate for current students and a 70.2% response rate for graduates). overall, 18 (90%) of the current student respondents and 29 (87.9%) of the graduate respondents indicated that they ranked salina number one on their supplemental application. seventeen (85%) of the current students and 29 (87.9%) of the graduates indicated that they were originally from a rural community the size of salina or smaller. twelve (60%) of the current students and 25 (75.8%) of the graduates were either planning to practice or were practicing primary care. twenty (100%) of the current students and 26 (78.8%) of the graduates were planning on or engaged in rural practice. all respondents in both groups (100%) stated that they were ultimately happy with the kusm-salina campus assignment, regardless of whether they ranked salina as their first choice. table 1. summary of respondent statistics factors that influenced a student’s decision to select the kusm-salina campus (table 2) were segregated into 3 ranges: 1) important to very important (≥75% of current students and > 75% of graduate respondents selected a likert score of 4 or 5 score = important or very important), 2) moderately important (50-74.9% of each group of respondents selected a 4 or 5 score), and 3) less important (≤50% of each group of respondents selected a 4 or 5 score). the factors that were ranked most important in influencing the decision to choose the salina campus were: the desire to work one-on-one with attendings and residents, small class size, and highquality core clinical experiences. the factors ranked moderately important were the desire to practice in a community the size of salina or smaller, the desire to receive individualized attention from the faculty/faculty mentors, a good “gut feeling” about the campus, the location of the campus in a rural community, and a short commute to school. the factors that were least influential in choosing the salina campus included: proximity to the student’s hometown, school/campus reputation, easy parking, opportunities for leadership roles, family medicine specialty emphasis, positive experience during the medical school interview, the history of salina graduates matching in top residency, family influences, campus differences in presentation of curriculum, few distractions outside of school, campus facilities, salina community assets, salina campusspecific scholarships , and research opportunities. we did not attempt to determine statistically significant differences in responses between current students and graduates; however, it was noted that there was relatively close agreement in ranking of responses to nearly all questions. journal of regional medical campuses, vol. 4, issue 2 original report table 2. factors influencing the decision to attend kusm-salina students and graduates were asked to provide text comments regarding their choice of the salina campus (table 3). among the respondents who ranked kusmsalina as their first choice, open-ended responses echoed similar themes: a desire to live in a small town, a desire for a small class size, studying on a campus close to home, kusm-salina’s history of providing frequent hands-on experiences, one-on-one experiences with attendings, and an interest in rural medicine. for those who did not rank salina as their first choice of kusm campuses, open-ended responses included: location far from home, foundational science lectures presented by interactive televideo (itv) conferencing rather than in person, less access to a wide range of specialties, and lack of knowledge about the kusm-salina campus. table 3: selected open-ended responses regarding factors influential in choosing kusm-salina one section of the survey was designed to determine how well the salina rmc delivered on the students’ expectations (table 4). elements of the educational experience were segregated into three ranges: 1) high satisfaction (≥75% of current students and graduates selected a likert score of 4 or 5 score = satisfied or very satisfied), 2) moderate satisfaction (50-74.9% of each group of respondents selected a 4 or 5 score), and 3) low satisfaction (≤50% of each group of respondents selected a 4 or 5 score). students were highly satisfied with the cost of living in salina, the exposure to attendings and residents in clinical years, the salina campus building and equipment, the exposure to specialties and sub-specialties in clinical years, and virtual lectures via itv. students were moderately satisfied with the salina clinical simulation lab, student health services provided locally, accessibility to student resources (i.e. library, financial aid, educational support), social environment/opportunities in salina during free time, the living space/housing options in salina, campus diversity, and assistance with financial aid/debt management questions. issues associated with lower levels of satisfaction were research opportunities, academic counseling services provided in salina and/or virtually by kansas city staff, number of student interest groups on campus, mental health services provided in salina, and residency program information provided on the salina campus (process, lifestyle, choices, etc.). journal of regional medical campuses, vol. 4, issue 2 original report table 4. current student and graduate satisfaction with kusm-salina discussion the salina rural rmc was particularly appealing to students from rural communities who eventually wanted to return to rural communities to practice. interestingly, interview site and the interview itself had a minor influence on campus choice, leading the authors to conclude that neither visualizing the campus nor the interviewer or interview process were major factors influencing campus selection. reputation and location were identified as important factors influencing school choice in multiple previous studies.1-4, 5-9 although the general topic of school or campus reputation was not a major factor influencing campus choice in this study, the reputation of the kusm-salina campus for specific attributes (small classes, high-quality core clinical experiences, and working one-on-one with attendings and residents) was important in campus choice. interestingly, in contrast to the findings of mihalynuk et al,10 family pressures had little influence on salina campus choice. also, the fact that kusm-salina offered a minimum of $5 000/year in scholarship support was not an important factor in campus choice. the cost of a medical school education is not trivial; however, participation by many kusm-salina students in the kansas medical student (kms) loan program may negate the need for scholarship awards. the kms loan program, offered to all kusm students, funded by the state of kansas and administered by kusm, pays tuition expenses and provides a modest living allowance during medical school. loans are totally forgiven if the recipient elects to practice primary care in one of 100 rural counties or the single underserved urban county in kansas. the majority of kusm-salina students are interested in rural primary care; therefore, a kms loan provides an excellent means to fund an expensive medical education. historically, 57% of kusm-salina graduates elected to receive kms loans to fund all or part of their medical education.19 in 2018 the kusm-salina moved from old and crowded quarters to a larger, completely remodeled, state-of-theart medical school building. it was anticipated that this new health education center would be a major draw for the current medical student group (classes of 20212023). surprisingly, the new facilities had minimal impact on campus choice for those students who would use it. a significant number of respondents were disappointed with the delivery of a number of support services: campus mental health services, academic counseling services, residency program information provided, research opportunities, and campus student interest groups. kusm-salina provided mental health services through a local behavioral health center, as well as via secure, confidential telehealth services provided by the main campus. whether respondents were fully informed regarding these services and/or dissatisfied with them is unknown. respondents also voiced dissatisfaction with academic counseling services. access to a learning specialist is available on campus and through the main campus in kansas city. it is unknown whether respondents were not fully cognizant of what the learning specialists could provide or were just dissatisfied with the services received. respondents were not satisfied with the information provided about residency programs and the residency application process. although there was not a designated kusmsalina campus office or faculty member to handle residency questions and concerns, the local kusm-salina faculty was available to provide information regarding residency programs and the residency application journal of regional medical campuses, vol. 4, issue 2 original report process. once again, respondents may not have realized what was available or wanted more than provided. despite the fact that no respondents identified research opportunities as an important factor in choosing the salina campus, after matriculation the majority of respondents were dissatisfied with the research opportunities offered. it is possible that once students realized that research experiences/scholarly engagement could be an important factor in competing for residency positions, their opinions regarding research opportunities changed dramatically. therefore, once on campus, they found the kusm-salina campus lacking in this respect. opportunities for leadership roles was another area deemed less important for prospective kusm-salina students; however, once on campus, opinions changed. although the salina campus offered students the opportunity to serve in tri-campus student government organizations, the opportunities to participate in a wide variety of campus student interest groups was limited and this was disappointing. student interest groups and student government organizations provide opportunities for students to meet other students with similar interests and assume leadership positions. engagement in such organizations may also strengthen their resume for residency positions. conclusion the small rural kusm rmc in salina has a 10-year history of providing a full 4-year allopathic medical education to a select group of students. although the small group of current students and graduates surveyed might be criticized, the response rate was nearly 75% and the results provided insight into what factors influenced the decision to choose a particular campus, what factors were less important, and how well that campus met student expectations. over 75% of respondents found kusm-salina’s small class size, strong clinical program, and one-on-one relationships with faculty attractive, and this campus met their expectations regarding these issues. our findings amplify previous reports that, when faced with the decision to choose a medical school or choose between medical school campuses, students are influenced by the school’s academic reputation and location. in addition, as noted by cecelia brown et al,2 students may be attracted by “intangible factors”— perhaps the “good gut feeling” noted by 70% of respondents in this study. the salina campus is not perfect. there is room for improvement in providing student research opportunities, expansion of student interest groups, delivery of mental health services, providing academic counseling, and providing information regarding residency programs and the process of residency application. the importance and methods of providing student support services at kusm-salina were previously reported by kollhoff et al.22 despite mechanisms established to address the support services required by the liaison committee on medical education and, more importantly, demanded by students, kusm-salina needs to review and redress several elements. identifying these deficiencies provides impetus to the kusm-salina administration to seek solutions, whether it be improved communication regarding what is available, or improvement/expansion of services provided. the lessons learned by kusm-salina are important in improving strategies for recruiting students to a rural rmc and providing them with an exceptional educational experience. kusm-salina was most attractive to students from rural communities who were interested in eventually returning to rural communities to practice. recruitment efforts should be focused on, although not entirely limited to, this cohort. in addition, promotional materials should emphasize what current and previous students have found most attractive about the rural rmc and what the rmc has historically delivered—small class size, quality clinical experiences, and working one-onone with clinical faculty. it may be difficult for rmcs to provide a robust array of research opportunities and interest groups, as well as other student support services, but they cannot ignore these important elements in the education, health and happiness of students. our findings may benefit other medical schools with rural rmcs in improving their programs and attracting the best students. references 1. wouters a, croiset g, schripsema nr, et al. students’ approaches to medical school choice: relationship with students’ characteristics and motivation. int j med educ. 2017 jun 12; 8:217-226. doi: 10.5116/ijme.5921.5090. pmid: 28624778. 2. brown c. a qualitative study of medical school choice in the uk. med teach. 2007 feb; 29(1):27-32. doi: 10.1080/01421590601032419. pmid: 17538829. journal of regional medical campuses, vol. 4, issue 2 original report 3. foster k. medical school choice: what influences applicants? clin teach. 2014;11(4):307-310. doi: 10.1111/tct.12146. 4. mcmanus ic, winder bc, sproston ka, styles va, richards p. why do medical school applicants apply to particular schools? med educ. 1993; 27(2):116-123. doi: org/10.1111/j.13652923.1993.tb00241.x. 5. roath s, miller ed, kilpatrick gs, et al. factors influencing students’ choice of medical schools. med educ. 1977; 11:319-323. doi: https://doi.org/10.1111/j.13652923.1977.tb00621.x. 6. adams t, garden a. what influences medical school choice? med teach. 2006; 28(1):83-85. doi: 10.1080/01421590500313027. pmid: 16627331. 7. zhang k, xierali i, castillo-page l, nivet m, conrad ss. students’ top factors in selecting medical schools. acad med. 2015;90(5):693. doi: 10.1097/acm.0000000000000537. pmid: 25406605. 8. halstead ls, geertsma rh. the evaluation and selection of a medical school: a student perspective. british j of med ed. 1973 jun; 7(2):94-99. doi: 10.1111/j.1365-2923.1973.tb02221.x. pmid: 4725064. 9. jones gi, dewitt de, cross m. medical students’ perceptions of barriers to training at a rural clinical school. rural remote health. apr-jun 2007; 7(2):685. epub 2007 may 28. pmid: 17532726. 10. mihalynuk t, snadden d, bates j, et al. size matters: what influences medical students’ choice of study site? med teach. 2008; 30(4):e108-e114. doi: 10.1080/01421590801931170. pmid: 18569653. 11. krahe l, mccoll a, pallant j, cunningham ce, dewitt de. a multi-university study of which factors medical students consider when deciding to attend a rural clinical school in australia. rural remote health. jul-sep 2010; 10(3):1477. epub 2010 sep 9. pmid: 20828219. 12. cathcart-rake wf, robinson m, owings cs, kennedy m, paolo a, chumley h. the birth of a rural medical school—the university of kansas school of medicinesalina experience. med sci educ. 2012; 22(4): 250-258. doi: https://doi.org/10.1007/bf03341793. 13. cathcart-rake w, robinson m, paolo a. from infancy to adolescence: the kansas university school of medicine– salina: a rural medical campus story. acad med. 2017; 92(5):622-627. doi: 10.1097/acm.0000000000001455. pmid: 27805948. 14. nguyen eh. factors contributing to the university of kansas school of medicine graduates’ choice of specialty and practice location [dissertation]. department of educational leadership and policy studies, university of kansas; lawrence, ks: 2013. 15. easterbrook m, godwin m, wilson r, et al. rural background and clinical rural rotations during medical training: effect on practice location. cmaj. 1999 apr 20;160(8): 1159–1163. pmid: 10234346. 16. rourke jt, incitti f, rourke ll, kennard m. relationship between practice location of ontario family physicians and their rural background or amount of rural medical education experience. can j rural med. fall 2005; 10(4):231–240. pmid: 16356384. 17. walker j, dewitt d, pallant j, cunningham ce rural origin plus a rural clinical school placement is a significant predictor of medical students’ intentions to practice rurally: a multi-university study. rural remote health. 2012; 12:1908. epub 2012 jan 9. pmid: 22239835. 18. laven g, wilkinson d. rural doctors and rural backgrounds: how strong is the evidence? a systematic review. aust j rural health. 2003 dec; 11(6): 277-284. doi: 10.1111/j.1440-1584.2003.00534.x. pmid: 14678410. journal of regional medical campuses, vol. 4, issue 2 original report 19. cathcart-rake w. producing physicians for rural kansas; the early success of the university of kansas school of medicinesalina regional medical campus. j regional med campuses. 2020; 3(1). doi: https://doi.org/10.24926/jrmc.v3i1.2314. 20. harris pa, taylor r, thielke r, et al. research electronic data capture (redcap) – a metadata-driven methodology and workflow process for providing translational research informatics support, j biomed inform. 2009 apr; 42(2):377-81. epub 2008 sep 30. doi: 10.1016/j.jbi.2008.08.010. pmid: 18929686. 21. harris pa, taylor r, minor bl, et al. the redcap consortium: building an international community of software partners, j biomed inform. 2019 jul; 95:103208. epub 2019 may 9. doi: 10.1016/j.jbi.2019.103208. pmid: 31078660. 22. kollhoff l, kollhoff m, cathcart-rake w. providing support services for medical students on a rural regional medical campus. med sci educ. 2015; 25:157162. doi: 10.1007/s40670-015-0108-8. microsoft word physicianpracticelocationarticle.docx published by university of minnesota libraries publishing physician practice location—an examination of physician workforce data sources, their spatial concordance and reliability emily onello m.d.; patrick bright m.a.; james boulger phd doi: https://doi.org/10.24926/jrmc.v2i5.2141 journal of regional medical campuses, vol. 2, issue 5 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc emily onello m.d.; university of minnesota medical school, duluth campus patrick bright m.a.; university of minnesota medical school, duluth campus james boulger phd; university of minnesota medical school, duluth campus corresponding author: emily onello m.d.; university of minnesota medical school, duluth campus 1035 university drive, duluth, mn 55812-3031; econello@d.umn.edu all work in jrmc is licensed under cc by-nc volume 2, issue 5 (2019) journal of regional medical campuses original reports physician practice location—an examination of physician workforce data sources, their spatial concordance and reliability emily onello m.d.; patrick bright m.a.; james boulger phd abstract purpose: this study compares and contrasts locational identification (physician practice zip code) between several physician demographic databases and a research team-verified zip code to determine spatial concordance. accuracy of physician location data is critical for both successful national physician workforce planning and for assessing the fulfillment of distinct regional medical school missions. methods: three physician databases; the american medical association’s physician masterfile, the national provider and plan enumeration system (nppes), and the minnesota board of medical practice’s licensure file were compared against each other as well as a set of actively verified practice location zip codes. a sampling frame of medical school alumni from 2003 to 2014 was selected. the sample included alumni from both regional and main campuses. from this alumni sample, a random sample of 400 individuals were selected for closer examination. descriptive frequencies are presented for the concordance of zip codes for the sample of 400 alumni. findings: from an initial cohort of 2 605 university of minnesota medical school alumni, a sample of 400 who also possessed a minnesota medical license were randomly selected to examine concordance rates. the highest rate of concordance was the verified zip code and the minnesota licensure board practice zip code at 68.8%. only 42% of practice location zip codes matched across all databases. conclusions: the concordance rate across practice zip codes in the databases does not inspire confidence in ability to characterize true physician practice location. some of the difficulties in defining, identifying, and maintaining information on physician practice location are discussed. without accurate and precise practice location information, the development and implementation of comprehensive national health policies for the united states may face difficulties. the lack of reliable physician practice location data also presents a challenge to regional medical school campuses that depend upon accurate physician location data to evaluate progress toward mission-directed workforce goals. introduction in the united states health care system, physician location is important “to demonstrate to lawor policy-makers the geographic distribution of the health care workforce to assist them in making appropriate, evidence-based decisions…(and) to identify areas of potential need for certain medical specialties for purposes of creating effective workforce strategies to expand patient access to care”.1 policy decisions that utilize spatial data have had major impacts on federal and state programs and policies that attempt to alleviate health workforce imbalances and to address population health inequities.2,3 studies have examined physician location in several contexts, ranging from the effectiveness of medical education in reducing disparities and contributing to rural health,4,5 to retention and workforce movement patterns,6,7 and the role of spatial access to care and outcomes.8 having correct locational data has major implications in relation to all of the efforts listed. for regional medical campuses especially, knowledge of physician location is critical towards the fulfilling the mission of the campus, such as training doctors to practice in rural or other targeted underserved communities. in light of the importance of physician location, the validity of major physician databases is a concern. a major source of physician spatial data is the american medical association’s (ama) physician masterfile, which is the primary source of data on u.s. physicians. the ama masterfile staff collects and attempts to keep updated information on physicians from the time of entry to medical school through their practice career.9 many studies have utilized the masterfile to study and analyze practice patterns and characteristics of the u.s. workforce.3–6,10–13 the common, oft-cited expectation is that reports have been accurate and necessary in the development of state, regional, and national health workforce policy development. this may not be the case when the validity of the data utilized is examined. knowing where physicians are practicing and whether databases that journal of regional medical campuses, vol. 2, issue 5 original reports are utilized for this purpose are accurate and concur is essential for such policy development. several studies have raised the concern that the ama masterfile may not be accurate enough to assist in the development of health policy or to understand physician shortages in their full extent.5,14–18 desroches et al. (2015) sampled 3 000 physicians from the national provider and plan enumeration system (nppes), and compared the listed addresses with the masterfile, and with the data available from sk&a (by iqvia, a private data-consulting firm). the ama masterfile had a low rate of matching practice address as listed by the nppes (32% to 54% depending upon specialty). the nppes and sk&a had higher address concordance rates (72% to 94% and 79% to 92% respectively, across specialties). however, henderson (2015) noted that desroches et al.’s methodologic use of the ama’s physician preferred address prevented a meaningful comparison of the databases since the physician’s preferred address is subjectively provided by the physician and by definition could vary from practice zip, home residence zip, or other location. (the ama allows physicians to indicate a preferred mailing address, which may not be a physician’s actual practice address).19 henderson asserts that comparing this address to that in the nppes and sk&a databases may have resulted in lower match rates. freed et al. (2006), while assessing the distribution and number of pediatric cardiologists, found that only 58% were listed by both the ama masterfile and the american board of pediatrics. of the 42% not in both databases, an additional 28% were only listed in the ama masterfile and 4% percent by only the board. mclafferty et al. (2012), similarly to henderson, noted that some unknown number of physicians report a home mailing address to the masterfile rather than a work address. reporting physician home address will result in misclassification of the physician in the workforce to an unknown degree. however, other studies affirm the extensive work that is performed by the ama’s division of health solutions data management. some have verified generally strong concordance with other physician databases.7,20–22 given the concerns raised on the validity of these data sources, a closer examination on the spatial aspects is warranted. this study aims to identify the degree of concordance between data sources for physician practice location, in terms of spatial location in the form of zip codes. zip code analyses are frequently used by state and federal agencies in delineating areas by their demographic, socioeconomic, cultural, and environmental characteristics.23 zip codes have often been used to create taxonomies such as the rural-urban commuting area codes (rucas) for delineating rural and urban areas.24 state medical licensure boards offer another source of physician location zip code data that may be higher in accuracy and validity, though few studies have compared licensure location data to other datasets. a recent study by bell et al. (2018) examined a sample of south carolina physician and nurse practitioner state license address data for correspondence to their place of employment, which was set as the location recorded in the national committee for quality assurance patient-centered medical home (pcmh) provider file. comparisons were also made to national provider identifier (npi) file zip code data. at the zip code level, physician state license data was found to have an 85.5% concordance rate with the pcmh location and 88.2% concordance rate with the physician npi file data. (interestingly, similar zip code comparisons for nurse practitioners between state license zip code data, pcmh file, and npi data demonstrated concordance rates of 35.8% and 76.5%, respectively).25 the study presented here uses a large cohort of medical school alumni that includes a regional medical campus. actual physician practice location was compared to the practice address listed in 3 major datasets (ama masterfile, nppes’s national provider identification (npi) number, and minnesota board of medical practice licensure file) in order to investigate the validity of the data sources. materials and methods our initial study population was 2 605 medical school alumni from the university of minnesota (umn) medical school graduating in 12 consecutive classes (2003-2014). the study intentionally included the span of 12 graduating classes using a cut-off date at least 3 years prior to the research study for 2 purposes: 1) to establish a large enough data set from which to randomly select the actual study sample of 400 alumni, and 2) to allow time for the majority of the alumni physicians to have completed residency and established their chosen medical practice location, thereby minimizing the chances of including physicians who are still in residency training. graduates from the study timeframe’s final year (2014) would have completed a 3-year residency (2014-17) and selected an initial practice location by the time of data collection in early 2018. the list of university of minnesota medical school graduates was assembled from the published national resident matching program (nrmp) match list and the printed graduation programs of the medical school. the list was then compared by name to each of the data sources (ama masterfile, nppes/npi, mn board of medical practice) to see if each graduate was identified in the data source. three datasets were chosen for our analysis of physician spatial location concordance: 1) the ama masterfile. the masterfile is publicly available and was purchased from medical marketing services, an official broker for the ama. among many other data elements, the ama masterfile includes the physician’s current office zip code. data was pulled from the masterfile on january 18, 2018; officezip was the zip code variable utilized (“office_zip”). journal of regional medical campuses, vol. 2, issue 5 original reports 2) the national plan and provider enumeration system’s (nppes). national provider identifier (npi) file was downloaded from the centers for medicare & medicaid services (cms) website in january 2018 and included the current practice zip code (“praczip”). 3) minnesota board of medical practice’s licensure file. data on physicians with a minnesota (mn) medical license was obtained on march 14, 2018 via a data request to the minnesota board of medical practice. this data included office zip code information on file with the license board (“zip”). the decision to utilize primary practice zip codes as our unit of analysis was made for several reasons. practice zip code was found across all 3 datasets, ensuring a common variable for analysis. this is also an attempt to address the concerns of henderson (2015), when comparing the databases by using office location rather than the physicians preferred address. the data obtained from the ama masterfile did not include the street address for identification purposes; only the practice zip code. practice zip codes were determined to be a reasonable approximation of location, noting that use of the actual street address could be too granular with the potential to overestimate the mismatch rates of physician location between datasets. for example, a physician may have a practice address at a hospital with one street address, but may also have an outpatient clinic practice address in a different clinic building on the same hospital campus with a different street address. however, both practice locations should share the same zip code. lastly, zip codes were utilized as they are adequate for workforce planning. of the initial 2 605 alumni physician population, 1 384 physicians held a minnesota license. this sub-group of alumni with mn medical licenses could be tracked using both the minnesota board of medical practice location data along with the ama masterfile and the npi sources. from this group of 1 384 minnesota license holders, a sample of 400 alumni was randomly selected ensuring 95% confidence of being within 5% of the true population count.26 a representative subsample was utilized due to the logistical barriers of actively verifying the practice addresses of all 1 384 alumni holding a minnesota license. in early 2018, the research team worked to actively over a period of several weeks to verify the practice zip code for each graduate in the sample of 400. practice addresses and zip codes were verified using hospital and clinic websites, professional network websites such as doximity and linkedin, and contact via social media. in addition, direct personal knowledge of graduates was utilized to characterize location, including face-to-face encounters between alumni and research team members during site visits to practice locations, alumni networking events, statewide medical conferences. in addition to these face-to-face meetings, phone conversations were used to establish the verified practice location. this process was used to establish the physician’s updated and verified practice location and represented our best effort to obtain current physician location data. once this actively verified practice zip code was ascertained, it was compared to the zip codes of the ama, npi, and state medical board zip codes of practice. if the verified zip code matched, a designation of “match” was given, otherwise the comparison was coded as “no match”. the following pairings were contrasted: 1. ama office zip code to npi practice zip code. 2. ama office zip code to minnesota license board zip code. 3. ama office zip code to verified zip code. 4. npi practice zip code to minnesota license board zip code. 5. npi practice zip code to verified zip code. 6. minnesota license board zip code to verified zip code. if the practice zip code was identical across all the datasets, locations were coded as “complete match”. results of the 400 alumni randomly sampled, the following was found: 36 (9%) had no ama office zip code, 1 (0.2%) had no npi practice zip code listed, and 16 (4%) we were unable to verify their practice zip code. comparisons between the data sets and the verified zip code demonstrated a range of zip code concordance rates. as figure 1 shows, the highest concordance rate was between the verified zip code and the mn license board zip at 68.8%. only 42% of the sample had a complete zip code match across all 4 data sets. figure 1. percent agreement: zip code data sources the 2 national level datasets, the ama masterfile and the nppes, had a 63.3% zip code match rate. notably, the masterfile had only a 58.3% match to the minnesota license board and a 59% match to the verified zip code, while the journal of regional medical campuses, vol. 2, issue 5 original reports nppes was marginally better with a 64.5% match to the verified zip code. differences between all the pairs were significant (χ2= 71.65, p<.001). these results clearly illustrate a difference in agreement between datasets when examining the practice zip code for concordance. the best agreement is that of the minnesota state license board zip with our verified zip code of 68.8%. of concern, this still leaves a strikingly high amount of nonmatched practice addresses (31.2%). the finding that the minnesota board of medical practice’s licensure file provided the best match rate with the verified practice zip code was not surprising. the minnesota board requires annual online renewal of medical licensure. as part of each physician’s renewal application, updated practice information is requested and subsequently provided by the physician. unlike the ama masterfile or the nppes databases, the minnesota state license board information is certain to be reviewed annually at a minimum. discussion this study illustrates a discord between major physician databases that have been used to develop and determine national health positions and policies. these findings suggest an urgent need for a standardized nationwide data repository, valid and freely available, in order to identify exact physician practice location. to achieve this universal standard, more precise definitions of physician practice location will be required. a major conceptual issue that remains unclear is the definition of a physician’s “place”. is this where they spend the majority of their time in practice? what if a physician is primarily an urban physician but also practices one day a week in a rural location? should this physician be counted as a rural physician despite not spending the majority of his/her time there? some physicians, such as anesthesiologists for example, may practice in multiple locations within a given city or municipality (providing services at multiple hospitals or outpatient facilities), introducing ambiguity when attempting to assign a static definition of “place” to these practices. the rise of health systems has further muddled the concept of “place”. these systems may utilize a central billing address for their physicians, some of whom may practice in multiple locations or in a satellite location distant from the central billing address. do we count the physical location of the physician or the billing address as their “place”? this kind of ambiguity in defining a physician’s place can have important implications for policy makers and public health strategists who interpret and plan around physician workforce data sets. again, establishing and applying standardized definitions of physician practice location across datasets could reduce such ambiguities. one potential alternative to improve data accuracy would be to acquire data from other sources such as professional medical specialty societies, such as the american academy of family physicians. professional medical societies generally require annual membership renewal by the member physician. in addition, many of these societies require physicians to keep up maintenance of certification to retain their board certification in a given specialty. it is likely that the professional relationship propinquity may well improve the validity of the address communications. further studies are required to ascertain potential means of improvement. this study does have several limitations. the first limitation is that the data sets were not acquired simultaneously from the 3 separate sources (ama and nppes in january 2018 and mn board of medical practice in march 2018). but given the relative stability of physician practices, it is unlikely that the 2-month difference introduced a significant amount of mismatch between datasets. the selection of zip code as the locator variable is not without complexity, as discussed earlier, as there are multiple potential classifications of zip code. for example, the ama masterfile includes 2 variables for zip code: mailzipcode, officezip. (the mailzipcode variable included 4 subcategories: physician’s home zip code, physician’s homeoffice zip code, physician’s office zip code, or unknown). this study used officezip only, as it provided a more consistent and less confusing method of geographic location. selection of the more specific zip code variable addresses the concern of mclafferty et al. (2012) and henderson (2015) of potential ambiguity of actual practice location if this variable is utilized to classify practice location. the study relies on an actively verified zip code that was established by exhaustive inquiry and cross-checking. while there is no clear metric to provide absolute confirmation of the veracity of our attempt at verifying physician location, these methods used to locate the physicians should result in a more valid determination of physician practice location than intermittent self-report by physicians or their employers to national organizations. additionally, regional medical campuses may have more detailed personal knowledge of their graduates than larger central campuses due to smaller class sizes characteristic of regional medical schools. another study limitation is that there were a few graduates who could not be located. some of the followed graduate cohort did not have an office zip code on file in the masterfile, or did not have a zip code listed in the nppes database. reliance upon manual searching for missing graduate practice data and a lack of an nppes npi number for identification did introduce a margin of error about current practice information. several instances of mismatches occurred as a result of the physician’s maiden names which was not at times reflected in the nppes database. furthermore, it is possible that a few of the graduates who could not be located may not have “officially” graduated, even if they had been listed in the medical school’s printed graduation ceremony program. similarly, some of the graduates may not have ever actually entered medical practice in the united states, despite earning the degree of journal of regional medical campuses, vol. 2, issue 5 original reports medical doctor. the total number of alumni who could not be located was very small in relation to the overall cohort and it is unlikely that this small number exerted any significant influence on the resulting analysis. while this study revealed that the minnesota board of medical practice data demonstrated the highest match rate with the verified physician location, the accuracy of state licensing board information may vary in other states. some state boards do not update annually, but do so less frequently, which could result in higher mismatch rates. conclusion surprisingly low concordance rates were found between data sources for physician practice location when comparing zip code data across the ama masterfile, the nppes npi database, and minnesota state board of medical practice against a verified standard. state licensing board data demonstrated the highest rate of agreement with verified data. our study confirms earlier findings that suggest it is more difficult to identify current physician practice location than previously thought. findings such as this have major implications for policy makers who utilize national level datasets for workforce decisions. furthermore, incorrectly attributing a physician’s practice location to an incorrect zip code will distort the picture of the workforce landscape. this also has the potential to make it more difficult to accurately characterize the effect of regional medical campus graduates on workforce needs in rural and underserved areas of the u.s. it is hoped that attention to this finding of spatial discord (in terms of reliability and validity), will result in the recognition of the importance of strong efforts to provide better information to policy and decision makers for not only the good of the general population but to correctly ascertain the positive effects regional medical schools have across the landscape. references 1. american medical association. health workforce mapper. https://www.amaassn.org/about/research/health-workforce-mapper. published 2018. accessed march 1, 2019. 2. american academy of family physicians. geographic distribution of primary care physicians affects health care, says policy brief. https://www.aafp.org/news/governmentmedicine/20130620geodistpolicy.html. published 2013. accessed august 13, 2018. 3. rosenthal mb, zaslavsky a, newhouse jp. the geographic distribution of physicians revisited. health serv res. 2005;40(6 i):1931-1952. doi:10.1111/j.1475-6773.2005.00440.x 4. chen fm, fordyce ma, andes s, hart lg. u . s . rural physician workforce : analysis of medical school graduates from 1988-1997. 2008;(october). 5. ko m, heslin kc, edelstein ra, grumbach k. the role of medical education in reducing health care disparities: the first ten years of the ucla/drew medical education program. j gen intern med. 2007;22(5):625-631. doi:10.1007/s11606-007-0154-z 6. cullen tj, hart lg, whitcomb me, rosenblatt ra. the national health service corps: rural physician service and retention. j am board fam pract. 1997;10(4):272-279. http://www.ncbi.nlm.nih.gov/pubmed/9228622. accessed august 15, 2018. 7. ricketts tc, randolph r. urban-rural flows of physicians. j rural heal. 2007;23(4):277-285. doi:10.1111/j.1748-0361.2007.00104.x 8. wan n, zhan fb, zou b, wilson jg. spatial access to health care services and disparities in colorectal cancer stage at diagnosis in texas. prof geogr. 2013;65(3):527-541. doi:10.1080/00330124.2012.700502 9. american medical association. ama physician masterfile. https://www.ama-assn.org/lifecareer/ama-physician-masterfile. published 2018. accessed august 15, 2018. 10. kletke pr, marder wd. the supply of renal physicians: an analysis of data from the american medical association physician masterfile. am j kidney dis. 1991;18(3):384-391. doi:10.1016/s02726386(12)80100-4 11. waters tm, lefevre f v, budetti pp. medical school attended as a predictor of medical malpractice claims. qual saf health care. 2003;12(5):330-336. doi:10.1136/qhc.12.5.330 12. schwartz mr. the physician pipeline to rural and underserved areas in pennsylvania. j rural heal. 2008;24(4):384-389. doi:10.1111/j.17480361.2008.00185.x 13. lango mn, handorf e, arjmand e. the geographic distribution of the otolaryngology workforce in the united states. laryngoscope. 2017;127(1):95-101. doi:10.1002/lary.26188 14. konrad tr, slifkin rt, stevens c, miller j. using the american medical association physician masterfile to measure physician supply in small towns. j rural heal. 2000;16(2):162-167. doi:10.1111/j.17480361.2000.tb00450.x 15. freed gl, nahra ta, wheeler jrc. counting physicians: inconsistencies in a commonly used source for workforce analysis. acad med. 2006;81(9):847-852. doi:10.1097/00001888200609000-00017 journal of regional medical campuses, vol. 2, issue 5 original reports 16. mclafferty s, freeman vl, barrett re, luo l, shockley a. spatial error in geocoding physician location data from the ama physician masterfile: implications for spatial accessibility analysis. spat spatiotemporal epidemiol. 2012;3(1):31-38. doi:10.1016/j.sste.2012.02.004 17. desroches cm, barrett ka, harvey be, et al. the results are only as good as the sample: assessing three national physician sampling frames. j gen intern med. 2015;30(s3):595-601. doi:10.1007/s11606-015-3380-9 18. xierali im. physician multisite practicing: impact on access to care. j am board fam med. 2018;31(2):260-269. doi:10.3122/jabfm.2018.02.170287 19. henderson m. assessing the accuracy of three national physician sampling frames. j gen intern med. 2015;30(10):1402-1402. doi:10.1007/s11606015-3483-3 20. cherkin d, lawrence d. an evaluation of the american medical associaiton’s physician masterfile as a data source--one state’s experience. med care. 1977;15(9):767-779. http://www.ncbi.nlm.nih.gov/pubmed/578284. accessed august 15, 2018. 21. werner rm, polsky d. comparing the supply of pediatric subspecialists and child neurologists. j pediatr. 2005;146(1):20-25. doi:10.1016/j.jpeds.2004.08.061 22. vanasse a, ricketts tc, courteau j, orzanco mg, randolph r, asghari s. long term regional migration patterns of physicians over the course of their active practice careers. rural remote health. 2007;7(4):812. doi:812 [pii] 23. onega t, weiss je, alford-teaster j, goodrich m, eliassen ms, kim sj. concordance of rural-urban self-identity and zip code-derived rural-urban commuting area (ruca) designation. j rural heal. 2019;0:jrh.12364. doi:10.1111/jrh.12364 24. hart lg, larson eh, lishner dm. rural definitions for health policy and research. am j public health. 2005;95(7):1149-1155. doi:10.2105/ajph.2004.042432 25. bell n, lòpez-defede a, wilkerson rc, mayfieldsmith k. precision of provider licensure data for mapping member accessibility to medicaid managed care provider networks. bmc health serv res. 2018;18(1):974. doi:10.1186/s12913-018-3776-4 26. mcgrew jc, monroe cb. an introduction to statistical problem solving in geography: second edition. second. long grove: waveland press; 2009. microsoft word alongitudinalmeasurearticle.docx published by university of minnesota libraries publishing a longitudinal measure of medical student empathy at a regional campus: are we different? could this be a valuable evaluation method for curriculum change? william j. crump, md; craig h. ziegler, phd.; r. steve fricker. mpa doi: https://doi.org/10.24926/jrmc.v4i1.3475 journal of regional medical campuses, vol. 4, issue 1 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc william j. crump, m.d., associate dean of the university of louisville trover campus at baptist health madisonville, madisonville, ky craig h. ziegler, ph.d., biostatistician with the university of louisville school of medicine office of graduate/undergraduate medical education, louisville, ky r. steve fricker. m.p.a., director of rural health/student affairs of the university of louisville trover campus at baptist health madisonville, madisonville, ky corresponding author: william j. crump, m.d. associate dean, university of louisville trover campus at baptist health madisonville 200 clinic drive, third north madisonville, ky 42071; p. 270.824.3515 f. 270.824.3590 e. bill.crump@bhsi.com all work in jrmc is licensed under cc by-nc volume 4, issue 1 (2021) journal of regional medical campuses original reports a longitudinal measure of medical student empathy at a regional campus: are we different? could this be a valuable evaluation method for curriculum change? william j. crump, md; craig h. ziegler, phd.; r. steve fricker. mpa abstract introduction empathy is an important characteristic of the ideal physician. various quantitative measures of empathy have shown a steep decline during the third year of medical school. methods we had 4 classes of medical students at our regional rural campus complete the jefferson scale of empathy after each of the first 3 years. we report longitudinal results of 30 students, individually matched, including an analysis by gender. separately, we report the cross-sectional results for 39 of our students as they began medical school. we compare our student scores to other allopathic and osteopathic student scores from large urban campuses. the baptist health madisonville irb approved the protocol as exempt. results as they begin medical school, our students have similar scores to those at large urban campuses (difference of 1.1 points, p=.421). after the m-2 year, our students had significantly higher scores than those at urban campuses (5.7 points, p=.002) and after the m-3 year, they show an even larger positive difference (9.0 points, p<.001). as in previous publications, females had higher overall mean scores at each measure, but with our students this was only significant in post-m-2 measures (8.9 points, p=.01). discussion we conclude that something about our students’ experience during their m-3 year is associated with a smaller decline in empathy measures than reported previously. we propose that some of this difference could be due to a formal professional identity curriculum we implemented recently during the m-3 year. however, without a concurrent or historical control group, we cannot be certain. we offer the concept of measuring empathy before and after curricular change as another useful evaluation tool for medical educators. introduction empathy is widely regarded as a key characteristic of a good physician. defining this characteristic is difficult. questions remain as to whether it is more an emotional or cognitive process and how best to measure it. the most widely used and wellvalidated measure was produced by a group that views empathy as largely cognitive.1 higher values by students on this empathy measure have been associated with positive clerkship faculty ratings of student clinical competence2 as well as better clinical outcomes in patients with diabetes in physicians with higher scores.3-4 most studies have also shown that measures of empathy decline across the m-3 year.5 recent studies have addressed the role of empathy in the development of medical trainees’ professional identity.6 although preliminary, some show that reflection exercises such as composing narratives, organized study of art, film, music, and literature, and opportunities to practice mindfulness have a positive effect on empathy measures.7-10 the general trend, regardless of the instrument used, was that measured scores increased after the intervention, and some have shown that the change was sustained for at least 10 weeks.10 at our regional rural campus, we began a professional identity curriculum that we intended to mitigate the decrease in empathy seen in previous studies of medical students as journal of regional medical campuses, vol. 4, issue 1 original reports their education progressed.11-12 for our purposes we defined sympathy as “i feel your pain” and empathy as “i understand your suffering”. whereas someone cannot always perceive another’s internal empathy, we defined compassion as empathy in action where someone could infer that empathy is the motivation for a physician’s behavior. we designed and implemented a series of sessions with our m-3 students intended to reach our goal. for this effort, we needed a reliable measure of our students’ and residents’ empathy. after a review of the literature, it appeared that the jefferson scale of empathy (jse) was the best instrument for our use.3,13 most reports using the jse were cross-sectional in nature, sometimes measuring one class of students and sometimes measuring multiple classes but all at a single point in time.14-15 others have been longitudinal in nature, following groups of students matched to their individual results, measuring how the same repeated empathy measures changed across time in medical school years.1,16 in this study, we set out to measure the jse in 4 classes of students across the first 3 years of medical school, matched for their individual results. method the regional campus was established in a town of 20 000 in 1998 and hosts 6-8 students each year for the clinical years after they complete the first 2 preclinical years in an urban university environment 160 miles away.17-18 applicants indicate interest in our campus at the time of secondary application, and those with previous rural experience are interviewed at both campuses. a regional campus selection committee makes recommendations to the single school admissions committee, and the students are assigned to a campus at the time of admission. in recent years, we have received about 200 applications for our 8 positions each year. about 55% of graduates go on to practice in rural areas, with almost 50% choosing family medicine and almost 85% choosing generalist careers. beginning in the fall of 2015, the empathy survey was completed either just before the new academic year began, or just after it ended, resulting in an annual survey for each student. each survey had the student’s name included for later matching, and these were placed by the students into an envelope confidentially, and participants were assured that a research assistant unknown to them would place an id number and subsequently no one would be able to connect their responses to their name. about one student per year had to miss the required session, and a staff member then had each student who missed this conference complete the survey within 3 days, again with confidentiality preserved. for this sample of 30, only those students who had all 3 annual doi: https://doi.org/10.24926/jrmc.v4i1.3475 surveys completed were included. the results are from the graduating classes of 2018-2021. beginning also in the fall of 2015, a formal professional identity (pi) curriculum was implemented during the m-3 year after the students relocated to the regional campus, with one session per month of the recurring “dean’s hour” being dedicated to pi. we used the other twice monthly dean’s hour sessions for clinical reasoning case presentations and chart review of the student-directed free clinic patients. the dean himself facilitated the first year while developing the pi session content, with subsequent years done by the same campus md faculty across the m-3 year. that first year is not included in this matched data set. the pi curriculum was very similar to the residency pi curriculum previously reported from this campus.12 this included an overview session on foundational concepts of professional identity vs professionalism, burnout, cynicism, and sympathy vs empathy examples. subsequent monthly sessions focused on prevention and management of burnout, mindfulness techniques, and reflective writing and drawing. the latter included the career eulogy exercise previously reported from this campus,12,19, 20 as well as discussion facilitated by drawing a “comic” with stick figures and text balloons representing a “best” day and “worst” day of the student’s recent experience.21 students also completed this “best and worst” reflection in the second half of the year using blank art paper and watercolors, a particular student favorite. we summarized demographic information using frequencies and percentages. we compared jse scores between the regional campus and the jefferson medical college (jmc) in philadelphia1 at post m1, post m2, and post m3 years using independent-sample t tests at each time. because some classes had already begun when we started the project and to report a fully matched set of results, baseline measures were not included. however, we had baseline measures from subsequent classes that have not yet completed their m-3 year. we report that group of 39 students separately as a cross section baseline measure to address the issue of whether our students (who were largely from small towns and had chosen our rural campus) might have different jse scores at entry into medical school from those reported from other medical schools. for comparison, we used the only 2 similar studies that reported baseline measures. these were jefferson medical college in philadelphia1 and boston university.14 to assess if differences existed among the 3 schools on the baseline jse scores we performed a one-way analysis of variance. because all previous reports had shown significant gender differences in jse scores, we also assessed gender journal of regional medical campuses, vol. 4, issue 1 original reports differences for the regional campus at post m1, post m2, and post m3 using independent-sample t tests. we used ibm spss statistics for windows (version 26.0, 2019, ibm corporation, armonk, ny, 877-426-6006) to analyze the data. we created figures with the r package ggplot2.22 statistical significance was set by convention at p <0.05. the baptist health madisonville irb approved the protocol as exempt. results as shown in table 1, the majority of students in the matched set of the post m1, post m2, and post m3 scores were female (21/30 [70%]) and predominately white (28/30 [93%]). eightythree percent (25/30) of the students were from rural areas and 18/30 (60%) from what the authors considered very rural areas. table 1: demographics of students completing post m1 through post m3 jefferson scale of empathy freq (%) gender male 9 (30%) female 21 (70%) race white 28 (93%) asian 2 (7%) rurala yes 25 (83%) no 5 (17%) very ruralb yes 18 (60%) no 12 (40%) arural was defined as a hometown population of <30,000 and a non-metro rural urban continuum code (rucc).23 bvery rural was defined as a hometown population of <15,000 and a non-metro rural urban continuum code (rucc).23 as shown in figure 1, the regional campus and jmc jse scores do not differ at the post m1 measure, but significantly diverge at the post m2 and post m3 years. at post m2, the regional campus jse average is 5.7 points higher than the jmc, t=3.15, df=149, p=0.002. by post m3, this mean difference increased to 9.0, t=3.95, df=149, p<0.001. doi: https://doi.org/10.24926/jrmc.v4i1.3475 figure 1: jse means across medical school year comparing the regional campus to jmc.a athere were significant differences between institutions at the post m2 (p=0.002) and the post m3 (p<0.001) measures. error bars reflect 95% confidence intervals. for the regional campus, table 2 shows significant gender differences at the post m2 year on the jse, as females had higher scores than males (mean difference=8.9, t=2.75, df=28, p =0.010). at post m1 and post m3, the differences between genders are not significant, although females still have higher scores. doi: https://doi.org/10.24926/jrmc.v4i1.3475 journal of regional medical campuses, vol. 4, issue 1 original reports table 2: gender comparisons of the jefferson empathy scale for the post m1, post m2, and post m3 scores for the regional campus. post m1 post m2 post m3 n mean (sd) mean (sd) mean (sd) jefferson scale of empathy males 9 113.6 (6.8) 115.2 (8.3) 112.9 (8.3) females 21 119.7 (8.5) 124.1 (8.0) 119.4 (14.0) p-value 0.066 0.010 0.204 figure 2: jse means across medical school year by gender at the regional campus.a aa significant difference at post m2 was found between genders, p=0.010. post m1 and post m-2 differences were not significant. error bars reflect 95% confidence intervals. table 3 shows the jefferson scale of empathy baseline mean score for the urban schools and the regional campus. there are no significant differences among the 3 schools. table 3: comparison of baseline jefferson scale of empathy scores among the 3 schools baseline count mean (sd) p – value jefferson scale of empathy jmca 456 115.1 (10.0) 0.421 bub 658 115.5 (1.8) regional campus 39 116.3 (8.05) ajefferson medical college bboston university discussion our results show that our students at this rural regional campus start medical school with remarkably similar jse scores to those from 2 private northeastern metropolitan schools. in comparison to the only comparable published longitudinal study, our students beginning their m-3 year have significantly higher scores. the difference at the end of their m-3 year is even larger, while still showing the decrease that all previous studies, including cross sectional, have shown. our students also showed the same gender differences reported previously with the jse. we found the jse to be an effective tool, requiring about 5 minutes to complete. our standard deviations were also similar, but naturally larger because the sample size is smaller. we now have 5 years of experience with using it along with other surveys in our annual longitudinal database. our results suggest that something is different about our students’ early m-3 through the late m-3 measured empathy from previous reports. it is tempting to attribute this difference to our pi curriculum, which we focused during the m-3 year. the actual increase in scores post m-2 was almost entirely from those who identified as female. previous comparable studies actually showed a very small decrement from post m-1 to post m-2 of 0.9 points1 and 0.8 points.15 we do have a pathways component during the m-2 year that returns our students to their hometowns over the december holiday, and it is possible that this had a larger effect on female students.24 alternatively, there could have been something during the m-2 year while our students were at the urban campus that affected women more than men. this sample was almost 70% female, and all studies using the jse have shown higher scores in women. on average, our classes are about 50% female, so using a larger data set in future studies may provide more insight. overall, since our students began medical school with jse scores very similar to students from urban, more selective private schools, we conclude that something about our m-3 year does buffer the decline in the jse score in both genders. limitations and strengths as with almost all educational interventions, a systemic selection bias is a concern. our students really want to be at our campus, and so when they return, the buffering of the decline in jse scores could be from generally being more satisfied rather than truly a measure of empathy. the scale itself has well established internal consistency reliability as measured by cronbach’s alphas in the .75 range, and test-retest reliability of .60.13 socially desirable answers bias is also a possibility, and some studies have addressed this with the jse as well.15 to separate any effects of our pi curriculum from the general effects of our campus experience, it would have been ideal if doi: https://doi.org/10.24926/jrmc.v4i1.3475 journal of regional medical campuses, vol. 4, issue 1 original reports we randomized half of our students to a control group not receiving the pi curriculum exposure, something that is not feasible. in hindsight, even a historical control providing a comparison before the pi curriculum was begun would have been useful. findings from our use of this pi curriculum with our family medicine residents where we did have a baseline measure, however, provide some support that the pi curriculum is effective. those sessions were required and were on a different day of the week and week of the month each month. therefore, the only residents not attending the sessions were those on rotations requiring them to be out of town that day or those on the inpatient service which rotates monthly, so no systemic scheduling issue could be involved. in this situation where resident choice was removed, there was a clear trend toward smaller decrements in jse score associated with the number of sessions attended. residents who only attended 3 or fewer sessions decreased by a mean of 6.83 points while residents who attended 5 or more decreased only by a mean 0.38 points. residents who attended 4 or fewer sessions decreased an intermediate degree, by a mean of 4.50 points.12 the complete matching of individual results over time was a strength of that study, as it is with this one. there is also concern that our small, selected sample may not be generalizable to other campuses. however, a national study of almost 11,000 do students recently found that end of year m-3 do students showed a mean jse score within 1 point of ours, again almost 7 points higher than previously reported allopathic school jse results.15 future studies we continue to collect our longitudinal data including the jse and offer our process for consideration for use at other, larger and more diverse regional campuses. when we at regional campuses choose or are compelled to make curriculum changes, we are accustomed to completing careful program evaluations including traditional academic preand post-intervention quantitative measures and student satisfaction surveys. if entering classes share similar jse scores, it may be possible to use the jse as another evaluation measure of the effects of such curricular changes. comparison measures prior to the changes are of course preferred. as we accumulate larger data sets, we will look more closely at gender differences. we are also studying other measures of compassion longitudinally and will share those results when available. references 1. hojat m, vergare mj, maxwell k, brainard g, herrine sk, isenberg ga, veloski j, gonella js. the devil is in the third year: a longitudinal study of erosion of empathy in medical school. acad med. 2009;84(9):1182-1191. doi: 10.1097/acm.0b013e3181b17e55. erratum in: acad med. 2009 nov;84(11):1616. 2. hojat m, gonnela js, mangione, et al. empathy in medical students as related to academic performance, clinical competence, and gender. med educ. 2002;36:522-527. doi: 10.1046/j.13652923.2002.01234.x. 3. hojat m, louis dz, markham fw, wender r, rabinowitz c, gonnela js. physicians’ empathy and clinical outcomes for diabetic patients. acad med. 2011;86(3):359-364. doi: 10.1097/acm.0b013e3182086fe1. 4. del canale s, louis dz, maio v, et al. the relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in parma, italy. acad med. 2012;87(9):1243-1249. doi: 10.1097/acm.0b013e3182628fbf. 5. newton bw, barber l, clardy j, cleveland e, o’sullivan p. is there hardening of the heart during medical school? acad med. 2008;83(3):244-9. doi: 10.1097/acm.0b013e3181637837. 6. cruess rl, cruess sr, boudreau jd, snell l, steinert y. a schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators. acad med. 2015;90(6):718-25. doi: 10.1097/acm.0000000000000700. 7. misra-hebert ad, isaacson jh, kohn m, hojat m, papp, kk, calabrese l. improving empathy of physicians through guided reflective writing. int j med ed. 2012;3:71-77. doi: 10.5116/ijme.4f7e.e332. 8. hojat m. ten approaches for enhancing empathy in health and human services cultures. j health hum serv adm. 2009;31(4):412-50. https://www.jstor.org/stable/25790741. 9. charon r. the patient-physician relationship. narrative medicine: a model for empathy, reflection, profession, and trust. jama. 2001;286(15):18971902. doi: 10.1001/jama.286.15.1897. 10. hojat m, axelrod d, spandorfer j, mangione s. enhancing and sustaining empathy in medical students. med teach. 2013;35(12):996-1001. doi: 10.3109/0142159x.2013.802300. epub 2013 jun 11. 11. crump, wj. professional identity curriculum at the university of louisville trover campus: reflection and meaning in medical education. j ky acad fam physicians. 2017;winter:88:18. 12. crump wj, ziegler ch, fricker rs. a residency professional identity curriculum and a longitudinal measure of empathy in a community-based program. j reg med campuses. 2018;1(4). doi: 10.24926/jrmc.v1i4.1353 . doi: https://doi.org/10.24926/jrmc.v4i1.3475 journal of regional medical campuses, vol. 4, issue 1 original reports 13. hojat m, gonnella js. eleven years of data on the jefferson scale of empathy-medical student version (jse-s): proxy norm data and tentative cutoff scores. med princ pract. 2015;24(4):344-350. doi: 10.1159/000381954. epub 2015 apr 28. 14. chen d, lew r, hershman w, orlander j. a crosssectional measurement of medical student empathy. j gen intern med. 2007;22(10):1434-1438. doi: 10.1007/s11606-007-0298-x. 15. hojat m, shannon sc, desantis j, speicher mr, bragan l, calabrese lh. does empathy decline in the clinical phase of medical education? a nationwide, multi-institutional, cross-sectional study of students at do-granting medical schools. acad med. 2020;95(6):911-918. doi: 10.1097/acm.0000000000003175. 16. hojat m, mangione s, nasca tj, et al. an empirical study of decline in empathy in medical school. med educ. 2004;38(9):934-941. doi: 10.1111/j.13652929.2004.01911.x. 17. crump wj, fricker rs, ziegler c, wiegman dl, rowland ml. rural track training based at a small regional campus: equivalency of training, residency choice, and practice location of graduates. acad med. 2013;88(8): 112-1128. doi: 10.1097/acm.0b013e31829a3df0. 18. crump wj, fricker rs, ziegler ch, wiegman dl. increasing the rural physician workforce: a potential role for small rural medical school campuses. j rural health. 2016;32(3):254-259. doi: 10.1111/jrh.12156. epub 2015 oct 30. 19. yu e, wright sm. “beginning with the end in mind”: imagining personal retirement speeches to promote professionalism. acad med. 2015;90(6):790-793. doi: 10.1097/acm.0000000000000690. 20. crump wj, fricker rs, crump-rogers a. a career eulogy reflective exercise: a view into early professional identity formation. marshall j med. 2020;6(2). doi: 10.33470/2379-9536.1266. available at: https://mds.marshall.edu/mjm/vol6/iss2/12 21. green mj. comics and medicine: peering into the process of professional identity formation. acad med. 2015;90(6):774-779. doi: 10.1097/acm.0000000000000703. 22. wickham h. (2016). ggplot2: elegant graphics for data analysis. new york, n.y.: springer-verlag; https://ggplot2.tidyverse.org. accessed september 17, 2020. 23. united states department of agriculture, economic research service. 2003 rural urban continuum codes. http://www.ers.usda.gov/dataproducts/rural-urban-continuum-codes.aspx last accessed september 17, 2020. 24. crump wj, fricker rs. keeping rural medical students connected to their roots: a “home for the holidays” immersion experience. marshall j med. 2016;2(1):8. doi: 10.18590/mjm.2016.vol2.iss1.8. microsoft word reviewofanintensivefacultydevelopmentarticle.docx published by university of minnesota libraries publishing review of an intensive faculty development program conducted at a regional medical campus steven r craig, md, hayden smith, phd, mph and marcy rosenbaum, phd journal of regional medical campuses, vol. 3, issue 3 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc steven r. craig, md is an adjunct clinical professor of internal medicine and assistant dean at the des moines branch campus of the university of iowa carver college of medicine, des moines, iowa. hayden smith, phd, mph is a senior research scientist at unitypoint health-des moines, des moines, iowa, orcid: https://orcid.org/0000-0002-2354-3468. marcy rosenbaum, phd is a faculty development consultant for the office of consultation and research in medical education and professor in the department of family medicine at the university of iowa, iowa city, iowa. corresponding author: steven r. craig, md, assistant dean (des moines branch campus), 1415 woodland avenue, suite 130, des moines, iowa 50309; telephone; 515-241-4455; email: steven.craig@unitypoint.org all work in jrmc is licensed under cc by-nc volume 3, issue 3 (2020) journal of regional medical campuses review of an intensive faculty development program conducted at a regional medical campus steven r craig, md, hayden smith, phd, mph and marcy rosenbaum, phd abstract purpose: the process of attracting, training, and retaining volunteer clinical faculty can be a challenge for regional medical campuses. it is important to have a faculty development program that addresses the specific needs of community-based faculty members. however, there is a shortage of literature on how to best develop and deliver such programs at regional campuses. objective: to describe the development and implementation of a comprehensive faculty development program at a regional medical campus. method: an intensive faculty development program was developed at the regional medical campus of a large us midwestern medical school. the faculty development program was created and directed by a senior faculty member at the regional medical campus working with a senior educator from the medical education office on the main campus. the program expanded the number of yearly faculty development workshops offered to all volunteer faculty at the regional campus and included an additional intensive 2-year certificate program for 12 faculty teaching scholars. the 2-year teaching scholars program was designed to provide more intensive training for faculty members interested in taking on leadership duties in medical education at the regional campus. results: additional workshops were administered across the reported 2-year period. the teaching scholars cohort was constructed and maintained regular session attendance. self-assessed knowledge and skills in completing common teaching activities improved for the teaching scholars across the study period. these faculty members rated the certificate program good (18%) to excellent (82%) and all indicated they would recommend the program to colleagues. conclusions: the described program can be accomplished by any regional medical campus working with faculty experts at the main campus. the financial costs of the program were minimal and data from the program supported its benefits. introduction many medical students receive clinical training at a regional medical campus. a challenge for these campuses is attracting, training, and retaining adjunct clinical faculty, who are generally unpaid volunteers often located at considerable distances from the main medical school. an element regularly cited as important to these adjunct community-based preceptors is having opportunities for faculty development to help them acquire and advance their teaching skills.1-3 in particular, there has been a documented need for local approaches to faculty development which address the specific needs of these community-based members.4-7 a key component of local faculty development is providing information on topics of interest to the community-based faculty members delivered by content experts.6,8 funding to support these efforts is usually limited.9 a review of the literature indicates only a few published studies examining how faculty development has been implemented at regional campus sites. previously published studies reporting interventions at regional campuses point to the need for identification of local administrative champions as well as content experts to help direct faculty development efforts at the regional campuses.8,10-12 in this paper, we describe the development and implementation of expanded faculty development opportunities at one regional medical campus using existing resources to direct these efforts. methods setting an intensive faculty development program was developed at the regional medical campus of a large us midwestern medical school. the regional campus consists of 2 community journal of regional medical campuses, vol. 3, issue 3 teaching hospitals, a children’s hospital, a county hospital, and a veterans affairs hospital, all located in the same metropolitan area 110 miles from the main medical school campus. the regional medical campus is recognized and accredited by the liaison committee for medical education. there is an assistant dean overseeing the regional campus who reports to the senior associate dean for medical education at the main campus. the 5 teaching hospitals on the regional medical campus are active in both undergraduate and graduate medical education. between the facilities, the 5 hospitals sponsor 8 acgme-accredited residency programs including 2 transitional year residency programs, 2 family medicine residency programs, 1 internal medicine residency program, 1 pediatric residency program, 1 psychiatry residency program, and 1 general surgery residency program. these programs train over 140 residents annually. in addition, residents in several specialty areas from the main campus rotate to the regional campus to complete part of their clinical training. in a typical year, 35 to 40 resident physicians from the main campus complete some training at the regional campus. medical students from the main campus complete basic and advanced clinical training at the regional campus. over 1/3 of third and fourth-year medical students from the main campus complete part of their clinical training at the regional campus. this includes 24 students (16% of the class) who complete all of their core clinical clerkship training at the campus. in a typical year, this represents more than 100 medical students from the main campus completing at least part of their clinical training at the regional campus. prior to 2017, faculty development at the regional campus was limited to twice yearly workshops provided by educational experts from the main campus. in early 2017, the regional medical campus assistant dean and other educational leaders at the campus approached leaders at the medical school main campus about the need for additional faculty development at the regional campus. there was a desire to expand programming for all regional medical campus faculty beyond the 2 annual programs. in addition, there was a desire to provide more intensive training for faculty interested in taking on leadership duties in undergraduate and/or graduate medical education at the regional campus. the senior associate dean for medical education of the medical school directed the regional campus dean to work closely with a senior educator in the medical education office on the main campus to address these 2 needs. together, they developed a plan to expand faculty development opportunities for all volunteer faculty at the regional campus from 2 workshops annually, to quarterly faculty development workshops throughout the year. regional medical campus faculty were surveyed to help determine what topics should be covered in these programs. an email survey was sent to all faculty involved in resident and medical student education at the regional campus with a list of 25 possible faculty development workshop topics. respondents were asked to list their top 3 choices and they were also able to write in additional topics they would like to see addressed. the 8 topics presented in the 2-year program were from the top 10 nominated by the faculty respondents. see supplemental files for a copy of the survey instrument (supplemental digital appendix 1). the regional campus dean and senior faculty development expert also developed plans to provide more intensive faculty development to key faculty educators at the regional campus. these 2 individuals co-directed a new 2-year teaching scholars certificate program, which was initiated in the fall of 2017. plans for the new teaching scholars program were developed during the first half of 2017 and included intensive faculty development for educators at the regional medical campus looking to take on future medical education leadership roles. over the summer, information was distributed to all faculty educators at the regional campus and they were invited to apply for one of 12 positions in the first teaching scholars cohort. curriculum applicants to the teaching scholars program were informed that the program would build and expand on the quarterly faculty development programming planned to be implemented at the regional campus. specifically, participants were asked to make a 2-year commitment to attend all of the quarterly faculty development workshops with additional work assignments before and after each workshop. these quarterly workshops were offered to all regional campus faculty regardless of participation in the cohort and were 90-minute interactive sessions on key topics requested by regional campus faculty (table 1; list of provided faculty development workshops). speakers for 6 of the 8 workshops were experts from the medical education office on the main campus and 2 speakers were senior educators from the regional campus. directly after each workshop, participants in the teaching scholars intensive faculty development program were asked to email the course directors on how they planned to apply information and methods taught in the quarterly workshops into their teaching activities over the next quarter. approximately 2 weeks prior to the next quarterly workshop, teaching scholars were then asked to submit a one to 2-page reflection on lessons learned from applying the information during the prior quarter. they were asked to address 3 questions in these reflections: 1) what happened: when you tried out the new teaching methods learned from the session; 2) so what: what did you observe about the effectiveness of the new methods you tried; 3) what now: how did this experience guide your use of the new methods going forward. immediately prior to each quarterly workshop, the course codirectors facilitated a 75-minute discussion with the teaching scholars participants. an open discussion was conducted to journal of regional medical campuses, vol. 3, issue 3 focus on the participants’ reflections and experience applying the new methods taught at the prior workshop. robust discussions were solicited from the entire group addressing what had worked and what had not worked, and why, when applying the new methods. discussions also focused on overcoming barriers that participants had identified in effectively implementing specific skills into their teaching practices. at the end of these discussions, each teaching scholar self-reported how they planned to apply these teaching methods going forward. since the teaching scholars program was developed for faculty members interested in taking on future medical education leadership duties, another component of this training was leadership training. each participant completed a disc® personality inventory profile. these individual profile reports allowed them to reflect on their leadership style. one of the group meetings was then devoted to discussing how educators with different leadership styles can best work with learners with the same, similar, or very different styles. program assessment several measures were used to assess the impact of the teaching scholars program on the cohort. these measures were consistent with the first 3 levels of the kirkpatrick model used to assess the effectiveness of faculty development efforts. first proposed by donald kirkpatrick in the 1950’s, the 4 stage model includes assessing: 1) learner satisfaction, 2) new learning (knowledge, attitudes, and skills), 3) behavior changes, and 4) subsequent impact on trainees.13 regional campus faculty in the teaching scholars cohort were surveyed at baseline, and on completion of the 2-year program. see supplemental files for a copy of these program instruments (supplemental digital appendices 2-5). participants were asked to self-assess their competence in performing 17 different common teaching activities before and after completing the 2-year program using a 4-point likert scale: 1 = generally not able to perform; 2 = somewhat able to perform; 3 = quite competent performing; 4 = highly competent performing, n/a = not applicable, do not engage in this teaching activity. cohort participants were also asked at baseline and at the end of the program to list the 3 most common settings in which they taught and to describe their perceived strengths and areas for improvement when teaching in these 3 settings. after completing this assessment at the end of the 2-year program, participants were provided assessments of the strengths and needed improvements they had originally reported on their entry into the program. they were given a worksheet allowing them to compare these pre and post assessments which asked if they observed changes in what they would now list as strengths and areas for improvement in the 3 teaching settings to assess for new learning. they were also asked to set goals for how they would approach making these needed improvements. on the completion of the 2-year program, the cohort was also asked to complete an evaluation survey that included a series of questions about the intensive faculty development program. the survey instrument included what the cohort considered highlights and what improvements they recommended to the program. the survey also queried participants about program logistics (e.g., frequency and length of the meetings) and the value of different components of the program. the study of the teaching scholars program was classified as exempt by the institutional review board at the regional medical campus (#ex2019-077). results a primary goal of the new faculty development program was to increase the number of faculty development workshops for all regional campus faculty from 2 to 4 programs per year. for the 2 years prior to this expansion (2015-2017), a total of 129 teaching faculty (representing 72 unique faculty) attended the faculty development programs at the regional campus. during the first 2 years of quarterly workshops (2017-2019), a total of 273 teaching faculty (representing 111 unique faculty) attended the faculty development programs at the regional campus. the second change was the implementation of an intensive 2year teaching scholars program. the program was successful in attracting 12 faculty members, with at least one faculty member from each of the 5 regional campus-affiliated teaching hospitals and an equal number of men and women. four participants had been teaching for less than 5 years, three for 5-10 years, and five had been teaching for 11-16 years. all of these participants were volunteer faculty and they received no compensation for their participation in the teaching scholars program. hospital and practice group leaders were supportive and provided protected time so these faculty members could participate in the activities. although 12 faculty members were accepted into the teaching scholars program, one dropped out of the program after 2 meetings due to practice relocation. of the remaining 11 participants, 9 maintained 100% attendance and the other 2 attended 7 of the 8 workshops and teaching scholars meetings. every participant completed the reflection assignments for the workshops they attended. participants were asked to self-assess knowledge and skills in completing 17 common teaching activities before and after the 2-year program. the number of faculty indicating they were not able (1), somewhat able (2), quite competent (3) and highly competent (4) to perform each of these activities before (pre) and after (post) completing the teaching scholars program is presented in table 2. participants’ selfassessment of competency performing the 17 teaching activities tended to improve for all activities across the program. improvement in 6 of the teaching activities was statistically significant (p < .05). although improvement was not significantly improved for the other 11 activities, in all but journal of regional medical campuses, vol. 3, issue 3 one activity 7 or more participants rated themselves as quite competent or highly competent performing these activities at the end of the 2-year program. the activity with the lowest post-program ratings was an area not specifically addressed during the 2-year program (i.e. writing effective test questions). this activity was included as a control item to see if improvement in skills occurred even if the activity was not addressed in the program. participants were also asked at baseline and program completion to list the strengths and areas for improvement in teaching for the 3 most common settings in which they taught. at the end of the program, when comparing their pre and post descriptions of strengths and areas for improvement in common teaching settings, participants noted positive changes in both strengths and in areas they had identified as needing improvement on entry into the program. participants were asked to identify 2 to 3 goals to further improve their teaching skills in those settings in which they most commonly taught. table 3 summarizes the goals the 11 teaching scholars identified to further enhance their teaching skills after completing the 2-year program. there was considerable overlap in responses resulting in a total of 12 unique goals/areas for further improvement identified by the 11 program participants. table 4 summarizes the anonymous program evaluation data provided by the 11 participants in this first teaching scholars cohort. as shown, when participants were asked to assess the value of the teaching scholars program, 82% rated it as excellent and 18% good. all participants indicated they would definitely recommend the program to colleagues. finally, participants were asked to list what aspects of the program they found most valuable and what aspects of the program could be improved. table 5 summarizes all unique free text response categories received. networking with other teaching scholars was cited as the most valuable aspect of the program. the 75-minute teaching scholars interactive sessions were also noted by all participants to be of value. learning from others’ experience trying to implement the teaching methods taught at the workshops was considered valuable, including learning what worked and did not work for others. completing the leadership style surveys and the session devoted to reviewing how faculty with different leadership styles can work with learners who have similar or different styles were also seen as valuable. participant suggestions for improving the program included reducing occasional redundancy of content, incorporating instruction on use of new teaching technologies, and developing a way for teaching scholars to electronically submit their critical analysis reflections to an online site that would allow all scholars to review the reflections from each other prior to each meeting. discussion this study describes a program that provided expanded faculty development at a regional medical campus. in particular, the program focused on providing more intense instruction to a cohort of faculty teaching scholars participating in a 2-year certificate program. the program addresses an area of great importance to all regional medical campuses, given there are few reports in the literature describing such types of training without major expenditures, such as hiring a new faculty development expert at the branch campus.8-12 the program also increased the number of overall faculty development workshops for regional campus faculty from 2 to 4 workshops per year. this change increased the number of general faculty at the regional campus participating in these development sessions. the total attendance at these workshops more than doubled and the number of unique faculty members participating in workshops increased by more than 50% during the first 2 years of the program. as for the 2-year teaching scholars program, it was successful in attracting at least one faculty member from each of the 5 regional campus-affiliated teaching hospitals. each of the participants expressed interest in taking on future medical education leadership roles at the regional campus. a key component of the teaching scholars program was having participants commit to applying session information and methods taught in the quarterly workshops into their teaching activities during the next quarter. immediately prior to the following meeting, each participant submitted a written reflection discussing lessons learned from applying the new teaching methods. these assignments were actionoriented reflections, similar to the rolfe et al. model, which have been demonstrated to help learners incorporate new knowledge and skills into their practice.14 another key component of the program was having each participant complete a disc® personality inventory profile. this instrument identifies an individual’s behavioral style based on their personality. it has been used in the corporate sector since the 1960s to assist with hiring and advancement decisions.15-16 it is being used more extensively in healthcare in a variety of ways.17-19 one newer application is to help educational leaders better understand their leadership priorities and preferences and how to best connect with people whose priorities and preferences may be different. participants in the teaching scholars program agreed that reviewing their individual profile report provided them great insight into their particular leadership style and how they can work with learners with the same, similar, or very different behavioral styles. evaluation of the teaching scholars program by participants was positive. the number of teaching scholars meetings and the length of these meetings was assessed as appropriate by the majority of participants. networking with other teaching scholars and learning from their experience applying the information and new methods taught at the quarterly workshops were cited as the most valuable aspects of the journal of regional medical campuses, vol. 3, issue 3 program. at the end of the 2-year program, the majority of participants rated it excellent, with the rest rating it as good. all participants indicated they would definitely recommend the program to colleagues. feedback from the first cohort of teaching scholars is being used to make improvements to the program for the next cohort that is being recruited. the 2 key components cited above will be continued: having participants complete leadership surveys and getting a commitment from each participant about how they will apply new methods taught at the workshops and then asking them to write an actionoriented reflection for discussion at the next teaching scholars meeting. efforts are also in place to create a method for scholars to submit their required reflection papers to a secure electronic site and to provide access to these reflections to all teaching scholars participants. there is broad support for continuing the 2-year intensive teaching scholars program. participants from the first cohort have helped recruit the next cohort of 12 teaching scholars by reaching out to colleagues who teach in the same discipline and/or at the same institution where they teach. all regional campus faculty and the first cohort of teaching scholars have been resurveyed to determine what topics will be addressed at the quarterly faculty development workshops for the next 2 years. this included reviewing the list of teaching activities that the first cohort of teaching scholars rated the lowest competence in performing at the end of the 2-year program. limitations the described program represents the outcomes from one main medical school campus with a single regional campus. the degree of trust and support between the 2 campuses was strong. it is unknown how well the program may work when the main campus has multiple regional campus sites and/or the degree of trust and support between the 2 campus sites is not as strong. this study reports on only one cohort of 12 teaching scholars and thus may be limited in generalizability. we chose to limit the program to 12 participants to allow for a large enough group to share different perspectives, but small enough to get to know each other well and to interact in an efficient manner. future research could assess the program’s success across several cohorts. there were initial plans to have each cohort participant video record themselves in educational settings of their choosing. they would have then reviewed the video recordings with a senior faculty development expert to provide feedback. this task proved difficult to arrange for a variety of reasons and a new method of observing participants in teaching settings with feedback is planned for the next cohort. objective structured teaching exercises (ostes) are planned for the second cohort as well. these participants will be videotaped interacting with simulated learners in the settings where they normally teach. they will then review the video recordings with a senior faculty development expert and receive feedback. finally, data used in this study was based solely on participant self-report and selfassessment. future studies could include assessment questions focused on knowledge acquisition. additionally, we were unable to determine if self-reported changes in teaching behaviors reflected actual behavioral changes. future research could collect observational data on teaching behaviors through pre-post video review, ostes and/or direct observations to determine the impact of the program on actual behaviors. to address kirkpatrick’s level 4, pre-post data could also be collected on trainee perceptions and evaluations of faculty teaching. conclusion this report describes a successful model for providing needed faculty development to regional campus faculty with the assistance of educators from the faculty development office of the main medical school campus. the program was simple in structure and successful in advancing the self-reported teaching abilities of busy clinical teachers at the regional campus. there were no additional costs incurred by the regional campus. the program achieved its stated goals of increasing faculty development opportunities for all volunteer faculty at the regional campus and providing more intensive training for a small cohort of faculty interested in taking on medical education leadership duties at the regional campus. references 1. langlois jp. support of community preceptors: what do they need? fam med. 1995;27(10):641-645. 2. levy bt, gjerde cl, albrecht la. the effects of precepting on and the support desired by community-based preceptors in iowa. acad med. 1997;72(5):382-384. 3. brink d, simpson d, crouse b, morzinski j, bower d, westra r. teaching competencies for community preceptors. fam med. 2018;50(5):359-363. 4. skeff km, stratos ga, bergen mr, sampson k, deutsch sl. regional teaching improvement programs for community-based teachers. am j med. 1999;106(1):76-80. 5. langlois jp, thach sb. bringing faculty development to community-based preceptors. acad med. 2003;78(2):150-155. 6. drowos j, baker s, harrison sl, minor s, chessman aw, baker d. faculty development for medical school community-based faculty: a council of academic family medicine educational research alliance study exploring institutional requirements and challenges. acad med. 2017;92(8):1175-1180. 7. nuss ma, cervero r, hill jr, gaines j, middemdorf b. the development of newly recruited clinical teachers journal of regional medical campuses, vol. 3, issue 3 at a unique regional medical campus. j regional med campuses. 2018;1(4). https://doi:10.24926/jrmc.v1i4.1041 . 8. trowbridge rl, bates pw. a successful approach to faculty development at an independent academic medical center. med teach. 2008:30(1):e10-e14. 9. sicat bl, o'kane kreutzer k, gary j, et al. a collaboration among health sciences schools to enhance faculty development in teaching. am j pharm educ. 2014;78(5):102. 10. akins r. evidence-based faculty development programming for regional medical campuses and the bask framework. j reg med campuses. 2019:2(4). https://doi:10.24926/jrmc.v2i4.1304. 11. hoffmann-longtin k, torbeck l, nalin p, cico s. tailoring the professional development of volunteer clinical faculty at regional medical campuses: :a needs analysis and targeted interventions. j. reg med campuses. 2019:1(6). https://doi.org/10.24926/jrmc.v2i2.1635. 12. jefferson kl, shultz m, heiselt a, jefferson kl et al. serving community faculty through a dedicated liaison. med ref serv q. 2018;37(1):1-9. 13. kirkpatrick dl. techniques for evaluating training programs. am soc train direct. 1959;13:3-9. 14. rolfe g, jasper m, freshwater d. critical reflection in practice: generating knowledge for care. 2nd ed. london, palgrave macmillan; 2011. 15. bhardwaj ca, mishra m, hemalatha s. an automated compatibility prediction engine using disc theory based classification and neural networks. int j eng technol sci res. 2017;4(8):1-9. 16. jordan, pj, troth ac. managing emotions during team problem solving. hum perf. 2004;17(2):195218. 17. keogh tj, robinson jc, parnell jm., keogh tj et al. assessing behavioral styles among nurse managers: implications for leading effective teams. hosp top. 2019;97(1):32-38. 18. ogunyemi d, mehta s, turner a, kim d, alexander c. emotional intelligence characteristics in a cohort of faculty, residents and medical students. j reprod med. 2014;59(5-6):279-284. 19. ogunyemi da, mahller yy, wohlmuth c, eppey r, tangchitnob e, alexander cj. associations between disc assessment and performance in obstetrics and gynecology residents. j reprod med. 2011;56(910):398-404. journal of regional medical campuses, vol. 3, issue 3 journal of regional medical campuses, vol. 3, issue 3 microsoft word tailoringtheprofessionaldevelopmentarticle.docx published by university of minnesota libraries publishing tailoring the professional development of volunteer clinical faculty at regional medical campuses: a needs analysis and targeted interventions krista hoffmann-longtin, laura torbeck, peter nalin, stephen john cico doi: https://doi.org/10.24926/jrmc.v2i1.1635 journal of regional medical campuses, vol. 2, issue 2 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc krista hoffmann-longtin, indiana university laura torbeck, indiana university peter nalin, indiana university stephen john cico, indiana university all work in jrmc is licensed under cc by-nc volume 1, issue 6 (2019) journal of regional medical campuses original reports tailoring the professional development of volunteer clinical faculty at regional medical campuses: a needs analysis and targeted interventions krista hoffmann-longtin, laura torbeck, peter nalin, stephen john cico abstract volunteer clinical faculty (vcf) are essential for the education of medical students at most medical schools with regional campuses. indiana university school of medicine is the largest medical school in the united states, with over 1400 medical students experiencing part or all of their medical education at 9 campuses (one academic center and 8 regional medical campuses). given the large number of students learning in the community, we surveyed our vcf in 2016 to better understand their characteristics, reasons for teaching, and professional development needs. survey participants reported personal enjoyment from teaching as their primary reason for continuing to teach, but time pressure as a limiting factor. they identified faculty development opportunities in areas of efficient teaching, giving feedback, and adapting teaching style for various learners. interventions were designed to create a unique, state-wide model of both face-to-face and online professional development to ensure the success of our vcf. introduction volunteer clinical faculty (vcf) are essential for the education of students at most medical schools, but they are especially important for those with regional medical campuses (rmcs). this is becoming even more important in medical education with the shift from traditional classroom teaching to an experiential model in which students are introduced to clinical medicine from the start of medical school.1,2 accreditation and medical-oversight agencies such as the association of american medical colleges (aamc) and liaison committee on medical education (lcme) require outpatient experiences as part of medical training. additionally, some medical schools have increased their medical school class size (or plan to do so) to address physician shortages. these schools often turn to vcf to fulfill the need for additional physician educators. across the nation, recruitment of vcf remains a challenge. in a regional medical campus model, few studies have investigated why physicians become involved in teaching medical students, what motivates involvement, and what unmet needs they have to become more successful as educators. some have speculated that a personal belief in the importance of education is a strong motivator.3 personal satisfaction and opportunity to give back rates at or near the top when vcf are surveyed.4 other benefits to vcf include receiving continuing medical education (cme) credit, fulfilling maintenance of certification (moc) requirements, and receiving financial compensation for their time.2,4 particularly with rmcs, research supports the importance of usingevidence based models to develop faculty in the community.5 along with benefits, there are also challenges in working with vcf. both the orientation and training of preceptors remain a particular struggle for medical schools.6 many vcf are geographically dispersed, making it difficult for them to frequently access the available faculty development resources of the institution. there remains a lack of evidence supporting which approach would be most efficacious for meeting the ongoing faculty development needs of vcf.7 another challenge involves the financial implications for vcf involved in teaching. though financial incentives or stipends are occasionally available, funds are becoming increasingly difficult to come by in today’s healthcare environment. time is also a frequently-cited barrier to precepting medical students.2 hosting students can affect physician productivity, resulting in less time to care for patients, possible decreased income, and potentially increased patient-care responsibilities placed on partners in the practice who may have to see additional patients. local context as a result of medical school expansion in the 1960s, the first rmcs were developed. since the call for increased medical school enrollment by the aamc in 2006, the rate of expansion of rmcs has increased, employing a variety of models for student education and training.8,9 indiana university school of medicine’s (iusm’s) expansion has mirrored this national trend. as the largest medical school in the us with 9 campuses throughout the state, the majority of iusm’s approximately 1400 medical students receive much of their training from vcf. the institution’s campuses are situated in both urban and rural areas in 2 different time zones. nearly half of the students are in indianapolis, and the remaining students are physically located at 8 rmcs that span the state of indiana. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports the furthest rmcs are approximately 3 hours (by car) from the main campus in indianapolis. this geography presents unique challenges to our institution, not only with the number of faculty needed, but also the distance from which we must recruit them. as iusm expanded its rmcs and class size, the need for additional vcf was identified. vcf are not recruited centrally. rather, each of the rmcs recruit vcf and each of the 11 clerkship programs based in indianapolis also recruit. when hired, each vcf is assigned an academic department and a campus affiliation. while vcf can be used by any campus in the system, most work primarily with one campus. appointing vcf is managed centrally through our faculty affairs unit and clerkship directors and rmc education personnel work with the faculty affairs office to verify credentials and manage the reappointment process. while both the faculty database and student placements are housed in centralized systems, the 2 systems do not interface, such that the faculty affairs unit knows which faculty are appointed, but not if and when the vcf are hosting a learner. as with many medical schools with rmcs, the decentralization and lack of clear “ownership” for vcf issues can create difficulties. however, units in faculty affairs and educational affairs try to work together collegially to help vcf have a seamless experience when working with the university. with this context in mind, we launched a survey of our vcf in 2016 to better understand their demographic characteristics, reasons for teaching, and professional development needs. the purpose of this study was two-fold: 1) to report on the vcf characteristics, reasons for teaching, and development needs and 2) to disseminate the interventions we implemented as we work towards developing a unique model of state-wide faculty development. our research questions included: rq 1: how often and why do vcf teach? rq 2: how do vcf connect with the institution? who do they consider to be their supervisor or their primary point of contact within the institution? how and to what extent do they feel connected to the institution? rq 3: what types of faculty development do vcf engage in? what resources of the institution do they access? rq 4: what faculty development needs do they have? how would they prefer to engage in faculty development (online, in-person)? methods survey development we developed our vcf survey by consulting literature and existing instruments on teaching competencies and faculty vitality.11,12 our survey instrument included 2 components: a core block of questions and 4 randomly assigned sub-surveys. first, the core block of questions included 13 items focused on vcf confidence in teaching competencies (adapted from smith and simpson,10 university resource utilization, perceptions of school leadership, and faculty vitality. second, all respondents were each randomly assigned to receive one of 4 sub-surveys, consisting of 2-5 questions each. this methodology, called split questionnaire survey design, has been shown to increase response rates and limit fatigue, while still maintaining a high degree of reliability.13 the subsurveys included questions on one of the following topics: a. faculty development needs b. relevant questions from the faculty vitality survey on perceptions of university leadership and climate11,12 c. satisfaction with their role (adapted from harvard university’s coache faculty satisfaction survey),14 and d. satisfaction with their title and reward mechanisms. the survey and subsequent distribution process was approved by our institutional review board. sample this study was limited to faculty at indiana university school of medicine. in the spring of 2016, we distributed the survey via email to 2625 volunteer faculty using qualtrics survey software. the email was sent from our general office email account, and the qualtrics survey software allowed us to send weekly reminders over a period of 6 weeks to those faculty who had not yet responded. after removing volunteer basic science and research faculty, the final sample consisted of 619 vcf, indicating a response rate of 24%. the majority of our participants were male (72%, n=447), and most held the rank of assistant professor (88.1%, n=545). table 1. participant demographics characteristic number (%) rank doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports assistant 545 (88.1) associate 46 (7.4) full 19 (3.1) lecturer 9 (1.4) gender male 447 (72.2) female 172 (27.8) degree md 557 (90) do 33 (5.3) other 29 (4.7) race/ethnicity white 479 (77.4) asian 100 (16.2) hispanic/latino 18 (2.9) black 16 (2.6) i prefer not to respond 4 (0.6) two or more races 2 (0.3) although the sub-surveys were evenly distributed to participants randomly, some participants chose not to respond to these questions, thus explaining the variability in the number of respondents across sub-surveys. results rq 1: how often and why do vcf teach? vcf at iusm reported regularly supervising learners, with the majority of respondents taking between 1-10 learners per year (69%, n=367). the mean amount of time the vcf had been teaching was 15 years. when asked how long our vcf intended to teach into the future, responses were distributed across the sample with about one-third indicating that they were not sure how long they planned to serve. table 3. duration vcf plan to serve frequency (%) less than 5 years 22 (18) more than 5, but less than 10 years 24 (19) more than 10 years 38 (31) not sure 41 (33) in addition, participants were also asked 2 open-ended questions about their service. first, they were asked to list the top 3 reasons they would continue serving as a vcf and they also were asked the 3 primary reasons they would discontinue teaching. most frequently, reasons to continue focused on satisfaction/enjoyment from teaching (63%); selflearning/keeping up-to-date (38%); contributing to the educational mission and disseminating knowledge (38%); and a sense of duty/giving back to the medical school (35%). by and large, vcf cited time constraints as the primary reason for discontinuing teaching (47%). other notable, but less frequent reasons cited included feeling unappreciated (14%); loss of control over/mandates in the curriculum (13%); and bureaucracy/paperwork associated with the position (10%). figures 1 and 2 illustrate a visualization of the frequency of responses to these questions. figure 1. reasons to continue serving as a vcf. figure 2. reasons to discontinue serving as a vcf. *these figures are a visualization of the frequency of responses provided by respondents. the size of the word represents how frequently it was expressed as a reason to continue volunteering at iusm. rq 2: how satisfied are vcf with their role? using items from the faculty vitality survey,11,12 we asked vcf to rate their level of satisfaction with the school’s leadership, the direction of the institution, and their role within it. about one-third of participants strongly or somewhat agreed that they felt a sense of belonging within the school (see table 4 for additional frequency details). they were also ambivalent about the level of inclusivity created by school leadership. more frequently, participants did not feel doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports as if their opinions were routinely solicited by the school. additionally, there was wide variation among responses to the statement: “my contributions are valued by the leaders at [our institution].” approximately one-third of our respondents neither agreed nor disagreed with this statement (table 5 includes frequencies and percentages from all sub-survey questions). despite these challenges, most of our participants were very or somewhat satisfied with their work (see table 6). rq 3: how confident are they in their teaching abilities? what types of faculty development do vcf engage in? what resources of the institution do they access? smith and simpson’s teaching confidence scale10 was used better understand our vcf’s level of confidence with a variety of teaching skills and tasks, including providing feedback, modifying instruction, and communicating professional values. this instrument uses a 4-point scale from “very confident” to “not at all confident,” with the sentence stem: “please rate your confidence with the following teaching tasks.” generally, our vcf were confident in their abilities to perform most teaching tasks, with percent responding “very confident” ranging from 70.3% (“communicate important values inherent to the profession”) to 40.7% (“accommodate different learners by using a variety of teaching methods”). however, participants showed the most variability in the aforementioned item regarding accommodating different learners. we asked our participants a number of questions regarding the types of professional development activities they participate in. in particular, we were interested in the number of faculty development activities they engaged in within the past year across 4 areas: teaching and learning, leadership, diversity and inclusion, and career management. vcf reported participating in diversity and inclusion related activities least frequently (n=127, 20%) of these faculty development categories. over half of our vcf participated in 0 faculty development programs regarding diversity and inclusion (56%) and career management (55%). however, about 45% of vcf had participated in at least one teaching and learning-related faculty development program within the last year (n=277). when asked to what extent they were engaged in faculty development activities in comparison to doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports other professionals in the field, most respondents reported only “some” (n=108, 17%) or “very little” (n=255, 41%) engagement. volunteer faculty at iu (both clinical and basic science) do have access to a number of resources within the institution, including an iu email address, free continuing medical education opportunities, access to the library, and free or discounted software. anecdotally, we had heard that many of our vcf were unaware of these resources; so, we used this survey instrument as a way to learn more. of the vcf who responded to the survey, about one-third had heard of just “a few” of these services and products. additionally, 71% said they had used “none” or just “a few” of these resources. rq 4: what faculty development needs do they have? how would they prefer to engage in faculty development (online, in-person)? when the vcf were asked what they believed their top needs were for faculty development, teaching in a busy practice, active learning, and teaching using case studies were the top 3 identified needs. topics with which they indicated the least interest included teaching in a laboratory, teambased learning, and teaching on rounds. table 4 details the frequency each topic was selected by survey respondents; up to 3 selections could be made by each respondent. in terms of the delivery mechanism for faculty development, receiving an electronic newsletter, participating in live webinars, and engaging in locally held faculty development events were preferred. one-on-one mentoring, receiving a hard-copy manual, and online discussion boards were the least preferred methods for faculty development delivery. discussion the education of medical students is dependent upon clinical faculty in every region where medical students are located. following a decade of expansions of medical schools, the overall number of vcf associated with regional medical campuses and their professional development needs have increased. like community-based medical schools where community hospitals partner with the medical school as the clinical teaching site rather than a traditional academic teaching hospital,15 iusm’s rmcs have partnered with community hospitals and physicians to offer clinical experiences to the medical students. although our survey results indicated that our vcf were relatively satisfied with their roles, we were concerned that approximately one-third of these critical faculty were not confident they would continue. indiana university school of medicine is the only allopathic school in the state; as such, it is critical that we continue to engage our students in community-based education. time is a critical factor for vcf, so these results helped us to make the case for additional resources to make the teaching process as easy and enjoyable as possible for vcf. interventions in response to the data from our survey, iusm implemented several interventions including programs that were tailored to meet the specific needs of regional campus vcf and designed to reward them for their contributions to the medical education mission of the school. ultimately, our goal was to maximize the rewarding aspects of the vcf role and minimize the challenges experienced by these critical faculty. four new assistant dean positions jointly funded by the educational affairs and faculty development units were created to direct and implement faculty development targeted to vcf. each assistant dean had between .2 and .4 fte to accommodate their work. each assistant dean serves as a liaison for 2 campuses, tailoring faculty development resources to the regional context. the goal was set to have 2 face-to-face faculty development workshops at each campus annually. the assistant dean team developed a traveling curriculum (table 9) and shared it with each rmc. this allowed each campus to choose topics appropriate to their local needs, and we offered these onsite when requested. the traveling curriculum took into account the top needs that faculty had identified through the survey, as well as topics that were timely at the medical school as a whole or within the strategic goals of the medical school. since active learning was identified as a need by faculty, all sessions were designed to incorporate the principles of active adult learning to demonstrate how these concepts can be incorporated into all teaching in which our vcf are involved. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports online and asynchronous faculty development resources were made available to vcf to support their teaching development, including purchase of an institutional subscription to teachingphysician.org.15 teaching physician is an online resource that connects community physicians to just-in-time resources which include videos, practical clinical teaching tips, and links to further information if needed. teaching physician offers cme to physicians through the academy of family physicians, and specific topics are able to be sent in email format with a direct link to specific topics. these resources are promoted to vcf by the assistant deans and via electronic newsletter, and we ensure that all development includes continuing medical education (cme) credit to incent participation. all of our rmcs employ staff-level education coordinators who recruit vcf, manage communication, and work to retain them. our survey results indicated that our vcf often communicated most frequently with the staff members. given their important link directly with vcf, we have developed an emphasis on coordinator professional development. professional development sessions have been offered to the coordinators during our annual clerkship summits, mid-year retreats, and periodically during monthly meetings. additionally, the assistant deans make themselves available to the rmc education coordinators via email to answer any questions or brainstorm ideas as to how to better facilitate vcf development. these strategies have helped us increase the number of academic clinical departments who formally recognize the teaching excellence of vcf during their annual faculty award ceremony has increased. additionally, the assistant deans are helping to increase the number of vcf seek promotion. collaboration among assistant deans with the regional campus faculty and administrators allows for improved communication between the medical school and the vcf. the intent of the 4 assistant dean positions created at iusm for vcf teaching development outreach was to signal to the entire campus that all faculty are valued and in need of support to be successful. after 18 months of the dean roles being assumed, this intervention is proving to be a model that is slowly but surely giving vcf increased attention that they deserve. there are many reports of faculty development programs designed to improve the quality of teaching by faculty members and to address what is identified as a concern by over 80% of medical and allied health school deans.16 though effective in increasing faculty satisfaction and confidence and widely available at all medical schools, these types of programs often do not reach vcf who are not located at the academic medical center.4,17 there are few published reports of formalized programs designed specifically to address the specific needs of vcf. the university of nevada reno school of medicine developed a liaison for their community faculty in partnership with their office for community faculty (ocf).18 the liaison serves as a resource between their vcf and the library resources needed. part of their motivation for establishing this program was to serve the vcf, to improve access to educational and clinical care resources, and to better communicate with their vcf. this liaison, however, was focused on a partnership between the vcf, the ocf, and their medical library.18 the model at iusm differs from the model at the university of nevada reno school of medicine in that the assistant dean model utilizes faculty members and these members serve as an access point for vcf for all resources and benefits at iusm. they are also involved in the faculty development of the vcf affiliated with the medical school. though still evolving, the iusm model of assistant deans dedicated to the faculty development and well-being of vcf is one model for addressing the needs identified by vcf at our regional campuses. direct outreach and asynchronous learning has been the initial focus, and now development of iusm-specific asynchronous short modules is the next step identified for addressing the needs of these faculty members. other initiatives include support and encouragement for promotion of vcf (nearly 90% of our current vcf are at the assistant professor rank). with overall satisfaction of vcf high, we hope to continue to recruit and retain the best vcf possible while giving them the support needed to function in the changing health care environment in which they practice. the education of medical students is dependent upon clinical faculty in every region where medical students are located. following a decade of expansions of medical schools, the overall number of vcf associated with regional medical campuses and their professional development needs have increased. like community-based medical schools where community hospitals partner with the medical school as the doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports clinical teaching site rather than a traditional academic teaching hospital, iusm’s rmcs have partnered with community hospitals and physicians to offer clinical experiences to the medical students.14 while the questions on the survey of vcf were written specifically for iusm, literature suggests that the challenges faced by our faculty are not unique.5,6 although our survey results indicated that our vcf were relatively satisfied with their roles, we were concerned that approximately one-third of these critical faculty were not confident they would continue. indiana university school of medicine is the only allopathic school in the state; as such, it is critical that we continue to engage our students in community-based education. time is a critical factor for vcf, so these results helped us and may help other institutions to make the case for additional resources to make the teaching process as easy and enjoyable as possible for vcf. references 1. greenlick mr. educating physicians for the twentyfirst century. acad med. 1995;70(3):179-85. 2. ryan ms, vanderbilt aa, lewis tw, madden ma. benefits and barriers among volunteer teaching faculty: comparison between those who precept and those who do not in the core pediatrics clerkship. med ed online. 2013;18(1):20733. https://doi.org/10.3402/meo.v18i0.20733 3. sharp mc. recruiting community faculty. pediatrics. 1996;98(6):1268-72. 4. kumar a, kallen dj, mathew t. volunteer faculty: what rewards or incentives do they prefer? teach learn med. 2002;14(2):119-24. https://doi.org/10.1207/s15328015tlm1402_09 5. nuss ma, cervero r, hill j, gaines j, middendorf b. the development of newly recruited clinical teachers at a unique regional medical school campus. journal of regional medical campuses. 2018;1(4). https://doi.org/10.24926/jrmc.v1i4.1041 6. erikson c, hamann r, levitan t, pankow s, stanley j, whatley m. recruiting and maintaining us clinical training sites: joint report of the 2013 multidiscipline clerkship/clinical training site survey. washington, dc: association of american medical colleges. 2014. http://members.aamc.org/eweb/upload/13225%20wc%report%20final.pdf. accessed january 13, 2018. 7. drowos j, baker s, harrison sl, minor s, chessman aw, baker d. faculty development for medical school community-based faculty. acad med. 2017;92(8):1175-80. https://doi.org/10.1097/acm.0000000000001626 8. cheifetz ce, mcowen ks, gagne p, wong jl. regional medical campuses: a new classification system. acad med. 2014;89(8):1140-3. doi: 10.1097/acm.0000000000000295 9. association of american medical colleges (aamc). statement on the physician workforce, june 2006. http://www.aamc.org/download/55458/data/workf orceposition.pdf. accessed february 28, 2018. 10. smith ks, simpson rd. validating teaching competencies for faculty members in higher education: a national study using the delphi method. innov high educ. 1995;19(3):223-234. https://doi.org/10.1007/bf01191221 11. dankoski me, palmer mm, nelson laid tf, ribera ak, bogdewic sp. an expanded model of faculty vitality in academic medicine. adv health sci educ. 2012;17(5): 33-649. https://doi.org/10.1007/s10459-011-9339-7 12. palmer mm, dankoski me, smith js, brutkiewicz rr, bogdewic sp. exploring changes in culture and vitality: the 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development initiatives designed to enhance teaching effectiveness: a 10-year update: beme guide no. 40. med teach. 2016;38(8):769-86. https://doi.org/10.1080/0142159x.2016.1181851 18. jefferson kl, shultz m, heiselt a. serving community faculty through a dedicated liaison. med ref serv quart. 2018;37(1):1-9. https://doi.org/10.1080/02763869.2018.1404379 microsoft word lessons learned though a partnership.docx published by university of minnesota libraries publishing lessons learned through a partnership with marshallese faith-based organizations to screen for hypertension and diabetes pearl mcelfish journal of regional medical campuses, vol. 1, issue 3 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc doi: https://doi.org/10.24926/jrmc.v1i3.1044 pearl mcelfish, ph.d.; associate vice chancellor at the university of arkansas for medical sciences, northwest campus all work in jrmc is licensed under cc by-nc volume 1, issue 3 (2018) journal of regional medical campuses original reports lessons learned through a partnership with marshallese faith-based organizations to screen for hypertension and diabetes pearl mcelfish abstract background: marshallese are disproportionately burdened with higher rates of obesity, diabetes, cardiovascular disease, and infectious disease than the general us population. objective: to describe the lessons learned from conducting health screenings in faith-based organizations in the marshallese community. methods: health screenings were implemented by interprofessional collaboration of faculty and students from the colleges of medicine, nursing, pharmacy, and health professions, as well as marshallese community health workers and faith-based organization leaders. health screenings took place in marshallese faith-based organizations in northwest arkansas. results: lessons learned in the study include the importance of cultural protocol, effective communication, partnership with health care providers, logistics of set-up and implementation, and building the capacity of the churches to act on the information received. conclusion: working with marshallese faith-based organizations to conduct health screenings demonstrated an effective strategy in documenting crucial health information, conducting survey research, and connecting the community with health care services. keywords: community-based participatory research; pacific islanders; interprofessional; health disparities; minority health. introduction pacific islanders are the second fastest growing population in the united states.(1-5) while pacific islander populations grew in every state between 2000 and 2010, the fastest growth occurred in the south, with extremely rapid growth in arkansas (252%).(4) most of the pacific islanders in arkansas are marshallese from the republic of the marshallese islands. arkansas has the largest population of marshallese in the continental us with a population of 12,000 persons. (3,6-10) this growth is primarily focused in springdale, arkansas and has been perpetuated by employment in the poultry industry. pacific islanders, including marshallese, are underrepresented in all types of research. (11-17) much of the existing research aggregates data on pacific islanders and asian americans. the lack of research and research aggregation has masked health disparities, limited intervention development, and negatively affected the resource allocation and policy development needed to address pacific islanders’ health needs.(11-17) the limited data that is available shows that the marshallese face significant health disparities with higher rates of obesity, diabetes, cardiovascular disease, and infectious diseases than the us population.(18-23) additionally, marshallese living in arkansas face challenges with social determinants of health including low-income employment, low educational attainment, limited english proficiency, and multiple barriers to healthcare access.(24-26) in 2007, the university of arkansas for medical sciences (uams) established a regional campus in northwest arkansas with 3rd and 4th year medical and pharmacy students, as well as graduate programs in nursing and physical therapy. in 2013, uams northwest regional campus founded the office of community health and research to engage in community-based participatory research and programs designed to reduce health disparities in northwest arkansas while also engaging faculty and students of the regional campus in scholarly activities. uams used a community-based participatory approach to work with the marshallese community in arkansas to identify and address community health concerns. (6,24,27-29) marshallese community members identified faith-based organizations (fbos) as important to their culture and recommended that we work closely with fbos. stakeholders stated that virtually all marshallese attend at least one fbo on a regular basis. there are more than 30 active marshallese congregations in northwest arkansas. these fbos vary in size and attendance but collectively provide the most common social gathering site for the marshallese community. there is a high level of respect for pastors, pastors’ wives, and other leaders within the fbos. highly trusted bilingual marshallese staff at uams initiated contact with the fbo leaders to determine their interest in different health intervention opportunities. interest in a variety of potential interventions was discussed including establishing a garden and health committee, holding diabetes education classes, recruiting congregation members for training as community health workers, and conducting health screenings. interest in these activities has varied widely, with several of the fbos interested in health screenings. other projects are described in prior articles. (6,9,24,27-32) in this article, we present the lessons learned from the health screenings. journal of regional medical campuses, vol. 1, issue 3 original reports methods health screenings the office of community health and research partnered with the colleges of medicine, nursing, pharmacy, and health professions at the uams northwest regional campus to plan and implement the health screenings. the office of community health and research was responsible for managing the interface with the marshallese community and the research activities related to the health screenings. the interprofessional faculty and students were responsible for the biometric screening activities. prior to the screenings, all faculty, staff, and students involved in the screenings were provided cultural competency training, data measurement training, and research ethics training. study procedures were reviewed and approved by the uams institutional review board (#202720). health screenings were held on sundays immediately after services. pre-event site visits were conducted to exchange information with the fbo leadership. this meeting typically included the pastor, pastor’s wife, and deacons. the process included asking questions about the structure of services, number of adult participants, the physical location, and any restrictions related to the use of the facilities. staff also answered any of the fbo leadership’s questions and provided information about what takes place during the health screening events and why they are important. following the site visits, detailed plans were developed. during the health screenings, potential participants were provided information about the study and had the opportunity to give written consent. all activities and materials, including the consent process, were completed in english or marshallese, depending on the participant’s preference. most participants preferred their native language throughout the screening process. after participants had completed the consent process, they completed the survey instruments that collected information regarding their selfreported health status using the behavior risk factor surveillance study (brfss) core module, a health beliefs module, and demographic information. biometric measurements including height and weight, body mass index (bmi) calculation, blood pressure, and hemoglobin a1c (hba1c) were collected. all participants were provided their biometric results at the time of screenings. persons with elevated blood pressure or hba1c readings were provided counseling from onsite health professionals. the consultations included a focused discussion to assure the participants understood their test results, provided basic health information, and referred participants to a health care provider. participants received a $15 gift card for their participation. a culturally appropriate meal was provided for them at the screening. from september 2014 to february 2016, nine health screenings occurred at eight marshallese fbos (one large fbo hosted two health screenings to accommodate more members) and a total of 401 persons participated. of the 401 persons screened, 152 (38.4%) had test results indicative of diabetes, 129 (32.6%) had test results indicative of prediabetes, 163 (41.2%) had blood pressure indicative of hypertension, 155 (39.1%) had test results indicative of prehypertension, and 346 (89.7%) had a bmi that indicated overweight or obese. all persons with elevated hba1c or blood pressure results were referred for follow up by a healthcare provider. the results of the screening are discussed in a separate article.(33) in this article we present the lessons learned, which are summarized in five general areas: cultural protocols, communications, partnerships, location and logistics, and building capacity. these lessons were derived from our ongoing process improvement efforts that included conversations with more than 50 fbo leaders, program staff, and marshallese community leaders. results: lessons learned cultural protocols success was predicated on following cultural protocols with regard to communication and social interaction. elements of the cultural protocol included communicating with both female and male leadership. within marshallese fbos, there are distinct leadership roles for men and women. therefore, inclusion of and communication with both male and female leadership was essential to successful health screenings. cultural protocols also meant that it was important for the staff to build trust by attending fbo functions when invited. the research team attended multiple sunday services, as well as birthday parties held at the fbos to build rapport. in addition, gifts of food were an important element in fulfilling the cultural protocols. fruit baskets were provided at the first meeting with fbo leadership, and lunch was provided at every screening event. communications most verbal communication was conducted in the native marshallese language. effective communication was possible because of the engagement of trusted bilingual marshallese staff and community health workers who facilitated the majority of communication before, during, and after the health screenings. the project was led by a bilingual marshallese project manager, with the assistance of six bilingual marshallese staff and community health workers. a sufficient number of well-trained bilingual research staff is critical to successful implementation. extensive pre-event communication with fbo leaders and the broader congregation is essential. bilingual staff met with fbo leaders prior to the screenings to fully explain the process. after the first few screenings, the research team found that participants were coming to the health screening events without a full understanding of what would take place. although the health screenings were explained to fbo leaders, the congregation members were not well informed prior to the health screening. this led to strategies to assure that the fbo leaders and congregation members had appropriate understanding and expectations prior to the day of the health screening. a one-page journal of regional medical campuses, vol. 1, issue 3 original reports information flyer about the health screening was created listing all of the activities that would be performed. additionally, bilingual marshallese research staff attended the fbo’s service a week or two before the health screening and provided both an oral and written description of what would occur. these congregational meetings were also important because they allowed bilingual research staff to answer any questions posed by the congregation. communication of results at the individual and congregational level is important. it was crucial for participants to immediately receive their health screening results alongside counseling with the health professionals and a referral to health services. we found that it was also important to provide aggregate results for the specific fbo and from all of the fbo screenings to the fbo leadership and the entire congregation in an oral and written report. then they could begin to address some of the health concerns documented as part of the health screenings. the local dissemination of results back to the fbos has created broader awareness and healthy competition among the fbos as they strive to improve the health of their congregations. providing the results at the individual, organizational, and community levels has aided in the overall understanding of the purpose of the health screenings and provided awareness of chronic disease management and chronic disease prevention. partnerships the screenings were part of an interprofessional partnership among the colleges of medicine, nursing, pharmacy, and health professions. there was a high level of participation from faculty and students within each of the colleges. the interprofessional partnerships with the colleges was key in having almost 30 trained data collectors at each health screening and allowed health care professionals to be on site to counsel participants and make appropriate referrals. additionally, it was important to partner with marshallese community health workers to follow-up with participants on the referral information provided and help participants overcome any social-ecological barriers they encountered when making appointments. as the screenings progressed, we partnered with other health care providers outside of our organization to offer additional health screening components. the local health department conducted tuberculosis skin test screenings as a way to help address the tuberculosis epidemic in the marshallese community. a local pharmacy provided influenza vaccines at no cost to the participants at some of the screening events. the federally qualified health center, which provided much of the primary care and chronic disease management for patients, came to the health screenings to discuss dental care and meet with participants who needed referral services. partnering with other health care providers was both beneficial and disruptive. some participants were distracted by additional activities. however, the direct benefit to the participants and community outweighed any challenges. location and logistics hosting the health screenings at the fbos where participants were already going removed logistical barriers and allowed participants to easily access health screenings in a familiar location. participants and fbo leaders noted that the convenience was an important component of success. while the location was convenient for participants, it did create logistical challenges for the study team. each health screening took place at a unique physical environment, and therefore, each health screening set-up and execution required a slightly different logistical plan. furthermore, the screenings often took place in the same physical space as the worship service, so the set-up process could not be done until the service was over. to mitigate these challenges, the team went to the locations several weeks prior to the event and mapped out where each screening station would be placed. this made set-up much easier, but it is important to note that the set-up process was always somewhat hectic regardless of the amount of planning and preparation. consent, surveys, and biometric screenings were typically done in one large open space, which reduces privacy and confidentiality. due to the private nature of the health counseling sessions, a separate room (often a small classroom) was identified at each location to serve as a private counseling room. however, there were still concerns about stigmatizing those who attend the health counseling sessions. the idea of working with fbos came directly from community stakeholders, and fbo leaders were consulted regarding health screenings during individual and group meetings. however, in retrospect, the research team would have engaged some of the pastors more intensely on the research planning team and in protocol development so that pastors could have taken an earlier and stronger role in leading the project. it is important to maintain flexibility and make changes as stakeholders continually provide input. we sought feedback from multiple stakeholders throughout the implementation which resulted in five different protocol changes that included changing instruments. these changes included dropping a survey instrument. we initially conducted a health belief survey and a modified version of the core module of the brfss. after feedback from participants and stakeholders, we stopped using the health belief survey to reduce participant burden. building capacity as we assessed our efforts, we understood that there were critical components missing in our health screening program. while we were providing participants and fbo leaders with health information, they often lacked the capacity for addressing health disparities that were identified. the lack of capacity to address health disparities created a significant ethical concern, which led to a concerted effort to develop the overall capacity of the fbos to address health journal of regional medical campuses, vol. 1, issue 3 original reports disparities. to build this capacity, we have begun implementing the manu-o-ku curriculum with the marshallese fbo leaders. the manu-o-ku was developed and implemented in hawaii and in us-affiliated pacific islands by the faith in action research alliance. the manu-o-ku training focuses on building the motivation and capacity of fbo leaders to address chronic disease through a focus on stewardship of the spirit, mind, and body. after providing motivation and context for health information and health behavior change, the curriculum focuses on teaching fbo leaders how to address chronic disease. in addition to building the capacity of the fbos, it was important to build the capacity of the research staff, faculty, and students. all staff, faculty, and students were required to complete cultural competency training that focused on marshallese history and health beliefs. the cultural competency training was an important component of the success as they helped staff, faculty, and students be aware of cultural considerations and helped them feel more comfortable interacting with participants during the health screenings. in western culture, receiving information about one’s health is considered very important, and we often refer to knowledge as power. however, not all cultures view information alone as power. marshallese stakeholders saw the information on health status as inappropriate unless we built capacity to address the identified health disparities. therefore, providing individual referrals and follow-up with patients, building the capacity of the fbos to address the health disparities, and working to design and implement programs and additional that address the health disparities identified is of critical importance. conclusion marshallese are severely underrepresented in all types of research. novel methods are needed to document local health disparities and engage the marshallese community in health disparities research. working with marshallese fbos to conduct health screenings has been an effective strategy to engage with the marshallese community to document critical health status information, conduct survey research, and link participants with the health care services they need. the manu-o-ku training allowed the research team to build the capacity of the fbos and fbo leaders to facilitate future research projects. the lessons learned through this study have been applied to future research that will focus on meeting the obesity, diabetes, and hypertension disparities identified. by attending to cultural nuances, the research ensured mutual and balanced benefits of the research activity to the study team, participants, and the community. acknowledgments this research is made possible because of our cbpr partnership with the marshallese consulate general in springdale, arkansas, marshallese faith-based leaders, the arkansas coalition of marshallese, and the gaps in services to marshallese task force. we also acknowledge the work of eleanor hughes and leslie hitt who organized interprofessional faculty and students to make the project possible. lastly, we acknowledge the students and faculty of the northwest regional campus for their contributions. funding/support: cbpr partnership support is provided by the university of arkansas for medical sciences translational research institute grant (#ul1tr000039), which is funded through the national institutes of health’s national center for research resources and national center for advancing translational sciences. the content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the funders. ethical approval: the institutional 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mcelfish p, rowland b, long c, et al. diabetes and hypertension in marshallese adults: results from faith-based health screenings. journal of racial and ethnic health disparities. 2017;4(6):1042-1050. microsoft word tracking medical students and graduates from hometown article.docx published by university of minnesota libraries publishing tracking medical students and graduates from hometown to practice using geographic information systems, 2011-2017 komal kochhar, laurie m. fancher, james j. brokaw, jeffrey s. wilson, peter m. nalin doi: https://doi.org/10.24926/jrmc.v1i3.1136 journal of regional medical campuses, vol. 1 issue 3 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc komal kochhar, office of research in medical education, dean’s office for educational affairs, indiana university school of medicine, indianapolis, indiana laurie m. fancher, office of research in medical education, dean’s office for educational affairs, indiana university school of medicine, indianapolis, indiana james j. brokaw, department of anatomy and cell biology, indiana university school of medicine, indianapolis, indiana jeffrey s. wilson, department of geography, indiana university school of liberal arts, indianapolis, indiana peter m. nalin, dean’s office for educational affairs, indiana university school of medicine, indianapolis, indiana corresponding author: komal kochhar, 410 w. 10th street, hits building, suite 2100, rm 2127, indianapolis in, 46202. e-mail: kkochhar@iupui.edu all work in jrmc is licensed under cc by-nc volume 1, issue 3 (2018) journal of regional medical campuses original report tracking medical students and graduates from hometown to practice using geographic information systems, 2011-2017 komal kochhar, laurie m. fancher, james j. brokaw, jeffrey s. wilson, peter m. nalin abstract background: indiana university school of medicine (iusm) through its statewide system provides medical education and clinical experiences across indiana for more than 1450 medical students in nine regions, including indianapolis and eight regional medical campuses (rmcs). the majority of medical students begin their education distributed among the rmcs, and some students continue clinical experiences at the rmcs for their third and fourth years. methods: we used a geographic information system (gis) to visualize and document the contribution of our rmcs in indiana to the physician workforce pipeline. using data from the 2011-2017 graduating classes, we created a geospatial database that linked key information from student records and public domain sources (e.g., hometown, campus assignment, pgy1 specialty, and practice) with their corresponding locational information. arcgis 10.5 gis software was used to produce a series of maps to visualize patterns in student outcomes among the rmcs over time. results: by using gis to track medical trainees from hometown to practice, we can provide accurate visualization of extensive geographic data. the maps revealed similarities and differences among the rmcs not fully appreciated until visually mapped, including the specialty choice of students from different campuses and the proportion of graduates practicing in medically underserved areas of the state. conclusions: gis maps and their analyses can identify strengths and distinctions among the rmcs while providing accurate descriptions of the role of geography in the professional development journey of the physician workforce. this ongoing project is a major step toward integrating gis as a familiar tool in academic administration and health workforce research to assist future decision-making by the school leadership. introduction according to the liaison committee for medical education (lcme), there are currently 166 lcmeaccredited medical schools in the united states and canada.1 about a third (55) of these schools operate regional medical campuses (rmcs) in geographically separate locations from the main medical campus.2 although rmcs must comply with the same lcme standards as the school’s main medical campus to ensure high-quality comparable education, the rmcs often have a unique focus or mission that differs from their parent campus (e.g., rural medicine).3 cheifetz et al.4 have proposed a classification system for rmcs based primarily on student class years on campus. with this system, rmcs can be classified into one of four models: basic science, clinical, longitudinal, or combined, depending on the particular mix of basic science and clinical instruction at a given campus. the indiana university school of medicine (iusm) employs a large geographically distributed system of medical education, with over 1450 students enrolled across eight rmcs and the main medical campus in indianapolis. approximately two-thirds of each entering class is distributed among the eight rmcs associated with university campuses at bloomington, evansville, fort wayne, northwest (located in gary), muncie, south bend, terre haute, and west lafayette. the remainder of the class matriculates at indianapolis. using the journal of regional medical campuses, vol. 1, issue 3 original report nomenclature of cheifetz et al.4, the rmcs of iusm would be classified under the combined model. iusm rmc students complete their basic science years one and two onsite. they may also complete their clinical years three and four at the rmc, or they may opt to return to indianapolis to complete their clinical years. in addition, iusm provides postgraduate training for nearly 1200 residents and 90 fellows per year through its 141 residency and fellowship programs. knowing exactly where our future physicians are coming from and where they eventually settle into practice can provide critical information for medical school administrators and policy makers who must strategically align iusm’s educational mission with the physician workforce needs of the region, thereby facilitating more equitable distribution of the physician workforce in indiana. however, tracking medical trainees in such a large and complex system presents a formidable administrative challenge. to address this challenge, we employed a geographic information system (gis) to track our trainees through the medical education ‘pipeline’ from their hometown origin to their professional practice location. the power of gis to store, analyze, and display data linked to geographic locations provides a visually-striking and easily understood way to convey complex information to administrators and policy makers. although gis is frequently used to investigate spatial relationships of health and disease, such as in disease mapping and access to care studies5, there are relatively few examples of gis being used for administrative purposes in medical education. for instance, some investigators have used gis to assess the spatial distribution, or ‘footprint’, of family medicine residency graduates in relation to patient populations in areas of need.6,7 we are not aware of any published studies using gis to track a large cohort of students from a single medical school across the continuum of medical education—from their hometown and college, entry into medical school, through residency and fellowship, and into professional practice. the purpose of this study was two-fold. the first was to compare the career paths of students doi: https://doi.org/10.24926/jrmc.v1i3.1136 at rmcs and students at the indianapolis campus in terms of their hometown origin, specialty choice, and practice location, particularly relative to health professional shortage areas (hpsas) or medically underserved areas (muas).8 the second was to provide a practical example of how gis can be used to inform decision-making and visually demonstrate the merits and unique attributes of rmcs. the campuses and communities of indiana’s statewide system the eight cities hosting the rmcs represent the largest population centers outside of indianapolis (table 1). each rmc is located on the campus of a local university, which provides the academic infrastructure for the faculty. all of the rmcs develop strong partnerships with their local medical communities to support students’ clinical education. by virtue of their locations, the rmcs produce graduates that are well-attuned to the local health care needs of the community. some graduates will return to the campus region to practice primary care medicine which helps alleviate local shortages of health care providers. this is because all of the iusm campuses, except the fort wayne rmc, are located in either a primary care hpsa or a mua. the health resources and services administration (hrsa) defines hpsas as geographic areas and populations with health care provider shortages in primary care, dental care, or mental health; muas are defined as geographic areas with inadequate access to primary care services.8 although several eligibility criteria are used in defining hpsas and muas, the population to provider ratio is especially important in both designations. there are currently 160 primary care hpsas and 45 muas in indiana, which collectively encompass 36% of the state’s population.8 due to the strict lcme accreditation standards mandating comparable educational experiences across multiple campuses, iusm closely monitors the curriculum delivery, student support services, and all other campus operations journal of regional medical campuses, vol. 1, issue 3 original report to assure that the education of students is as similar as possible across all instructional sites. table 1 demographic characteristics of cities with iusm campuses data from: www.statsamerica.org/town methods using data from the 2011-2017 graduating classes of iusm, we compiled a geospatial database that linked student data obtained from official school records with locational information about graduates acquired from publically-accessible sources. the office of medical student education provided us with information concerning each graduate’s hometown, iusm campus assignment, and pgy1 match specialty. google searches of university and hospital websites were conducted to determine each graduate’s professional practice location as of the summer of 2017. in this manner, a longitudinal record of each graduate’s journey through the medical education pipeline was created to facilitate individual tracking. after the completion of the geospatial database, arcgis 10.5 software (esri, redlands, ca) was used to produce a series of maps to illustrate the career progression and location of these graduates over time. data was aggregated across the study period to provide a more robust sample size and dampen the effects of year-to-year variation in graduating classes. for the purposes of this study, three maps have been selected that visually highlight similarities and differences in the graduating classes associated with each of the nine iusm campuses. these three maps show the composition of each campuses’ graduating class relative to the county of their hometown, pgy1 match specialty, doi: https://doi.org/10.24926/jrmc.v1i3.1136 and current practice location relative to hpsas or muas. results table 2 summarizes the entire cohort of iusm graduates by their hometown, pgy1 match specialty, and practice location relative to hpsas or muas. table 2 – characteristics of indiana university school of medicine graduates (2011-2017) a hometown data unavailable for 2011 graduates b primary care is defined as general internal medicine, family medicine, and pediatrics (including internal medicine-pediatrics) c graduates of 2014-2017 are not yet in practice iusm divides the state into nine non-overlapping campus regions (shown using bold black lines in figure 1). each campus region consists of the county containing the iusm campus and a surrounding cluster of contiguous counties. these nine campus regions represent each campus's recognized sphere of influence with regard to fundraising, community support, and clinical affiliations. as a group, the majority of graduates (63%) had hometowns in counties located outside the region of the iusm campus they attended. most of the iusm graduates entered a specialty care field (62%), and after their post-graduate training, the majority of iusm graduates (60%) settled into practice locations outside of hpsas or muas in indiana or elsewhere. in contrast to these aggregate statistics, the maps revealed some interesting variations among the rmcs and indianapolis campus. doi: https://doi.org/10.24926/jrmc.v1i3.1136 journal of regional medical campuses, vol. 1, issue 3 original report as shown in figure 1, nearly half of the graduates from the northwest rmc (48%) and indianapolis campus (48%) originated from the corresponding campus regions (blue and green wedges), whereas only 11% of the graduates from the terre haute rmc had hometowns in its region. the remaining rmcs had intermediate values between these two extremes. figure 2 shows that the proportion of graduates entering the primary care fields of general internal medicine, family medicine, and pediatrics (including internal medicine-pediatrics) was similar among all of the iusm campuses (ranging from 32%-41%), with the notable exception of the terre haute rmc, which had over one-half (56%) of its graduates match into primary care fields. also, the terre haute rmc had a greater proportion of its graduates entering family medicine than any other iusm campus. journal of regional medical campuses, vol. 1, issue 3 original report as is evident in fig. 3, the graduates from the rmcs are no more likely to practice in hpsas or muas compared to graduates from the indianapolis campus. the south bend and bloomington rmcs produced the greatest proportion (45%) of graduates practicing in hpsas or muas, and the muncie rmc produced the smallest (27%). discussion using gis, we have traced the career paths of iusm students at the rmcs and indianapolis campus from their place of origin, through their medical training, and into practice. the resultant maps revealed patterns that are easily discerned and interpreted with minimal effort, which is perhaps doi: https://doi.org/10.24926/jrmc.v1i3.1136 the greatest advantage of gis. although the same data could be presented in tabular format for each campus, the underlying patterns would not be as readily apparent nor as compelling as when presented in maps. when sharing class data with the school leadership, we have found that maps such as these can communicate key similarities and differences among the rmcs and the indianapolis campus effectively, and can even help dispel some long-held misconceptions about the rmcs. to properly interpret our maps, it is necessary to understand how newly admitted students are assigned to a campus. the assignment of students to an rmc or the indianapolis campus is not random, but based on a combination of student preference and the availability of space. when students are notified of their acceptance into medical school, they are asked to rank order their preferred campus assignment. the campus assignment process occurs after acceptance into medical school and has no bearing on the admission decision (e.g., a student cannot enhance his or her chances of admission by expressing a desire to attend an rmc). a computerized lottery system is used to optimally match each student’s rank list to the available campus capacity at the time of assignment. certain categories of accepted students automatically receive their first choice of campus assignment (e.g., early decision applicants), whereas others are not given the option of campus preference and are assigned strictly on the basis of available space (e.g., late admits taken from the alternate list). as might be expected, not all iusm campuses are equally popular with students. a few campuses, especially indianapolis, receive more first-choice requests for assignment than available space permits, but other campuses must fill their classes with students who would have preferred another campus assignment. when the study cohort was entering medical school during the 2007-2013 timeframe, iusm was incrementally expanding the class size from 294 in 2007 to 344 in 2013. over one-half of each incoming class was assigned to the rmcs. for example, the entering class of 2013 was distributed as follows: indianapolis (138), bloomington (36), journal of regional medical campuses, vol. 1, issue 3 original report fort wayne (32), northwest (26), muncie (24), south bend (24), terre haute (24), evansville (20), and west lafayette (20). iusm currently admits 364 students per year and the majority (62%) are assigned to the rmcs. the map of hometown origins (fig. 1) reflects both the vagaries of the school’s campus assignment process as well as the unique attributes of each iusm campus that may serve to attract an incoming student. as a state-supported medical school, iusm favors indiana applicants over nonresidents, which comprise only 15%-20% of the entering class overall. it is therefore expected that the vast majority of students assigned to iusm campuses are indiana residents. what is noteworthy, however, is that some rmcs are able to fill a sizable portion of their entering class with students from the surrounding campus region, but other rmcs fill primarily with students from more distant regions of indiana. in the case of the terre haute rmc, the relatively small subset of students from that campus region is explicable because this particular rmc offers a unique curricular track for students interested in rural medicine, which will naturally attract students from across the state. the observed variation in the proportion of rmc students who are from the corresponding campus region is probably attributable to several factors, including the number of students accepted into medical school from that particular region and how those students rank the local rmc during the campus assignment process. after graduating from medical school during the 2011-2017 timeframe, most of the study cohort entered post-graduate training in specialty fields, especially anesthesiology, emergency medicine, and general surgery. a smaller percentage of the cohort matched into primary care. what is particularly revealing about the map of top specialties (fig. 2) is that most of the rmcs appear to produce about the same proportion of specialists as the indianapolis campus, which contradicts a common misconception about the rmcs—that they are designed chiefly to produce primary care physicians, particularly family practitioners. the terre haute rmc does produce doi: https://doi.org/10.24926/jrmc.v1i3.1136 proportionally more primary care physicians than any other iusm campus, but that is largely due to its special rural medical education program, which emphasizes primary care. in contrast, the other rmcs tend to mirror the indianapolis campus in terms of specialist production, suggesting that students attending the rmcs and indianapolis campus have similar career aspirations. when iusm’s statewide system of medical education was established in the early 1970s, it was generally assumed that students who were exposed to the training environments of the rmcs would be predisposed to eventually return to those regions to practice, and that they would be more inclined to practice primary care medicine. by analyzing a large dataset of iusm graduates from the classes of 1988-1997, researchers found that students who attended the rmcs were statistically more likely to practice primary care medicine in local communities compared to students who attended the indianapolis campus.9,10 however, in the ensuing 20-30 years since these graduates completed residency and settled into practice, the rmcs have evolved considerably and are no longer limited to pre-clinical education since they now offer third and fourth year clerkships as well. perhaps as the training environments of the rmcs and indianapolis campus have become more similar over time, the specialty preferences of their students have followed suit. another somewhat surprising observation is the relatively low percentage of rmc graduates practicing in hpsas or muas, which might be assumed to be higher given the history of the statewide system of medical education. after all, one of the rationales for establishing the rmcs in the first place was to improve the supply of primary care providers to rural communities and other areas of need. nevertheless, the map of practice locations (fig. 3) clearly shows that the rmc graduates are no more or less inclined to practice in underserved communities than are the graduates from the indianapolis campus, which further underscores their similar career aspirations. few published studies have taken advantage of gis to track medical trainees for journal of regional medical campuses, vol. 1, issue 3 original report research or administrative purposes, and those that have used gis were focused on graduates of family medicine residency programs. for example, reese et al.6 combined information from the american medical association physician masterfile and the graduate registries for two family medicine residency programs in north dakota and louisiana that closed between 2000 and 2006 to determine the practice locations for 209 of the program graduates. the resultant maps revealed the local impact of the program closures on physician access in rural areas and hpsas. in a similar study, hixon et al.7 mapped the practice locations for 86 university of hawai’i family medicine and community health graduates from 1993 to 2010 to determine the percentage working in hpsas. our study may be the first application of gis for the large-scale tracking of medical students across the spectrum of their training and into practice. limitations as in any large dataset collated from multiple sources, our geospatial database had the inevitable missing or inaccurate data elements. we were unable to obtain the hometown information for the class of 2011, though all other data elements for that class were present. determining the current practice locations of graduates was sometimes challenging because we relied on the accuracy of publically-accessible sources on the internet, such as hospital and clinic websites, which are not always updated in a timely manner. in addition, name changes due to marriage or other circumstances occasionally made it difficult to verify a graduate’s practice location. nevertheless, we were able to confirm the practice locations for 79% of the study cohort now in practice. conclusions by using gis to trace the career paths of iusm students at the rmcs and indianapolis campus over time, we have revealed some interesting aspects of the rmcs that were not fully appreciated until visualized in the form of maps. the most striking observation apparent on even casual inspection is how similar the career doi: https://doi.org/10.24926/jrmc.v1i3.1136 outcomes of the students at the rmcs versus the indianapolis campus were with regard to specialty selection and practice location. this suggests that the training environments of the iusm campuses are sufficiently alike to engender similar career paths for the students. we believe that gis offers a powerful tool to track medical students across the continuum of medical education, and that the administrators and policy makers in particular can benefit from using gis maps to inform their decision-making. future studies although beyond the scope of this descriptive study to properly answer, our findings did raise some interesting questions about the rmcs that may warrant further study, for example: • why are some rmc’s more popular than others in attracting newly admitted students and what can be done to enhance these students’ opinions of the less popular rmcs? • do students who come from outside of indiana have career aspirations different from those of indiana students? • do students who were early decision admits have career aspirations different from those who were late admits? • is the specialty choice and practice location of graduates who spend their entire four years at a single rmc different from those who transferred to indianapolis after two years? • why are some rmcs more successful than others in producing graduates who choose to practice in hpass or muas? at present, we can only speculate about the causal factors that produced our observations. more indepth studies using both quantitative and qualitative methods will be necessary to obtain definitive answers to these questions. references 1. liaison committee for medical education. medical school directory. doi: https://doi.org/10.24926/jrmc.v1i3.1136 journal of regional medical campuses, vol. 1, issue 3 original report http://lcme.org/directory/. accessed january 7, 2018. 2. association of american medical colleges. group on regional medical campuses. official medical regional campuses may 2013. https://www.aamc.org/members/grmc/. accessed january 7, 2018. 3. rabinowitz hk, diamond jj, markham fw, wortman jr. medical school programs to increase the rural physician supply: a systematic review and projected impact of widespread replication. academic medicine 2008; 83(3):235–243. 4. cheifetz ce, mcowen ks, gagne p, wong jl. regional medical campuses: a new classification system. academic medicine 2014; 89(8):1140-1143. 5. lyseen ak, nøhr c, sørensen em, gudes o, geraghty em, shaw nt, bivona-tellez c. a review and framework for categorizing current research and development in health related geographic information systems (gis) studies. yearbook of medical informatics 2014; 9:110-124. 6. reese vf, mccann jl, bazemore aw, phillips jr rl. residency footprints: assessing the impact of training programs on the local physician workforce and communities. family medicine 2008; 40(5):339-344. 7. hixon al, buenconsejo-lun le, racsa cp. gis residency footprinting: analyzing the impact of family medicine graduate medical education in hawai’i. hawai’i journal of medicine & public health 2012; 71(4):31-39. 8. health resources and services administration data warehouse. find shortage areas by address.https://datawarehouse.hrsa.gov/to ols/analyzers/geo/shortagearea.aspx. accessed february 1, 2018. 9. brokaw jj, mandzuk ca, wade me, deal dw, johnson mt, white gw, wilson js, zollinger tw. the influence of regional basic science campuses on medical students’ choice of specialty and practice location: a historical cohort study. bmc medical education 2009; 9:29. doi:10.1186/14726920-9-29. wade me, brokaw jj, zollinger tw, wilson js, springer jr, deal dw, white gw, barclay jc, holloway am. influence of hometown on family physicians’ choice to practice in rural settings. family medicine 2007; 39(4):248-254. microsoft word outcomes of a rural focused article.docx published by university of minnesota libraries publishing outcomes of a rural-focused family practice residency: exploring influences impacting obstetric practices sandra stover, md, faafp; julia lasswell; samantha c. friedrichsen, mph; rebecca l. emery tavernier, phd, lp, pmh-c doi: https://doi.org/10.24926/jrmc.v5i1.4338 journal of regional medical campuses, vol. 5, issue 1 (2022) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc sandra stover, md, faafp, assistant professor, department of family medicine and biobehavioral health, university of minnesota medical school, duluth campus, duluth, minnesota julia lasswell, medical student, university of minnesota medical school, minneapolis, minnesota samantha c. friedrichsen, mph, senior healthcare analyst, blue cross and blue shield of minnesota, eagan, minnesota rebecca l. emery tavernier, phd, lp, pmh-c, licensed psychologist, essentia health, duluth, minnesota corresponding author: sandra stover, md, faafp dmed family medicine & biobehavioral health 155 smed 1035 university drive duluth, mn 55812-3031 218-370-1100 stove007@d.umn.edu all work in jrmc is licensed under cc by-nc volume 5, issue 1 (2022) journal of regional medical campuses original reports outcomes of a rural-focused family practice residency: exploring influences impacting obstetric practices sandra stover, md, faafp; julia lasswell; samantha c. friedrichsen, mph; rebecca l. emery tavernier, phd, lp, pmh-c abstract purpose: family medicine physicians play a crucial role in maternity care in community-based settings. however, residency graduates are decreasingly likely to provide delivery services. we explored residency training and graduates’ inclusion of obstetrical care in practice by surveying graduates of the duluth family medicine residency, which traditionally produces a high number of graduates serving rural communities and providing obstetrical care. methods: graduates (n = 48) were surveyed about their maternity care provision and perceptions of preparedness for such services during residency. additional factors impacting decisions to provide obstetric care (eg, postresidency training, community size, and presence of obstetricians providing delivery services in their community) were evaluated using chi-square or fisher’s exact tests. findings: of the 46% of graduates providing maternity services, most provided perinatal clinical care (68% provided delivery care and 4% provided operative deliveries). seventy-one percent worked in a community with an available obstetrician. graduates providing obstetric services were more likely to live in rural communities (66% vs 35%, p < .01). thirty percent of graduates received extra obstetrical training in residency. those providing obstetric services were more likely to cite that their decision to practice obstetrics was influenced by the number of deliveries performed, interactions with attending obstetricians, and interactions with prenatal and laboring patients during residency compared to those not providing obstetric services (p < .05). conclusions: residency training has an impact on the provision of maternity care and potential practice of family physicians in rural communities. attention to curricular support, particularly exposure to maternity patients, is important for resident comfort in obstetrics. introduction availability of community-based obstetrical care for rural families has declined in the united states over the past 2 decades.1 hospitals with birth volumes fewer than 240 per year are more likely to have family physicians and general surgeons attend deliveries, while higher-volume centers are more likely to have obstetricians and midwives in attendance.2 family medicine physicians play an important role in rural areas, as they provide the majority of the maternity care.3 however, despite some positive benefits in reduction of career burnout,4 there is a smaller percentage of family medicine residency graduates adding obstetrical delivery care to their practices than there was in 2000.1 family physicians face challenges in providing maternity care, including variation in available obstetrical training during residency, credentialing problems postgraduation, and perceived “turf battles” over which type of provider has the best skill set to administer maternity care.4-6 recent studies show that residency graduates with interest in obstetrical care have difficulty finding positions that allow them to use their delivery skills.7 sustainability of a rural practice, including obstetrics, can also be challenging for fellowship-trained providers.8,9 a scarcity of trained providers within a community has the journal of regional medical campuses, vol. 5, issue 1 original reports potential to impact optimum maternity care for rural communities, as increased distance to access delivery care can increase maternal anxiety10 and separating perinatal care from delivery care may interrupt continuity relationships between provider and patient. as such, understanding optimal training and experiential skill development by family physicians, ensuring the provision of best practice in obstetrical care, and addressing provider sustainability are all important aspects to building an effective delivery team within health care systems. the variability between family medicine residency training programs has not gone unnoticed.4 in 2014, the accreditation council for graduate medical education (acgme) updated training expectations for family medicine residencies to include competencybased requirements rather than volume-based ones; unfortunately, the definition of obstetrical competencies in this redirection was not well defined. residencies have responded variably in their program parameters and in skills assessments regarding obstetric competencies following this change.11 less than a decade has passed since the acgme changes went into effect, and the repercussions to those changes should soon begin to be noticeable. there are opportunities for comparing and tracking graduate outcomes and how they impact objectives in providing needed obstetrical care, particularly in rural areas, though there have been limited efforts to do so. this study aimed to understand characteristics of family medicine physicians who currently practice obstetrical care, with a focus on aspects of their residency training that may have influenced their decision to provide such care. these aims were explored in a sample of graduates who trained at the duluth family medicine residency program. this rural-focused residency has been in operation since 1975, and its graduates primarily serve communities with populations under 25,000. residency graduates were surveyed to determine whether they currently practice maternity care in their communities. perceptions of how well the residency prepared them to provide such services were assessed. additional factors that impacted decisions to provide obstetric care—such as postresidency training options in obstetric fellowships, community size, and if there were obstetricians providing delivery services in their community—were also evaluated. doi: https://doi.org/10.24926/jrmc.v5i1.4338 methods participants and procedures data for this study were collected between august and october 2020. graduates of the duluth family medicine residency program who had contact information available were invited by email to complete a redcap survey assessing their experiences delivering obstetric services.12 this study was determined to be exempt by the university of minnesota institutional review board. measures the electronic survey included a researcherdeveloped questionnaire assessing participant demographics (eg, gender, zip code of current medical practice, population of the town where current medical practice is located), residency information (eg, year of residency graduation, feedback on training experiences during residency), current obstetric practices (eg, obstetric practices available in community, types of obstetric practices provided by participant), residency experiences that influenced participants’ decisions to practice obstetrics (eg, interactions with prenatal and laboring patients, number of deliveries performed), and residency program feedback. all questions were multiple choice or short text write-in, apart from one residency feedback question. for this question, participants were asked to provide a write-in response describing what they think would be most beneficial to include in a family medicine residency program to promote obstetrical training. statistical analysis analyses were conducted using sas 9.4 (sas institute inc., cary, nc). descriptive statistics were initially calculated for all survey items. zip codes of the participants’ medical practice locations were classified as rural or urban according to the federal office of rural health policy’s rural areas listing (https://www.hrsa.gov/rural-health/aboutus/definition/ datafiles.html), and these locations were mapped. this method of using zip codes to designate ruralurban status is based off rural-urban commuting area (ruca) codes. chi-square tests were conducted to explore whether the likelihood of practicing obstetrics varied by (1) participation in the obstetrics fellowship, journal of regional medical campuses, vol. 5, issue 1 original reports (2) participant gender, (3) availability of a local obstetric practice, (4) rural or urban medical practice location, and (5) year of residency graduation. the prevalence of residency experiences noted as contributing to participants’ decisions to practice obstetrics was also compared between graduates practicing versus not practicing obstetrics using chisquare tests. fisher’s exact tests were used when cell sizes were too small for chi-square tests. p values < .05 were considered statistically significant. in addition to statistical significance, clinical significance was also considered in the interpretation of results. given the limited sample size, write-in responses were not formally qualitatively analyzed. instead, key quotes from these write-in responses were organized according to similarity and used to inform the quantitative results. results sample characteristics of the 130 survey invitations sent, 45 participants completed the entire survey and 3 participants partially completed the survey, resulting in an analytic sample of 48. as shown in table 1, just more than half of survey respondents identified as female (52%, n = 24/46). years of residency graduation ranged from 1975 to 2020, with nearly half of respondents having completed residency after 2010 (46%, n = 22). respondents were currently located at practices in towns that varied in population size from 300 to 300,000 people. most practices were located in a rural zip code (63%, n = 29). just less than half of the respondents had changed clinical sites since their first postresidency site (46%, n = 22), and the median number of hospital beds at the current practice was 25, ranging from 0 to 500 (data not shown). practice locations are displayed in figure 1. table 2 provides details on the types of obstetric services provided at the respondents’ practice locations. as shown, most respondents were practicing in a community with an obstetrician (71%, n = 34), with at least 1 physician practicing obstetric care (85%, n = 39). there were only 4 respondents (9%) who reported at least 1 general surgeon providing c-sections in the community. the number of deliveries per year at the practice varied widely from 0 to 2,000, with more than one-quarter of doi: https://doi.org/10.24926/jrmc.v5i1.4338 respondents reporting that the delivery trend is decreasing (27%, n = 13). as shown in table 3, nearly half of respondents (n = 22, 46%) were currently providing obstetric services, the majority of whom reported providing prenatal (n = 20, 91%) or postpartum (n = 19, 86%) care, while fewer are conducting vaginal (n = 15, 68%) or operational (n = 9, 41%) deliveries. nearly 30% of respondents obtained additional obstetrics training during residency (n = 14), though only 4% went on to complete an obstetrics fellowship (n = 2). for respondents who stopped providing obstetric services, there were a variety of reasons reported, but the majority indicated that they stopped due to personal choice for career change (42%, n = 11). examining key characteristics by whether or not residency graduates are currently providing obstetric services as shown in table 1, residency graduates located in rural areas were more likely to be providing obstetric services than those practicing in urban areas (66% vs 12%, p < .001). relatedly, of the 13 graduates practicing in a town with a population of more than 30,000, none were practicing obstetrics. generally, graduates who received obstetric-specific training were more likely to be practicing obstetrics. graduate gender, year of graduation, or whether there was an obstetrician in the community were not associated with practicing obstetrics. experiences specific to residency that influenced decision to practice obstetrics as shown in table 4, those providing obstetric services were more likely than those not currently doing so to report that their decision to practice obstetrics was influenced by the number of deliveries performed during residency, their interactions with attending obstetricians during residency, and interactions with prenatal and laboring patients during residency. for example, 96% (n = 21) of graduates currently practicing obstetrics said the number of deliveries performed impacted whether they decided to practice obstetrics, compared to only 68% (n = 17) of graduates not currently practicing obstetrics (p = .025). table 5 summarizes residency program feedback provided by graduates. almost all residency journal of regional medical campuses, vol. 5, issue 1 original reports graduates (92%, n = 43) reported feeling prepared or very prepared to provide obstetric services after residency, though only 68% (n = 32) felt prepared or very prepared to provide high-risk obstetric services. just more than one-third (38%, n = 18) of graduates wished that their residency program had provided more continuity with patients, 28% (n = 13) wished they had had more exposure to family physicians delivering babies, 17% (n = 8) wished there had been more faculty presence on labor and delivery, and 26% (n = 12) wished there had been more lectures and didactics on prenatal issues. as shown from the key quotes in table 6, respondents further described a desire for additional residency training (1) in surgical and emergent deliveries and postdelivery care, (2) on best practices for family practice physicians to provide obstetric care, and (3) through online modules and exposure to alternative health care practices. discussion nearly half (46%) of the duluth family medicine residency program graduates assessed in the present study practiced obstetric care, which is a substantially higher percentage than the national average of 7%.13 graduates practiced in a wide variety of community types across minnesota and wisconsin but practiced at distant sites as well. overall, most graduates (90%) were doing some form of preor postpartum maternity care, with lesser numbers doing vaginal deliveries and the smallest number doing operative deliveries. similar to other reports,2,14 respondents in urban communities were less likely to be doing delivery care, and no respondents in towns with populations greater than 30,000 were doing delivery care. overall, providers reported satisfaction with the training provided at the duluth family medicine residency program. ninety-one percent of respondents felt prepared or very prepared to provide obstetric services postresidency. most respondents (60%-80%) reported wishing for the same amount of key obstetric training components in their residency program, while the other 20%-40% wanted more didactic and hands-on skill training, faculty support, exposure to family physicians doing deliveries, and continuity of care with patients. the write-in responses were particularly representative of additional areas respondents would like to see doi: https://doi.org/10.24926/jrmc.v5i1.4338 included in training. for example, further instruction in higher-risk situations such as neonatal resuscitation and maternal emergencies was included in the comments as a desired area for training, as well as additional guidance on best practices for family practice physicians to provide obstetric care. given that family physicians frequently cite a limited scope of obstetrical training in residency as a barrier to providing obstetric services later in their careers,4-6 these findings support the need to incorporate additional training in and opportunities to provide obstetric care in family medicine residency programs to promote comfort in providing obstetric care. only one-third of physicians providing delivery care had accessed additional training postgraduation, though fellowships were not common. for career discernment, the number of deliveries attended, the interaction with attending physicians, and direct patient care during residency were most important to the graduates in deciding whether to practice obstetrics. a high percentage of respondents also noted having an obstetrician available in their community, which implies existing community relationships between maternity care providers. the intersectionality between family medicine and obstetrical providers in rural and urban communities is an important factor to consider given that training, proof of competency, and interprofessional relationships are key in successful maternity care programs6 and allow for an opportunity to educate diverse professionals on the role of family medicine physicians in providing obstetric care. it is important to note that reasons for discontinuation of delivery care varied and reflected both individual choices and community attributes. the most common reason identified for discontinuing with delivery care was a personal choice for a career change. additional responses in the write-in comments included aspects of institutional change as well as individuals’ readiness for retirement. limitations to the study include a spread of responses across a broad range of graduation years, which did not provide large enough numbers to compare outcomes over time. in addition, we did not have valid contact information for all graduates and had a low response rate (37%), which resulted in a relatively small sample size. although the write-in responses obtained in this study are valuable, numbers were too small for a formal qualitative analysis. finally, results doi: https://doi.org/10.24926/jrmc.v5i1.4338 journal of regional medical campuses, vol. 5, issue 1 original reports are from a relatively small number of graduates from a single residency program, which limits generalizability of the findings. it will be important for future studies to identify specific opportunities to adjust the residency curriculum using a more robust representation of respondents. having a better sense of incoming graduates’ intentions to practice obstetrics and how that changes during their time in residency would also be helpful in directing curricular improvements. the overall findings of our study reflect the importance of residency training experiences in influencing family medicine physicians’ decisions to provide obstetric care. these findings highlight the utility of including a range of didactic and hands-on training in obstetric care and support the need to incorporate exposure to working with perinatal patients and offer additional education on the role of family physicians in providing obstetric care within their communities during residency training. the idea of strategic planning for cross-specialty obstetric care is intriguing, and further studies examining existing community-centered integration for obstetric care programming would be valuable. interdisciplinary training for obstetric care providers could begin in residency, continue during fellowships, and be an important part of team-based continuing education opportunities in the community setting, which could be extrapolated to include a strategy for regional approaches to support maternity care in resourcepoor areas. doi: https://doi.org/10.24926/jrmc.v5i1.4338 journal of regional medical campuses, vol. 5, issue 1 original reports doi: https://doi.org/10.24926/jrmc.v5i1.4338 journal of regional medical campuses, vol. 5, issue 1 original reports references 1. hung p, kozhimannil kb, casey mm, moscovice is. why are obstetric units in rural hospitals closing their doors? health serv res. 2016;51(4):1546-1560. 2. kozhimannil kb, casey mm, hung p, han x, prasad s, moscovice is. the rural obstetric workforce in us hospitals: challenges and opportunities. j rural health. 2015;31(4):365372. 3. young ra. maternity care services provided by family physicians in rural hospitals. j am board fam med. 2017;30(1):71-77. 4. eden ar, barreto t, hansen er. experiences of new family physicians finding jobs with obstetrical care in the usa. fam med community health. 2019;7(3):e000063. 5. magee sr, radlinski h, nothnagle m. maternal-child health fellowship: maintaining the rigor of family medicine obstetrics. fam med. 2015;47(1):48-50. 6. eden ar, peterson le. challenges faced by family physicians providing advanced maternity care. matern child health j. 2018;22(6):932-940. 7. barreto tw, eden a, brock a. the impact of practicing obstetrics on burnout among earlycareer family physicians. fam med. 2020;52(6):408-413. 8. rodney wm, martinez c, collins m, laurence g, pean c, stallings j. ob fellowship outcomes 1992-2010: where do they go, who stops delivering, and why? fam med. 2010;42(10):712-716. 9. chang pecci c, leeman l, wilkinson j. family medicine obstetrics fellowship graduates: training and post-fellowship experience. fam med. 2008;40(5):326-332. 10. pearson j, siebert k, carlson s, ratner n. patient perspectives on loss of local obstetrical services in rural northern minnesota. birth. 2018;45(3):286-294. 11. fashner j, cavanagh c, eden a. comparison of maternity care training in family medicine residencies 2013 and 2019: a cera program directors study. fam med. 2021;53(5):331-337. 12. harris pa, taylor r, thielke r, payne j, gonzalez n, conde jg. research electronic data capture (redcap)—a metadata-driven methodology and workflow process for providing translational research informatics support. j biomed inform. 2009;42(2):377-381. 13. worth a. the numbers quandary in family medicine obstetrics. j am board fam med 2018;31(1):167-168. 14. avery d, graettinger kr, waits s, parton jm. comparison of delivery procedure rates among obstetrician-gynecologists and family physicians practicing obstetrics. am j clin med. 2014;10(1):16-20. microsoft word motivating factors article.docx published by university of minnesota libraries publishing motivating factors of and perceived barriers to research at a canadian medical university with regional campuses: a cross-sectional survey study jennifer leigh, md, msc; maroof khalid; jennifer tsang, md, phd, frcpc doi: https://doi.org/10.24926/jrmc.v4i3.3934 journal of regional medical campuses, vol. 4, issue 3 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc jennifer leigh, md, msc; department of medicine, the university of ottawa, ottawa, canada maroof khalid; michael g. degroote school of medicine, mcmaster university, hamilton, canada; niagara regional campus, michael g. degroote school of medicine, mcmaster university, st. catharines, canada; department of medicine, mcmaster university, hamilton, canada jennifer tsang, md, phd, frcpc; niagara regional campus, michael g. degroote school of medicine, mcmaster university, st. catharines, canada; department of medicine, mcmaster university, hamilton, canada; niagara health, st. catharines, canada all work in jrmc is licensed under cc by-nc volume 4, issue 3 (2021) journal of regional medical campuses original reports motivating factors of and perceived barriers to research at a canadian medical university with regional campuses: a cross-sectional survey study jennifer leigh, md, msc; maroof khalid; jennifer tsang, md, phd, frcpc abstract introduction research training programs are an integral part of a well-rounded medical education. these programs help students contribute to medical knowledge, develop skills in critical evaluation and research dissemination, and they facilitate the training of our future medical researchers. existing literature suggests barriers including lack of available time and access to projects may hinder a medical student’s research training. these barriers likely differ based on the medical school curriculum, and there exists limited data looking at these attitudes in canadian students, students outside large academic centers, or those in condensed programs. given this, our study aims to further explore medical students' perceptions, perceived barriers of research in a 3-year canadian undergraduate medical school with regional campuses. methods we conducted a cross-sectional survey of medical students (classes of 2019, 2020, and 2021) representing the main and regional campuses of the michael g. degroote school of medicine in ontario, canada to explore their attitudes towards research. descriptive statistics were used to describe participant demographics, research background, and attitudes towards research. results overall, 70.4% of students identified as being involved in a research project at some point during their medical school tenure. motivating factors for research participation included the goal of obtaining a residency spot (63.0%), and interest in their research topic (74.7%). barriers to research included perceived lack of available time (31.5%), and difficulty in finding a research project (44.5%). perceived curriculum deficiencies included inadequate education in research methodology and appraisal of scientific literature (93.8% and 90.1%, respectively). lastly, regional campuses tended to, more often, conduct their research outside of their home campus (43.6% vs 3.3%, p<0.0001). conclusion the findings from our study highlighted the students’ attitudes towards research in a canadian medical school that has multiple campuses and a shortened curriculum (3-year). it identifies potential areas of improvement from a student perspective, which can hopefully be utilized by medical educators to continue the improvement of medical trainee research training. introduction research training programs are an integral part of a well-rounded medical education. these programs facilitate the training of our future medical researchers by helping students develop skills in critical appraisal of medical literature.1,2 existing literature suggests that undergraduate medical students largely view scholarly research programs as positive and/or necessary.3-6 these students often believe that their research experiences will contribute doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports to their career progression, help them select their medical specialities, and increase their confidence when applying to their desired residency programs.5 despite these widely held positive beliefs, not all students participate in research activities during their undergraduate medical education. a canadian survey conducted in 2016 found that only 23.8% of undergraduate medical students participated in research-related activities, despite 74.2% believing that they should and 83% believing that research participation would be valuable.5 the current available literature suggests that there are a number of barriers impacting these students’ ability to participate in medical research, including perceived lack of time, lack of acknowledgement, and lack of available opportunities.6-12 currently most medical schools in canada provide students with opportunities to engage and participate in research.2 every research curriculum is different, with some having integrated formal curriculums while others only offer informal opportunities. students at traditional 4-year undergraduate medical programs, which make up the majority of medical schools in canada, are encouraged to participate in research opportunities during their summer breaks.2 typically, this occurs through formal summer student research programs, some of which are funded and might not be officially affiliated with the medical schools.13 these students often also have dedicated time for research activities throughout the academic year, where they can potentially continue the projects they began during the summer.13 alternatively, students in 3-year undergraduate medical programs, such as that of the michael g. degroote school of medicine, do not have the same opportunities. given the condensed curriculum, there is no summer break, dedicated research time, or funding for students to work on research projects. they must conduct their research solely throughout the school year in addition to their other academic responsibilities, therefore making participation in research uniquely challenging. there is also less overall time to complete and hopefully publish their research given the overall program duration is shorter. from a research perspective they are at a unique disadvantage to their peers in 4-year programs. in addition to being a 3-year undergraduate medical program in canada, the michael g. degroote school of medicine is one of few canadian medical schools to have multiple regional campuses in addition to their main campus. the school is made up of the main campus in hamilton, ontario and the 2 regional sites in waterloo, ontario and st. catharines, ontario respectively. each year, the medical school admits 203 students, with 147 at the main hamilton campus and 28 students at each of the regional sites. following acceptance, students are asked to rank the 3 campuses in order of preference and are matched to their top possible campus choice using their acceptance ranking. all students spend the first 3 months of medical school in hamilton together, and then go off to their respective sites for the remainder of the program. the regional campuses provide a unique learning experience by having lectures either video conferenced from hamilton or given locally, tutorials are run by local physicians, and core medical training takes place in community hospitals. in addition to the core education, regional campuses provide a unique research experience where students can work with local, community based researchers. this may not be without its downside, however, as there are often fewer academic researchers, and limited access to specialized fields that may only be present at a large academic center. overall, the literature regarding facilitators of and barriers to research participation in undergraduate medicine remains limited. data on medical students’ attitudes and perceptions towards research during undergraduate medical education, as well as what barriers to participating in meaningful research students may face while in medical school in a specifically canadian population is especially lacking. even more specifically, there is no existing exploration of these perceptions in medical schools that have a 3year curriculum, or in schools with students at different learning sites. for that reason, our study aims to explore the medical students' perceptions of and perceived barriers to research in a 3-year canadian undergraduate medical school. methods a cross-sectional survey study of medical students at the michael g. degroote school of medicine, mcmaster university, was conducted in 2019. this is a doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports 3-year undergraduate medical program with a main campus in hamilton, ontario, and 2 regional campuses in waterloo, ontario and st. catharine’s, ontario. each academic year, 203 students are enrolled into the program, with 28 being at each of the regional campuses and 147 in hamilton. at time of acceptance students are asked to rank the 3 campuses in order of preference. they are then allocated to their most preferred campus possible based on their ranking in the admissions process. as a result, students are not guaranteed to be matched to their top choice campus. when it comes to research specifically, students are allowed to travel between campuses to participate in projects. participation in our study was completely voluntary. confidentiality was maintained at all times and no identifying information was recorded in the survey. ethics approval was obtained from the michael g. degroote’s school of medicine protocols review committee. study tool the survey consisted of 39 closed-ended questions (appendix a) addressed to report the research experiences and attitudes of medical students. the goal was to identify a number of issues: why do students choose to be involved in research, what is the relevance of student research to career aspirations, and what are the barriers to successful participation in research? the questionnaire consisted of 2 parts: demographic information and questions related to research interest and barriers to research. the survey was modified from a validated survey provided by the author (siemens et al, 2010). the survey was available only in english, and on average took 7 minutes to complete. subject recruitment students were recruited using the mcmaster medicine email list. one email was sent to all students’ medical school emails, asking them to voluntarily complete the survey. this included students at all 3 campuses and in all 3 current academic classes (2019, 2020, 2021). following that, the survey was advertised to all students (classes of 2019, 2020, 2021) through each classes’ social media page. a request to complete the survey was posted on each social media page once every 2 weeks, for a total 2-month period. all responses were anonymous. each student who completed the survey was given the option to provide their email, so that they could be entered in a drawing to win an ipad, or one of 10 twenty-five-dollar visa prepaid gift cards. data analysis plan descriptive statistics were used to describe demographics and research background of students. mean likert score was calculated for each item based on the responses of the participants. for ease of reporting, we grouped responses in agreement (likert 4 and 5), and those in disagreement (likert 1 and 2). univariate analysis with mann-whitney test was used to determine statistical differences between different campuses. one-way anova was used to determine a statistical difference between the 3 different classes (2019, 2020 and 2021). statistical significance was defined as p<0.05. results demographics overall, there was a total of 162 respondents with a response rate of 25.9%. the response rate between the 3 classes varied, with 42 participants (25.9%) being from the class of 2019, 47 (29.0%) from the class of 2020, and 73 (45.1%) from the class of 2021. of the total responses, 100 (61.7%) were from hamilton campus, 46 (28.4%) from the niagara regional campus, and 16 (9.9%) from the waterloo regional campus. in total, 139 (85.8%) respondents reported that they had chosen hamilton as their primary campus in the initial campus lottery, with 100 (61.7%) respondents actually ending up at the hamilton campus. of the students at regional campuses, 40 (64.5%) students had actually reported hamilton to be their first-choice campus, whereas 99 (99%) students at the hamilton campus had chosen it as their first choice. the average age of students was 23.8 years (table 1). research experiences overall, 114 (70.6%) of students had a post-secondary education background in life or health sciences (table 1). the majority of students had prior research experience (n=145, 89.5%) with that mostly commonly in the form of a university undergraduate thesis project (n=59, 38.6%). there was a significantly greater proportion of students at regional campuses doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports with graduate degrees (n=18, 29%), as compared to hamilton campus (n=12, 12%, p= 0.005). there were overall 115 students (70.4%) who had participated in at least one research project to date in medical school. the most common type of research that the students were involved in was quality improvement, followed by chart reviews (figure 1). the least common type of research that students were involved in were clinical trials (figure 1). of students who participated in research projects, 89 (77.4%) were able to present their research in the form of a poster or podium presentation, and 36 (27.2%) were able to publish a peer-reviewed paper. there was a total of 8 (26.7%) students with graduate degrees as compared to 39 (29.5%) students without graduate degrees who did not participate in any research to date during medical school. table 1. demographics and research experiences of survey participants. data is represented as combined (all respondents), hamilton, or regional campuses (waterloo and niagara combined). represented as percent participants from that campus. the p-value is based off of a comparison of hamilton to regional campus students. figure 1. type of research students participated in throughout medical school. students responding to the study were asked to report what type of research they are involved in. data is represented as the % of students participating in each type of research. it is separated into all students (black), hamilton students only (red) and regional campus students only (white). motivating factors for research participation as part of the survey, students were asked about their attitudes towards the importance of research, their involvement in research, and perceived barriers to partaking in research during their undergraduate medical education (table 2). the majority of students cited the goal of obtaining a residency spot as a motivating factor for research participation (n=102, 63%). they also believed that it was an important factor in helping them obtain that residency spot (n=124, 76.5%). interestingly, only 22 (13.6%) of students felt that it should be an important criterion for acceptance to a residency program. just over half of students intended on pursuing a residency in family medicine (n=89, 55%), with internal medicine being the second most popular discipline (n=56, 34.6%). most students (n=115, 71.0%) believed being involved in research would help them achieve their long-term career goals. lastly, close to three-quarters of students cited that they were involved in research because of their interest in the topic (n=121, 74.7%). barriers to research participation barriers to involvement in research included perceived lack of available time (n=51, 31.5%) and perceived difficulty in finding a research project (n=72, 44.5%). a total of 99 (61.1%) students felt that there should be time set aside in the curriculum to pursue research interests. less than one-third of doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports students felt that their research supervisors provided adequate guidance and instruction towards research (n=52, 32.1%). students also believed that it was very hard to present their research at non-medical school forums (n=37, 22.8%) and to publish in a non-medical school journal (n=43, 26.5%). lastly, very few students felt that training in research methodology (n=10, 6.20%) and interpreting scientific literature was adequate (n=16, 9.87%). differences between main and regional campuses responses from students of the main campus and regional campuses were compared, as reported in table 1 and 2. students of the regional campuses were on average older (mean age of 23.23 (sd 2.1) versus 24.47 (sd 3.2), p=0.0167) and more likely to have a graduate degree (12% vs 29%, p=0.005). a larger proportion of main campus (hamilton) students did not participate in research during medical school (n=36, 36%), compared to students of regional campuses (n=11, 17.7%, p<0.005). regional campus students also tended to participate in more projects, however this was not statistically significant. it was apparent that the majority of students participated in research projects at their home campus: 69 (69%) hamilton campus students conducted research in hamilton, and 39 (62.9%) regional campus students conducted research at their respective regional campuses. one notable trend was that students from regional campuses were more likely than their counterparts to conduct research at a different campus (43.6% versus 3.3%, p<0.0001). despite main campus students more often completing their research at an academic center, there was no difference in the percentage of students publishing their work in form of a poster or podium presentation (hamilton: n=47 [73.4%] vs regional: n=42 [82.4%], p=0.273) or peer-reviewed publication (hamilton: n=17 [27%] versus regional: n=14 [27.4%], p=0.999). there was, however, a significant difference in the proportion of students who presented at conferences between regional campus students who travelled for research (n=20, 64.5%) compared to those regional students who conducted research at their home base (n=22, 100%, p=0.0014). there was no significant difference between these 2 groups in the proportion who published their research (travel: n=8 [25.8%] vs no travel: n=7 [31.8], p=0.76). table 2. attitudes towards research of students who participated in the survey. students were asked to answer the above questions using a likert scale. results are divided into combined (all respondents), hamilton students only, or regional campus students only (waterloo and niagara). presented as % respondents in agreement with the statement, which is defined as having either answered to agree or strongly agree on the likert scale. the p value is based on hamilton versus regional campuses. differences between graduating classes research participation and attitudes towards research stratified by graduating year are outlined in table 3. the most senior students, who were those in the class of 2019, had significantly more research participation (2019: n=34 [81%], 2020: n=36 [76.6%], 2021: n=35 [47.9%], p=0.0002), presentations at conferences (2019: n=37 [88.1%], 2020: n=21 [44.7%], 2021: n=33 [45.2%], p<0.0001), and publications doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports during medical school (2019: n=15[35.7%], 2020: n=13[27.7], 2021:n=9[12.3], p=0.01). there was a trend where the class of 2020 felt that participating in research would help them obtain the residency of their choosing (2019: n=23[54.8], 2020: n=39[83.0], 2021: n=50[68.5], p=0.007), and stated that their goal of partaking in research was to obtain said residency spot (2019: n=21[50.0], 2020: n=36[76.7], 2021: n=40[54.8], p=0.004). they also were more likely to think that it should be an important criterion for acceptance into residency (2019: n=4[9.52], 2020: n=10[21.3], 2021:n=5[6.85], p=0.0494). there was a significant difference between the 3 years in belief that research methodology training was adequate in medical school (2019: n=1[2.98], 2020:n=6[12.8], 2021:n=3[4.11], p=0.001), however the proportion of patients who felt this overall was low. there was no significant difference in proportion of students who felt training in scientific literature was adequate, or those that believed presenting at non-medical school conferences and publishing in non-medical school journals was difficult. table 3. attitudes towards research of students who participated in the survey, stratified by graduating class. students were asked to answer the above questions using a likert scale. results are divided into students from the class of 2019, 2020 and 2021. presented percentage of respondents who are in agreement with the statement, which is defined as having either answered to agree or strongly agree on the likert scale. the p value reflects analysis of the difference between the 3 groups. discussion our study is the first to describe the research landscape for medical students at a 3-year undergraduate medical school, and the differences between main and regional campuses. it highlights important demographics and attitudes towards research involvement, which can ideally be used to doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports improve the research experiences of this unique student population. with a condensed (3-year) undergraduate medical program, the michael g degroote school of medicine provides different challenges for students compared to their peers enrolled in 4-year undergraduate medical programs, including less available time to participate in research. additionally, having students at both academic centers and affiliated regional sites leads to even further variation in research experiences. the majority of undergraduate medical training for regional campus students occurs away from an academic center, and by nature of this, students have less local access to academic researchers, resources, and research in highly specialized fields that are not available in community hospitals. this can potentially lead to a different research experience. identifying areas of weakness in the research curriculum as perceived by students such as that done in our study is key to the ongoing growth and development of both 3-year curriculums and regional programs. a systematic review and meta-analysis found that there are 4 main factors that predict whether a student participates in research during medical school: previous research experience, greater academic success, completion of a graduate degree at the time of matriculation, and concerns that academicians command less income than nonacademicians.3 a separate review found that little acknowledgement in publication and lack of available protected time were potential barriers to participation.8 outside of the concern about potential income, these barriers are consistent with those found in our study. specifically, lack of available time was widely perceived as a barrier to research participation by the students in our study and should serve as an area for medical schools to focus on. there is likely an even greater time constraint in a 3year curriculum as students at traditional 4-year programs often use their summer vacations to participate in research, which is an opportunity that students enrolled in 3-year curriculums are not afforded.13-14 additionally, students in 3-year programs are already tasked with having to learn the same amount of medical knowledge in less time. given this, strategies to address this barrier will be unique to the shortened timeline. the michael g. degroote school of medicine is not the only condensed curriculum in north america, and thus this information can be applied to other 3-year programs as well.14 in addition to lack of available time to participate in research, close to half of the surveyed students felt that there was a lack of available research projects. there are many contributing factors including shortened curriculum and thus time to find projects, as well as limited student access to researchers especially in regional sites. while there was no statistically significant difference between students of regional campuses and main campus, there was a trend towards more regional campus students feeling that it was difficult to find a project. additionally, there was a significantly larger proportion of medical students at regional campuses who travelled to another campus in order to conduct their research, instead of simply conducting it at their home campus. this travel time also potentially impacts their research productivity, as evidenced by our finding that regional campus students who did not travel for research were more likely to have presented at a conference. some highly specialized areas of medicine are only present at academic centers, making it impossible for regional students interested in these fields of medicine to find projects at their home campus.15 this highlights an important difference between the 2 types of campuses, and a potential barrier for regional campus students to partake in research. universities with regional sites should focus on further improving the research experiences of their students with innovations such as the implementation of local research teams who act to support and engage students and local faculty in their research endeavors.15 this program has been implemented at the michael g. degroote school of medicine and has led to expansion of the research programs at each regional site. perceived inadequate research curriculum was another barrier identified in our study. an overwhelming majority of students felt that training in both research methodology and appraisal was inadequate. the proportion of students who felt this way in their first and final year of the program was largely similar, suggesting that it is a problem throughout the whole 3-year curriculum. this is again similar to that found in prior canadian surveys, where only 15% of students felt there was adequate training in research endeavors, and 25% agreed that there was adequate training in appraising scientific doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports literature.5 as these numbers are similar to those in our study, it highlights that feelings of inadequate research training are a widespread concern for canadian medical students regardless of duration of medical school. being able to interpret and translate research is an important aspect of any medical career, and the research curriculum offered by undergraduate medical schools plays a key part in teaching clinicians to do so. in order to address this barrier, it is important that medical schools ensure that they dedicate time to a mandatory research curriculum as part of the canmeds framework (scholar role), which not all canadian medical schools currently do. implementing mandatory evidencebased medicine training and research methodology into the medical school curriculum may be some such ways that schools can further improve their curriculums. the use of flexible online research education modules tailored to each students’ needs could also be used to supplement students’ education needs and to fulfill the scholar role of the canmeds framework. there are a few limitations to the present study that should be highlighted. first, the data from our study is taken from a small sample size, with only 25.9% of current medical students responding to the survey. this is likely a product of our ability to only reach our intended audience through one email and social media posts, as well as the survey fatigue that is generated in medical schools. secondly, the data is taken from a survey where students were asked to self-report, which precludes us from verifying the data. lastly, while we are able to see what the attitudes towards research, and research demographics for medical students are, we are unable to elucidate the reasons behind these. for example, while we found that a significant proportion of medical students at regional campuses travel for their research projects, we were unable to determine why this is from the structure of our survey. this highlights the need for future small group sessions to help better tease out these factors. conclusions the findings from our study are unique as they highlight students’ attitudes towards research during medical school in a specifically canadian population. additionally, it is the first to explore these attitudes in a 3-year medical school curriculum with both main and regional campuses. all physicians regardless of whether they intend on having active research careers need a baseline level of research competency, and this training process often starts during medical school. additionally, the role of medical scholar has been adopted by the royal college of physicians and surgeons as a core competency in specialty training, thus it is important that medical students at least obtain some formal training prior to entering residency. the information we present identifies potential areas for medical schools to improve their research curriculum, and hopefully improve the research experiences of students. further in-depth analysis into why there exists differences in participation and attitudes between main campus and regional students through small focus groups of students would be highly beneficial in future planning. references 1. kondro w. eleven satellite campuses enter orbit of canadian medical education. cmaj. 2006; 175(5):461. https://doi.org/10.1503/cmaj.060954 2. ellaway r and bates j. distributed medical education in canada. can med educ j. 2018;9(1):e1-e5 3. chang y and ramnanan cj. a review of literature on medical students and scholarly research: experiences, attitudes, and outcomes. acad med. 2015; 90(8):1162-73. 10.1097/acm.0000000000000702 4. weaver a, mccraw tr, fifolt m, hites l and lorenz rg. impact of elective versus required medical school research experiences on career outcomes. j investig med. 2017;65(5):942-948. http://dx.doi.org/10.1136/jim-2016000352 5. siemens dr, punnen s, wong j and kanji n. a survey on the attitudes towards research in medical school. bmc med educ. 2010; 10(4). 10.1186/1472-6920-10-4 6. amgad m, tsui mmk, liptrott sj, shash e. medical student research: an doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports integrated mixed-methods systematic review and meta-analysis. plos one. 2015;10:1-31. https://doi.org/10.1371/journal.pone.0 127470 7. abushouk ai, hatata an, omran m, touniss mm et al. attitudes and perceived barriers among medical students towards clinical research: a cross-sectional study in an egyptian medical school. j biomed educ. 2016; article id 5490575, 7 pages 8. bhagavathula as, bandari dk, tefera yg, jamshed sq, elnour aa and shehab a. the attitude of medical and pharmacy students towards research activities: a multicenter approach. pharmacy. 2-17; 5(4):55. https://doi.org/10.3390/pharmacy504 0055 9. memarpour m, fard ap, and ghasemi r. evaluation of attitude to, knowledge of and barriers toward research among medical science students. asia pacific family medicine. 2015;14(1). https://doi.org/10.1186/s12930-0150019-2 10. soe hh, thran n, lwin h, htay m, phyu k and abas a. knowledge, attitudes, and barriers toward research: the perspectives of undergraduate medical and dental students. j edu health promot. 2018;7(23). 10.4103/jehp.jehp_61_17 11. mohd i, bazli my, and o’flynn s. and universiti sains malaysia. 2013: social and behavioral sciences. 116:26452649 12. nel d, burman rj, hoffman r and randera-rees s. the attitudes of medical students to research. 2014. samj. 104(1). https://doi.org/10.7196/samj.7058 13. patel s, walsh cm and udell j. exploring medically related canadian summer student research programs: a national cross-sectional survey study. 2019. bmc medical education. 19(14) 14. raymond j, kerschner je, hueston wj and maurana c. the merits and challenges of three-year medical school curricula. 2015. academic medicine. 90(10):1318-1323 15. cathcart-rake w and robinson m. promoting scholarship at regional medical campuses students. 2018. journal of regional medical campuses. 1: 16. galletly ,chur-hansen a, air t and chapman i. academics of the future? a survey of final year medical students. 2009. australas psychiatry. 17(6):502-505. https://doi.org/10.1080/103985609032 84935 microsoft word a teleneurology teaching service article.docx published by university of minnesota libraries publishing a teleneurology teaching service at a rural regional campus: an effective solution when specialty availability is limited anne-taylor beck, bs; leeandra b. cleaver, bs; joshua d. fuqua, bs; katlyn b. clark, bs; rohit s. nair, ms; e. paige hart, ba; rebecca r. bolinger, ba; william j. crump, m.d. doi: https://doi.org/10.24926/jrmc.v4i3.3534 journal of regional medical campuses, vol. 4 issue 3 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc anne-taylor beck, bs, m-3 medical student university of louisville school of medicine trover campus at baptist health madisonville (ulsom trover campus); leeandra b. cleaver, bs, m-3 medical student university of louisville school of medicine trover campus at baptist health madisonville (ulsom trover campus); joshua d. fuqua, bs, m-3 medical student university of louisville school of medicine trover campus at baptist health madisonville (ulsom trover campus); katlyn b. clark, bs, m-3 medical student university of louisville school of medicine trover campus at baptist health madisonville (ulsom trover campus); rohit s. nair, ms, mba, m-3 medical student university of louisville school of medicine trover campus at baptist health madisonville (ulsom trover campus); e. paige hart, ba, m-3 medical student university of louisville school of medicine trover campus at baptist health madisonville (ulsom trover campus); rebecca r. bolinger, ba, m-3 medical student university of louisville school of medicine trover campus at baptist health madisonville (ulsom trover campus); william j. crump, m.d., associate dean, university of louisville school of medicine trover campus at baptist health madisonville (ulsom trover campus) all work in jrmc is licensed under cc by-nc volume 4, issue 3 (2021) journal of regional medical campuses original reports a teleneurology teaching service at a rural regional campus: an effective solution when specialty availability is limited anne-taylor beck, bs; leeandra b. cleaver, bs; joshua d. fuqua, bs; katlyn b. clark, bs; rohit s. nair, ms; e. paige hart, ba; rebecca r. bolinger, ba; william j. crump, m.d. abstract regional rural medical school campuses offer many opportunities for medical students to gain more hands-on experience, have more direct interaction with attending physicians, and cultivate a deeper understanding of challenges and opportunities specific to rural medicine. some specialty services such as neurology are not always readily available at these small regional campuses, and telemedicine technology can be a valuable tool to address this need. we report the implementation of teleneurology stroke consultation services as part of the third-year neurology clerkship at a regional medical school campus. we analyzed daily clinical notes and student satisfaction surveys. students saw many common presentations of cerebrovascular events as part of a multi-disciplinary care team. while students followed patients through their hospital course they were provided effective instruction by remote stroke neurologists. all students strongly agreed that telemedicine was a positive component of the clerkship. we conclude that teleneurology is effective in providing inpatient neurology clinical exposure, especially when remote attendings have a strong screen presence and are enthusiastic about teaching. we believe these findings could be useful to other campuses considering similar teaching methods, as innovations in telemedicine continue to address challenges in medical education and clinical care. introduction telehealth is the broad term that describes the vast range of technology used to connect healthcare providers to patients and other providers. telemedicine is a more specific term referring to the provision of medical care remotely through electronic communication between a health care provider and a patient. the use of telemedicine dates back to the 1940s, however, the advancement of technology has propelled this field forward with growing interest.1,2 increasing internet speed and access along with widespread use of technological devices, such as smartphones and computers, in rural areas has opened the door for telemedicine to meet challenges regarding access to primary and specialty medical care.3 in addition to its application in addressing physician shortages in the rural setting, telehealth has become an invaluable tool in the fight against the novel coronavirus disease (covid-19). not only has the use of telemedicine increased exponentially, we have also witnessed a surge of interest in telemedicine by the united states population.4 neurology is a specialty that has a significant provider shortage in comparison to the growing population in need of these services.5 this is particularly evident in doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports rural regions of the united states where there are large differences in rural-urban neurologist density.2 an effective solution in many of these underserved regions comes in the form of telemedicine or, specifically, “teleneurology”. teleneurology is a specialized form of telemedicine where a neurologist sees patients remotely, whether it is in the outpatient setting for chronic neurologic conditions or for inpatient acute care.6 this approach utilizes synchronous communication methods via live audio and video to provide comprehensive neurology care to a rural patient population. small regional medical school campuses have many benefits, including one on one teaching, carrying responsibilities of an intern, and collaborating with many members of the care team. this environment provides students with unparalleled hands-on patient and care team experience, which later contributes to a vital skill set utilized daily as a resident physician. despite the many advantages of this training environment, there are challenges for regional campuses. one such challenge is decreased availability of specialty providers (i.e. neurologists, dermatologists, rheumatologists) in the rural setting, resulting in minimal on-site training opportunities with these specialists. the team of physicians serving our rural medical campus included neurology until 4 years ago. the lack of a neurologist presented a gap in the required neurology clinical experience for the rural track medical students. one possible solution was to have the rural-based students travel back to the main campus university hospital, located 160 miles away, to complete this rotation. returning to the urban environment for the 4-week rotation was not ideal due to the student housing obligation, disruption of rural-focused training,7 and the interruption of longitudinal student experiences including regular small group teaching sessions and providing care for longitudinal patients at the weekly student-run free clinic. it was ultimately decided that the rural-based students would commute an hour away to a neurologist’s office 2 to 3 days a week, and on the days students did not commute, they spent time with sleep medicine and inpatient geriatric psychiatry on the rural campus. these clinical experiences provided opportunities to learn about the presentation and management of chronic plus outpatient neurological diseases including insomnia, narcolepsy, restless legs syndrome, parkinson’s disease, multiple sclerosis, other neurodegenerative diseases, dementia, and delirium. the adapted neurology curriculum produced comparable student performance on shelf exams and student feedback when compared to main campus students. despite providing rural students with adequate chronic and outpatient neurology clinical experience, there remained a significant learning gap in acute inpatient neurology care. in the spring of 2019, the hospital which hosts the medical campus began the process of implementing teleneurology stroke consultation with full-service care beginning in summer 2019. not only would this address an evident need for acute neurology care in our rural area, but also it held significant potential to meet the educational need for the rural medical students. a literature review revealed no publications about student educational outcomes or opportunities involving telemedicine used in rural medical student training sites. most research published to date emphasized rural inpatient outcomes in acute teleneurology or telestroke services2,5,6,8,9,10 or focused on the need for additional neurology resident or medical student training on general telemedicine practices.11,12,13,14,15,16 an essay was recently published describing the anecdotal experience by the first student to participate in this learning experience.17 this study describes in detail the results of the first semester of the new teleneurology teaching service, including student evaluations and the clinical characteristics of the patients seen. we hope this report may serve as a guide for other regional medical campuses considering similar teaching methods. methods our regional medical campus is located in a madisonville, kentucky, which has an approximate population of 20 000. this campus is the primary clinical training site for 14-16 allopathic thirdand fourth-year medical students who move here after doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports completing the first 2 years of basic science education at the main urban campus 160 miles away. students who have a proven affinity for rural settings are assigned at the time of admission to medical school to this campus where they have the opportunity for unique, first-hand clinical experiences with rural and underserved patient populations. these students complete required thirdand fourth-year clerkships and electives in this rural setting and work closely with their respective attending faculty, typically in a one-to-one apprenticeship model. academic outcomes including clerkship shelf exams and step 2 usmle scores are comparable to those of main campus students.18 one of only 2 published multivariate analyses of predictors of rural practice showed that participation at this campus was the strongest predictor even when controlling for the usual variables of rural upbringing and family medicine specialty choice.19 design of telestroke teaching service the inpatient teleneurology care team began fullservice acute stroke care at our regional medical campus in august 2019. the students reported here rotated with the team during the winter of 2019/2020 and then after the gap necessitated by the pandemic another student rotated in the fall of 2020. teleneurology care was provided via live communication using a standard healthcare cart, hp all in one central processing unit (cpu) and monitor and a standard 20x zoom remotely controlled camera (figure 1). this system used the hospital password protected secure wireless internet connection and allowed the teleneurologist to interact with patients and their families from his or her urban referral hospital location in a synchronous manner. this design also facilitated close synchronous interaction and communication with the comprehensive rural neurology care team, including a physical therapist (pt), occupational therapist (ot), nursing staff, speech therapist, and the rotating medical student. a dedicated nurse practitioner (aprn) was added to the team in the spring of 2020. the medical student made daily rounds with the inpatient neurology team 2 to 3 days per week for the duration of the 4-week rotation and followed their stroke patients between commuting days to the outpatient neurologist. there were no audio or visual technical diffuclties. however, in the case of technical difficulties, all members of the team have direct access to the neurologist and it support by telephone. figure 1. [teleneurology cart setup]. when a patient presented to the emergency department (ed) or had an acute change suspicious of stroke while hospitalized for another reason, a “code stroke” was called within the hospital. this resulted in a rapid cascade of events where the oncall neurologist was notified promptly. often, the rotating medical student (or nurse practitioner) was the first member of the team to assess the patient following a code stroke. the student was often responsible for transporting the teleneurology robot to the ed or patient room. this process allowed for stroke patients to be seen and evaluated within 30 minutes of the “code stroke” by the on-call neurologist. when the attending neurologist appeared on screen, he or she began their assessment and followed doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports typical stroke protocol. if a cerebral vascular event (cve) or transient ischemic attack (tia) not requiring neurosurgery was suspected, the patient was admitted to the hospitalist service in the critical care unit (ccu) and followed by the teleneurology team. if tissue plasminogen activator (tpa) was appropriate, it was administered in the ccu. patients with a clinical presentation and imaging consistent with hemorrhagic stroke were promptly evaluated and transported to the neurosurgical-capable facility one hour away. each morning the neurology care team met in the icu conference room for morning report to review and discuss new and follow-up patients. the medical student completed pre-rounds on all patients before morning report, completing a full history and physical examination. the student documented his or her findings with a detailed teleneurology daily record note. any updates on the patients were presented during morning report. team members from pt, ot, nursing, and speech contributed their discipline specific updates for each patient. when morning report was finished, formal rounds began. the team went to each patient room and the neurologist, via the robot, conducted a focused history and neurological exam. the medical student performed most of the neurological exam. this not only allowed the neurologist to see the exam findings, but also provided an opportunity for one-on-one instruction of the medical student. if there were no new consults, the remote neurologist spent 30 to 90 minutes teaching about topics relevant to the patients seen that morning. students reviewed recent publications and articles related to acute neurology care as recommended by the remote faculty. in addition to this supplemental teaching, rural track students participate in the same virtual lecture series, readings, and online patient case materials as main campus students. the required curriculum covers a broad range of acute, chronic, inpatient, and outpatient neurologic topics. the medical students were responsible for completing daily record notes for each patient seen with the neurologist. this note template, developed by the students, served as a running record of each patient with distinct sections as shown in table 1. the student completed 2 notes for each patient. the student version was completed as soon after admission as possible and was used for later review with the outpatient neurologist. the second version of the note was for research purposes and included the final summary of imaging results and the assessment and plan of the remote neurologist, which we report here. the student version was considered a catalyst for active learning and allowed for guided practice with critical thinking in the setting of acute neurology care. immediate feedback on the draft student notes was provided by the on-site nurse practitioner. in addition to inpatient clinical experience, medical students commuted 2 to 3 times per week to an outpatient neurology office located one hour away. in this setting, students learned common outpatient complaints and management protocols. students saw patients in the office where they obtained patient history, performed physical examination, developed an assessment and plan, and presented to the inperson neurologist. students also wrote notes on patients seen. in addition, students observed common office procedures like electromyography (emg) and botulinum toxin injection. the neurologist reviewed the student version of the inpatient daily stroke notes and provided additional feedback to the student. we summarized demographic and clinical information using frequencies and percentages, with the patient population of 49 as the denominator. comorbidities were obtained using the patient doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports problem list as shown in the electronic medical record (emr) and re-checked using the patient medication lists from emr. the presenting complaints were the chief complaints provided by the patient on arrival at the emergency department. these were obtained directly from the patient chart or by talking directly with the patient. we measured student satisfaction by having each rotating student complete a series of surveys at the conclusion of their neurology clerkship. the surveys evaluated student satisfaction with the overall rotation experience, as well as an evaluation of teleneurology attending performance and teaching. direct individual feedback was not sought from patients, but the tele-stroke team leaders provided comments specific to student involvement. results data from 4 third-year medical students was included in this study. a total of 49 neurology patients were seen by the medical students. the patient population seen by students is described in table 2 and patient outcomes outlined in table 3. student evaluation data and comments are summarized in table 4, along with staff comments. the survey responses were on a likert scale (strongly disagree -1, disagree -2, neutral 3, agree4, strongly agree-5). we combined all student responses to provide the mean response and range. student/staff comments “faculty 1 had great screen presence and was able to keep everyone involved and interested” “faculty 3 had a great screen presence and answered all questions by patients and families.” “faculty 4 had a very positive presence and in no way over-critical to students.” “faculty 5 was very approachable and understood the knowledge base of a typical third year student. faculty 5 recommended several articles which were beneficial with shelf studying. he reviewed 2 articles with me daily and asked great review questions.” doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports “faculty 3 was extremely enthusiastic about teaching, gave me lectures on stroke, but also other neuro topics that would be helpful for the shelf. faculty 3 also gave me feedback with each patient, so i knew exactly how i needed to improve. wonderful teacher.” “faculty 2 did not attempt to teach. i am not sure if he was unaware that he was supposed to teach. he did not attempt to bring me into each patient's care but did passively allow me to perform the neuro exam in place of the nurse.” “faculty 1 is very knowledgeable and ecstatic to teach, joy to learn from. can't speak highly enough.” “faculty 1 talked through abnormal mris, mras, ctas and ct scans and explained when to use with vs without contrast cts and explained the difference between t1 and t2.” “faculty 1 expects students to take part in neuro examination on rounds, present patients, and be an active member of the care team.” “faculty 3 actively included me in new consults, and i was able to see and perform full neuro exams in the ed." “faculty 4 asked my input and inquired about my assessment and plan.” “as the first medical student to participate in the teleneurology curriculum i felt like we were still trying to work out the details of how things would work in reality vs. in theory. it did not take long to work out most of those factors. i found the addition of teleneurology inpatient curriculum very helpful to my overall learning of neurology as a discipline. i felt that this portion of the rotation specifically helped me grow in my presentation and physical examination skills, as well as my abilities to work with a large multi-disciplinary team.” “during my rotation, the neurology faculty schedule was in flux and changing constantly (making it hard to get in a routine). otherwise, neurology via telemedicine has been incredibly enriching. i met all required diagnoses quickly, improved my presentation skills, and perfected my physical examination skills.” “student involvement has been a positive addition to the team as a whole. students are learning how to educate patients on stroke care and prevention. in addition, they will be able to identify high risk patients and risk factors. they are a valuable addition to the entire team.” – aprn “overall, patients are positively impacted by students on the rotation and are extremely receptive to student rotators taking an active role in their care.” aprn “having medical students on the teleneurology service was so refreshing and added a new level of intellectual stimulation. the students bring a curiosity and passion for working with the patients. they allow for the entire team to be reminded and refreshed on basic science components through their questions.” pt “patients are more than accepting of having medical students as a part of their care team. the students spend quality time listening to the patients, talking with them, and helping to educate the patient. the degree to which students are able to spend with each patient allows for them to act as a valuable liaison between the patient and the team.” pt with the adapted neurology curriculum for the study time period, students scored 1.5 points higher on the clinical evaluation than did the main campus students and 2.6 points higher on the shelf exam. in this patient group, all but 2 patients received all acute neurologic care and were medically managed within the rural hospital. none of the patients included in this group received thrombolytics because they presented outside of the required time window. discussion the primary goal of implementing teleneurology into the clerkship curriculum was for each student to participate in full scope neurology clinical care. the new curriculum allowed for continued outpatient doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports experiences, and patient-centered, multidisciplinary approaches to inpatient acute stroke care. the addition of inpatient teleneurology curriculum was well accepted by all participating students. our survey indicated that all 4 medical students responded “strongly agree” when asked if they were satisfied with telemedicine as a part of their learning experience. weakness was the most common presenting symptom of patients seen followed by dysarthria, numbness, and confusion. all of these are common and important presentations for students to understand. overall, the most frequent diagnosis was cerebral infarction, followed by transient ischemic attacks, and non-stroke diagnoses. medical students were able to follow patients who initially presented with symptoms suspicious for cve until diagnosis and disposition. students were encouraged by telemedicine attendings to create a differential diagnosis, assessment, and plan for each patient. the fact that 95.9% of our patients were able to be cared for in our community hospital where they may know staff and where their family can easily visit speaks to the value to our patient population. the teleneurology service also keeps revenue for acute care in our local hospital, an important concern for all community hospitals. each faculty received mostly high marks on student evaluations. student surveys indicated that remote faculty teaching was considered effective by all medical students. the medical students worked with and evaluated 5 teleneurology physicians. students commented on certain faculty members taking extra time to explain key neurology concepts and review diagnostic imaging, including information on when to use specific forms of imaging in patient scenarios. this unique form of communication allowed for faculty to provide lectures on stroke, review up to date, evidence-based articles, and give feedback to students on physical exam and topics discussed. faculty screen presence was specifically noted by students and contributed to the overall learning experience. in this context, we define screen presence as the ability to connect with and engage the person (colleague, care team member, patient, patient family, or student) with whom one is communicating via telemedicine robot or live video conference. this attribute includes speaking distinctly and allowing for the audio delay to avoid talking over someone. it also includes pausing to recognize persons at the other end and giving them opportunities to contribute without having to interrupt. student feedback suggested that many of the faculty demonstrated quality screen presence that in turn enhanced the patient’s experience and the learning for students. a positive screen presence resulted in improved patient and family engagement by the neurologist and gave the medical student the confidence to perform the neurologic exam and ask questions. in addition, participation in the multidisciplinary care team provided students with structure and purpose. our survey indicated that students gained valuable skills by working with other healthcare disciplines on a team. this is an important skill for future physicians that cannot be taught in traditional didactics. through patient presentation during morning report, medical students were able to demonstrate active knowledge of each patient case. medical students saw new consults, formulated their own assessments and plans, and received important constructive feedback from teleneurology faculty. in addition to pre-rounds each morning, by acting as the “hands” of the remote neurologist, the medical student held an active role in patient care. our survey indicated that all medical students were observed directly by the neurologist while completing the full neurology examination. enthusiastic interest in teaching, thoughtful screen presence, and high expectations for the student as an essential part of the team were faculty characteristics that resulted in positive learning outcomes for students. students noted that direct feedback on presentation and exam skills added to the overall educational value. overall, the staff who were surveyed remarked that medical students were a positive addition to the care team, and they noted that patients were very accepting of having students be an active part of their care. most patients appreciated the extra time medical students spent with them and felt that their concerns were heard based on staff observation. patients were not surveyed, however, based on student and faculty observation the patients and their doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports families were very receptive to this method of care. the live communication between the patient or family and the teleneurologist was smooth and without delay, almost as if the neurologist were physically in the patient room. study limitations and strengths our study included only 4 students. two additional medical students were expected to participate during the study period, but the covid-19 pandemic caused a nation-wide disruption in clinical training for third and fourth-year medical students. however, the strong similarity of feedback from all 4 students suggests that they are representative of the larger group. the exception was the one student who felt that the organization and the daily stroke record needed improvement. further discussion with this student showed that many of the details of the teleneurology team were being worked out at the time of her rotation, and the organization of the overall rotation improved as she progressed over the 4-week period. she also provided valuable feedback for improving the daily stroke record to maximize efficiency and learning potential. lack of continuity between student and remote faculty was cited as an issue by some students. more continuity is always preferred, but the same discontinuity is encountered on most university teaching services, where the team attending may change weekly or even more frequently depending on their other responsibilities. although students became very familiar with the requirements and contraindications for thrombolytics in acute stroke symdromes, they had no experience following patients who received them. at our hospital during this time period, very few patients presented during the appropriate time window. this is largely thought to be due to a lack of understanding of common presenting stroke symptoms within the community and the community is still learning about these new capabilities in the hospital. the hospital system is actively trying to educate the community on common signs and symptoms of stroke through informative videos online and radio broadcasts. it was important for students to learn of these obstacles. the hospital is not yet considered a certified stroke center, and the closest certified stroke center is located 48 miles away in evansville, indiana. identified strengths of the experience include preceptor willingness and enthusiasm for teaching which added to the students’ learning experience as preceptors provided excellent feedback and established the student as an integral part of the stroke care team. an important benefit of this process was the ability of the student to participate directly in a multidisciplinary care team. this allowed the student to develop communication and team building skills necessary for quality patient care and success in their future residency training and career. conclusion we conclude that participating students were satisfied with the teleneurology rotation experience and enjoyed learning from remote faculty. students felt that their learning was more comprehensive with the inclusion of teleneurology in the inpatient setting. in addition, students had an increased confidence in conducting the neurological examination and collaborating as a part of a multidisciplinary team at the conclusion of the rotation. students expressed increased understanding of telemedicine services and its many uses within the inpatient and outpatient settings. students expressed overall satisfaction with the daily record as a learning tool to record history, physical exam findings, assessment, and plan. students were exposed to a wide variety of common inpatient neurological complaints, diagnostics, and management protocols. all students completing the neurology rotation at our regional campus were able to see all required diagnoses in-person, and the addition of teleneurology technology greatly assisted in student engagement in the direct care of patients with suspected strokes. telemedicine holds significant promise for medical student education and facilitating access to care for rural and other underserved patient populations. further research and innovation are needed to optimize the effective use of this technology. acknowledgment we express our sincere appreciation to steve fricker, the director of rural health/student affairs at the trover campus for data base management. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports references 1. crump wj, pfeil t. a telemedicine primer. an introduction to the technology and an overview of the literature. arch fam med. 1995;4(9):796-803; discussion 804. doi: 10.1001/archfami.4.9.796. 2. wechsler lr. advantages and limitations of teleneurology. jama neurol. 2015;72(3):349354. doi: 10.1001/jamaneurol.2014.3844. 3. crump wj. telemedicine: has the time really finally arrived? j rural health. 2020. doi: 10.1111/jrh.12435. 4. hong yr, lawrence j, williams d, jr., mainous ia. population-level interest and telehealth capacity of us hospitals in response to covid-19: cross-sectional analysis of google search and national hospital survey data. jmir public health surveill. 2020;6(2):e18961. doi: 10.2196/18961. 5. patel uk, malik p, demasi m, lunagariya a, jani vb. multidisciplinary approach and outcomes of tele-neurology: a review. cureus. 2019;11(4):e4410. doi: 10.7759/cureus.4410. 6. hatcher-martin jm, adams jl, anderson er, et al. telemedicine in neurology: telemedicine work group of the american academy of neurology update. neurology. 2020;94(1):3038. doi: 10.1212/wnl.0000000000008708. 7. crump wj, barnett d, fricker s. a sense of place: rural training at a regional medical school campus. j rural health. 2004;20(1):8084. doi: 10.1111/j.1748-0361.2004.tb00011.x. 8. dorsey er, glidden am, holloway mr, birbeck gl, schwamm lh. teleneurology and mobile technologies: the future of neurological care. nat rev neurol. 2018;14(5):285-297. doi: 10.1038/nrneurol.2018.31. 9. guzik ak, switzer ja. teleneurology is neurology. neurology. 2020;94(1):16-17. doi: 10.1212/wnl.0000000000008693. 10. laghari fj, hammer md. telestroke imaging: a review. j neuroimaging. 2017;27(1):16-22. doi: 10.1111/jon.12402. 11. govindarajan r, anderson er, hesselbrock rr, et al. developing an outline for teleneurology curriculum: aan telemedicine work group recommendations. neurology. 2017;89(9):951959. doi: 10.1111/jrh.12156. 12. afshari m, witek np, galifianakis nb. education research: an experiential outpatient teleneurology curriculum for residents. neurology. 2019;93(4):170-175. doi: 10.1212/wnl.0000000000007848. 13. jagolino al, jia j, gildersleeve k, et al. a call for formal telemedicine training during stroke fellowship. neurology. 2016;86(19):1827-1833. doi: 10.1212/wnl.0000000000002568. 14. fleming da, riley sl, boren s, hoffman kg, edison ke, brooks cs. incorporating telehealth into primary care resident outpatient training. telemed j e health. 2009;15(3):277-282. doi: 10.1089/tmj.2008.0113. 15. jonas ce, durning sj, zebrowski c, cimino f. an interdisciplinary, multi-institution telehealth course for third-year medical students. acad med. 2019;94(6):833-837. doi: 10.1097/acm.0000000000002701. 16. masters k. preparing medical students for the e-patient(). med teach. 2017;39(7):681-685. doi: 10.1080/0142159x.2017.1324142. 17. beck at, crump wj, shah jj. neurology telemedicine as virtual learning for regional medical campuses. j rural medical campuses. 2020: 3(2). epub. doi: https://doi.org/10.24926/jrmc.v3i2.2957 18. crump wj, fricker rs, ziegler c, wiegman dl, rowland ml. rural track training based at a small regional campus: equivalency of training, residency choice, and practice location of graduates. acad med. 2013;88(8):1122-1128. doi: 10.1097/acm.0b013e31829a3df0. 19. crump wj, fricker rs, ziegler ch, wiegman dl. increasing the rural physician workforce: a potential role for small rural medical school campuses. j rural health. 2016;32(3):254-259. doi: 10.1111/jrh.12156. microsoft word student-generated learning article.docx published by university of minnesota libraries publishing student-generated learning objectives and curricular innovation thomas laux; mark stephens, md; jennifer meka, phd doi: https://doi.org/10.24926/jrmc.v4i2.3637 journal of regional medical campuses, vol. 4, issue 2 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc thomas laux, ba; medical student, penn state college of medicine, university park, pa mark stephens, md; professor of family and community medicine and professor of humanities, penn state college of medicine, university park, pa jennifer meka, phd; director of medical education and educational research institute and assistant dean for medical education, university at buffalo jacobs school of medicine and biomedical sciences, buffalo, ny corresponding author: thomas laux; address: suite 308 1850 e. park ave., state college, pa 16803; telephone: 814-689-0008; email: tlaux@pennstatehealth.psu.edu all work in jrmc is licensed under cc by-nc volume 4, issue 2 (2021) journal of regional medical campuses original report student-generated learning objectives and curricular innovation thomas laux; mark stephens, md; jennifer meka, phd abstract introduction recent focus from accrediting bodies emphasizes learning objectives as a means of mapping and standardizing content coverage. while most educational training centers on faculty-derived learning objectives that are geared towards didactic lectures, student-centered teaching modalities like problem-based learning continue to gain popularity. one opportunity is the integration of student-generated learning goals in curriculum development. the educational philosophy at the penn state college of medicine university park regional campus centers on discussion-based inquiry groups that focus on students’ experiential case learning which leads to student-generated learning objectives. this study examined a studentcentered approach to learning objectives. methods our quantitative analysis explored student-generated learning objectives during the first-year curriculum. primary outcome measures included process variables investigating the growth and change of objectives across the year that include bloom’s taxonomy-based verb scores, verb numbers per session, and learning objective word lengths. knowledgebased content coverage variables were compared with existing curricular models. results student-derived learning objectives changed substantially over the year. taxonomy scores decreased while the learning objective verb number, word length, and calculated value per session increased significantly. content and comparator analyses showed that coverage and verb quality met or exceeded existing curricular models. discussion student-generated learning objectives are not only plausible and achievable, they also provide distinct pacing and engagement benefits. our findings serve as a model for student-centered educational innovations. introduction learning objectives (lo) are used broadly as a standard tool to clarify educational goals.1 current regulatory guidelines from the liaison committee on medical education (lcme) and accreditation council for graduate medical education (acgme) promote lo to establish educational standards for undergraduate and graduate medical education.2-4 historically, program, course, and session lo are written by faculty. however, with the proliferation of problem-based learning, student-generated lo are increasingly being used in medical, dental, and nursing education.5-7 to date, studies examining lo designed by both students and faculty suggest that student-generated lo are equivalent to faculty-generated lo in terms of breadth and depth of content.8-10 given the apparent congruence between faculty and student-derived lo, a gap in the literature exists when examining the impact of student-generated lo on student learning processes and outcomes. when designing curricula, content coverage correlates poorly with learner retention and usable knowledge.11 as such, goals beyond maximizing content coverage must be considered. therefore, lo are vital to instructional design. lo help identify the specific, measurable competencies to be achieved while also providing guidance as to the level of depth and type of transfer that is anticipated at any given stage of the learning process. promoting long-term knowledge retention and journal of regional medical campuses, vol. 4, issue 2 original report critical thinking skills helps prepare learners for current and future professional practice. experiential learning provides opportunities for context-specific learning and has long-term knowledge retention benefits over traditional lectures.12 strategies such as distributed practice, interleaving, and desirable difficulty also help to promote learner retention.13 with this background in mind, in 2016 the penn state university college of medicine (pscom) sought a curriculum redesign for a new regional medical campus. from the outset, the curriculum needed to meet lcme standards for content coverage, while simultaneously creating opportunities to promote long-term retention, experiential learning, and critical thinking skills.12,13 student-generated lo stemming from authentic clinical experiences was agreed upon as the bridging mechanism to meet these goals. using the constructs of design thinking from the engineering realm, pscom partnered with 5 medical students who deferred admission for one year—medical student design partners—to pilot curricular strategies to build the pscom university park regional campus (uprc).14 respecting the unique design of this curriculum, the present study explores process and content changes related student-generated lo across the first year of medical school. we predicted that lo verbs per session would change in quantity and quality throughout the year to fit growing learner content capacity, and that overall verb quality would be comparable to facultyderived samples. we also hypothesized that our class sessions would be as good or better than comparator faculty-driven sessions from a content coverage perspective. methods the inquiry group cycle this study examines the inaugural uprc class during the 2017-2018 academic year. institutional review board reviewed and exempted the study prior to data analysis. the uprc first-year curriculum consists of 2 complementary semester-long courses that utilize student-derived lo based on the problem-based learning model.17 twelve incoming students were divided into two 6-person inquiry groups (iq). students were immersed into local primary care practices for several clinical sessions each week (figure 1). students acclimated to the practices by initially working with front desk staff to learn about clinical workflow and gain health systems knowledge. they progressed to working with nursing staff obtaining vital signs and helping to guide patients to examination rooms. finally, students progressed to more traditional clinical roles: reviewing patient information from the electronic medical record, conducting a history and physical, and then working with an assigned preceptor to develop the assessment and plan for each patient. by the end of the first year, each student engaged in approximately 100 clinical half-days. figure 1: the inquiry group (iq) weekly cycle this immersive experience was designed to provide students with authentic patient narratives to bring to iq each week to share with their peers. students brought these patient-based narratives to class to generate lo for weekly study. on mondays, students prepared a summary narrative from a patient encounter of their choosing.18 after each student presented their selected case, the iq group voted to select 2 cases for further study to discuss on wednesday and friday of that week. using the pscom 4 pillars model—biomedical sciences, clinical sciences, health systems sciences, and health humanities—students created lo considering each pillar for each of the 2 cases.19 the lo creation was studentled. experienced faculty helped to facilitate the process using bloom’s taxonomy as a shared framework, and while taxonomic charts were posted in classrooms no explicit bloom’s-based training was given for students. students then used the co-created lo as the roadmap for their preparations, reconvening on wednesday and friday to discuss each case at a much deeper level. the selected cases and associated lo were designed entirely by the students based on their clinic experiences. drawing on contextual learning theory, this intentionally asynchronous model of coursework leveraged in vivo experiential clinical learning to maximize student engagement and ‘ownership’ of both content and process to enhance transfer and retention. the iq design was intended to promote distributed practice and interleaving relative to traditional coursework.13 tuesday-friday: lo-guided independent study for iq sessions wednesday: iq session case 1 friday: iq session case 2 previous monday-friday: primary care clinical immersions inspire cases monday: case presentations, selection, and student-generated learning objectives journal of regional medical campuses, vol. 4, issue 2 original report process variables—lo verbs and bloom’s taxonomy process variables illustrate the quality of lo and their value to learner thinking and development in the class session. process variables including average lo score, number of lo verbs per iq session, total lo value per iq session, and lo word count analyzed the structure of lo over time. as part of each monday iq session, there were 3 to 7 student-generated lo per session. some lo included multiple verbs. for example, in a session on lung cancer one lo stated “review the literature on the relationship between socioeconomic status and healthcare delay and treatment. develop medical and/or public health strategies which might respond to the evidence you discover in the literature”. each of these 2 distinct verbs, “review” and “develop”, comprised an individual lo-related element for the purposes of analysis. once the number and distinct nature of lo verbs were established for a session, each verb was individually scored using the bloom’s taxonomy of measurable verbs.20 this corresponds to a score of 1 to 6 for each verb along the progressive continuum of knowledge, comprehension, application, analysis, synthesis, and evaluation. lo and verbs were scored by one primary rater using the standardized scoring system, and were reviewed by the 2 other authors.20 a small number of verbs from the student-generated lo were not readily mapped to the standardized scoring system, and in these instances the rater designated their best attempt at an appropriate scoring relative to similar standardized verbs; for example, “simulate” score as 5 due to its semantic similarity to the standardized 5 of “roleplay”. after each individual verb was scored, the mean verb scores associated with each individual session were calculated to determine an average lo score for the individual iq session. in addition, the average lo score was multiplied by the number of verbs in the individual session to determine a total lo value for each session in order to measure verb quantity as well as quality. the average word length for each lo was also calculated. content variables—are we covering enough material? content variables illustrate the factual medical knowledge discussed in the class session. at the conclusion of each iq, faculty facilitators mapped session content to a list of 10 competencies and 23 unique subcompetencies students required for graduation.21 session content was also mapped to a list of 222 unique core content areas associated with usmle core content.22 session content was also mapped to the up50. the up50 consists of 50 core topics critical to “preclinical” medical education such as headache, abdominal pain, and stroke derived from iterative consultation with multiple curriculum innovators in the us and canada.23,24 thus given our 12 month first-year coursework comparing to a typical 18 to 24 month “pre-clinical” curriculum, we would expect half to two-thirds of the up50 should be covered as a baseline. data analysis to assess lo changes throughout the year, we conducted a quantitative analysis for each process variable individually to determine lo growth and change over time. the same was done for each content variable to determine if our student-guided sessions were on track from a content coverage perspective. data for each variable in the first half of the academic year was compared to data from the second half of the academic year with a 2-sample t-test assuming unequal variances. for pattern analysis, trendlines of best fit were calculated along with r2 values using individual values for each variable, weekly averages for each variable, and monthly averages for each variable. the total up50 count and interleaving topic count for the year were used to compare to expert-driven hypotheses about medical school pre-clinical curricular content coverage. the overall percentage of “high quality” (scoring 4, 5, or 6) and “low quality” (scoring 1, 2, or 3 on bloom’s taxonomic list) lo was compared to baseline samples from the medical and nursing literature.20,25-27 year-long content variable counts were also compared with those mapped from the pscom hershey campus (hc) as a convenience sample. results over the course of the year there were 67 iq sessions. thirty-eight sessions took place during the fall of the academic year and 29 during the spring. from these 67 sessions, there were a total of 261 lo containing 425 verbs for analysis. process variables the average lo score per session decreased significantly (p=0.0073) from fall to spring. the average verb scores most approximated a second-degree polynomial line-ofbest-fit with r2=0.25 (figure 2). the number of learning objective verbs per session increased significantly throughout the year (p<0.001). verbs per objective increased significantly as the year progressed. journal of regional medical campuses, vol. 4, issue 2 original report figure 2: uprc average lo score per session total lo value per session was calculated by multiplying average verb scores for the session by the number of verbs in that session. the increase in total lo value per session significantly increased (p=0.0081; two-tailed ttest) from fall to spring. while the average lo score followed a decreasing polynomial curve, the number of lo increased to compensate, leading to an increase in the total lo value through the year. due to high intersession variability, weekly and monthly data were also plotted, showing linear trendlines with r2 values of 0.37 and 0.69 respectively (figure 3). figure 3: uprc monthly total lo value per session the average lo word count per session increased significantly from fall to spring (p<0.001; two-tailed ttest). content variables sub-competency count per session increased significantly from fall to spring semester (p=0.010). due to high intersession variability, weekly and monthly data were also plotted, showing linear trendlines with r2 values of 0.23 and 0.53, respectively. the increase in core content count per session was significant (p=0.0094) when comparing the first and second halves of the year. given high intersession variability, weekly and monthly data were plotted with linear trendlines showing r2 values of 0.22 and 0.57 respectively. the up50 count per session was not significant (p=0.70) when comparing the 2 semesters. generalizability to explore whether our students were writing lo of significantly lower quality than other curricula, we compared our data with 3 studies utilizing similar coding systems based on bloom’s taxonomy.25-27 in these studies, course outcomes objectives and faculty session questioning—the closest surrogates for lo available in the literature—were faculty-generated rather than student-generated. results from these studies showed that 79% of course outcome objectives in the medical school study and 69% and 91% of faculty session questions in the nursing school studies were of lower quality—scoring 1, 2, or 3 out of 6 on their bloom’s scales. by comparison, only 54% of our studentgenerated learning objectives rated as lower quality. the 67 iq sessions covered 40 unique up50 topics, 23 of which were also addressed at least twice. thus, 80% of the most fundamental “pre-clinical” content areas were addressed during the first year using student-generated lo. more than half of those topics had an interleaving opportunity during a follow-up session. to demonstrate proof of concept and comparison, we used the same sub-competency and core content mapping variables to compare our data with that of the hc. a 2-sample t-test revealed the uprc monthly sub-competency average (p<0.0001) and the uprc monthly core content (p=0.00011) were significantly higher than the more faculty-guided hc. the uprc sample shows increases over the year in sub-competency and core content counts—linear-fit r2 values of 0.53 and 0.57, respectively—unlike the relatively flat hc comparisons (figure 4). y = -0.0084x + 3.5796 r² = 0.0481 y = 4e-05x3 0.0052x2 + 0.1606x + 2.3318 r² = 0.2545 0 1 2 3 4 5 0 20 40 60 80 average lo score per session y = 1.0154x + 15.213 r² = 0.6929 0 10 20 30 0 2 4 6 8 10 12 monthly total lo value per session journal of regional medical campuses, vol. 4, issue 2 original report figure 4: sub-competency and core content per session by month for uprc vs. hc comparator discussion this study reviews outcomes from the first-year of a new curriculum emphasizing the use of student-generated lo based on immersive clinical experiences. we hypothesized that our content variables would score similarly if not favorably compared to our more facultyguided main campus and that our process variables would show elements of growth and change in student learning throughout the year. our results largely validate the principles of process improvement and content comparability. as expected, student-generated lo changed significantly over the course of the academic year. while the average lo scores decreased on our bloom’s-based rating scale, the number of objective verbs per session, the word length of objectives, and the total value of objectives per session improved significantly. the quadratic trend of average lo scores shows that our students initially improved in the taxonomic quality of verbs before ultimately shifting towards a preference for quantity over quality. this suggests students may be taking ownership of their learning process, concurrently adapting the lo process to maximize clarity and efficiency in terms of course preparation both for the sake of the iq group and its broader week of independent studying. process variables with regard to bloom’s taxonomy, average lo verb scores decreased through the year. at the beginning of the year, there was limited a priori training for students in terms of selecting lo verbs. while students regularly engaged with bloom’s taxonomy as part of the lo creation process, there was no explicit curricular goal to maximize verb quality. the mid-year peak in lo score may be due to relative inexperience with lo creation early on, followed by improved student engagement mid-year towards a perceived goal of maximizing bloom’s hierarchy. this later shifted perhaps to a goal of designing lo for effective study and learning rather than linguistic embellishment. as the year progressed, students gained comfort and confidence generating lo with multiple verbs to clarify key concepts and maximize studying preparation for class discussions. over time lo value scores increased, which could be explained by a priority shift among the students who eventually focused less on the taxonomic quality of individual verbs and more on the quantity and fit of each verb to clarify and facilitate their independent studies. for example, compare the fall diarrhea clinical science lo “distinguish between the most common types of diarrhea” with the spring eating disorder clinical science lo “define the dsm v criteria for anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified. identify risk factors for each disorder, clinical workups (including physical examination findings), and management for patients (focusing on healthy weight gain and including referral criteria)”. this spring lo is neither pithy nor does it contain high quality verbs—“define” and “identify” score 1 and 2 out of 6, respectively. it does, however, paint a specific roadmap for students to study in their topics of group interest. given that verb score didn’t significantly increase while verb value did, this reveals a powerful increase in verb number per case over the year, indirectly implying that students over time more readily engaged with the lo development process and likely with their overarching studies. the evolution of average verb score and value, including the polynomial transition throughout the year in verb score, illustrate potential scaffolding for learners with regard to their perceptions of self-generated lo and the underlying content they are seeking to understand. more broadly, our results question the specific goal of bloom’s taxonomy in scientific thinking. whereas bloom’s is generally discussed as a hierarchy with the goal of maximizing higher-order questions and thoughts, journal of regional medical campuses, vol. 4, issue 2 original report perhaps a blending of verb order scoring, or even something more complex like the polynomial findings of our study, could be beneficial for the ultimate goal of learning.28 similarly, the increase in lo word counts reveal possible changes in lo purpose. as an example, the early year lo “compose 2 potential open-ended questions to build shared decision making in our case of abdominal pain” scores highly, fulfills operationality, and works beautifully for packaged lectures. such an lo does not, however, provide clear guidance for students to thoughtfully prepare for an upcoming iq session. lo that work to summarize and focus a 50-minute didactic lecture do little to help students prepare for a robust 4-hour inquiry-based discussion and hours more of independent study. for our example above, consider the potential addition, “…demonstrating an understanding of pqrst pain assessment, acute abdomen definitions, and medical as well as surgical treatment options”. in such settings, longer wording with higher degrees of clarity and nuance prove to be an asset. the interplay between the polynomial shift in average lo score alongside the increases in lo value and word length suggest a transformation in student mental models of their content learning and the curricular preparation mechanisms driving that learning. this can be seen with objectives like the spring medical humanities lo during a diabetic ketoacidosis case, “revisit biases by outlining how this patient’s care may have changed given his label of ‘prisoner.’ what are some strategies that we can use (or promote for others) to avoid making these assumptions and ultimately providing this patient with equal care?” while this lo had relatively low-scoring verbs—"revisit”, “outline”, and “what” rate as 2, 1, and 1 out of 6, respectively—the lo is quite long at 41 words and elicits numerous streams of potential academic exploration, from a textbook review of cognitive biases to a literature review of strategies for working with vulnerable patient populations to a potential introspective dive into the ethics and realities of working with incarcerated folks as a healthcare worker. lo like these show learners designing multi-level and multi-modality objectives far more nuanced than they themselves did earlier in their training and likely more engaging and nuanced for them in that moment than their faculty could have written for them. content variables from a content mapping standpoint, sub-competency and core content counts per session increased from fall to spring. since the content variable mapping task was completed at the end of each session by clinical faculty rather than the students themselves, changes through the year would not be due to operator input skill. the increase in sub-competency count more likely reflects skill changes of students as they created their lo. early in the year, simpler topics covering a smaller number of sub-competencies fully sated student appetites for study and iq preparation. as the year progressed, students wrote better lo—exhibited by process variables data— and were better able to weave in a wider swath of content, representing more robust integration of content domains. interestingly, up50 counts per session did not increase significantly, likely due to the individual casebased focus of each iq session which tended to correspond to a single case-content theme. further, the concurrent increase in clinical responsibilities of our trainees throughout their first year may be driving some of the increases in these content-related variables; the symbiosis between clinical and classroom experience may have impacted the lo they were primed to develop. generalizability our process variable data shows that while students did not generate higher scoring lo as the academic year progressed, they did improve with regard to the number, length, and total lo value over time. our comparator data from the medical and nursing education literature show that despite decreasing through the year, our student-generated lo verb quality still has a much higher percentage of higher-order bloom’s verbs than faculty-derived objectives from these external samples.2528 this suggests that our student-generated lo were at least as rigorous as those in peer curricula. respecting the concern that a student-guided approach to learning could miss higher yield topics and leave students underprepared for clerkships, our up50 data showed that there was at least as much critical content exposure (80%) as we had envisioned (50-66%). our uprc vs. hc sub-competency and core content comparisons revealed that while the starting point for the 2 campuses was relatively similar on both variables, uprc sub-competency and core content counts increased over time whereas hc counts decreased over time (figure 4). while student bodies of the 2 campuses were not explicitly matched pairs, they compare similarly demographically and these findings are more likely due to the student-generated lo process at uprc. these results give further reassurance that our student-based journal of regional medical campuses, vol. 4, issue 2 original report approach to lo generation during the ms1 year is not inferior to other curricula, and may instead be of benefit. broader takeaways lo created for faculty lectures tend to focus on knowledge transfer. as such, these lo benefit from concise, high-quality objectives and shape how educators are taught to think about writing lo in general. our results highlight the importance of context in the lo creation process. students may pivot away from the traditional view of lo to develop their own brand of longer, more varied objectives to guide independent explorations. our comparator studies demonstrate that while our students did not progressively improve verb quality, the studentgenerated lo were still of higher quality than external faculty-generated samples. as with many educational processes, there is the pervasive need to carefully balance quality with quantity when it comes to creating effective lo.25-27 our students designed lo at the outset of each week to guide their research and course preparation for the week to come. as students grew in experience and confidence as the year progressed, they crafted lo to fit their interests and their cognitive load capacity. students alter linguistic hierarchy to favor detailed comparisons, differential diagnoses, and illness scripts. students begin to think more like clinicians, using the learning objectives as a tool for multifaceted, specific, and clinicallyapplicable preparation rather than a more general session goal. for example, the late spring lo, “demonstrate how to administer an nih and cincinnati stroke scale, explain how you would interpret the results, and defend how the results should inform treatment” not only meets the operationality of any lo, but also guides hours of independent study and gears learners towards practical knowledge for their upcoming clerkships. while process growth is a main target of our curriculum, it falls flat if content delivery is inadequate. as such, our goal of being similar if not favorable in terms of content coverage was met. the up50 count over the year met our expectations. internal measures of sub-competency and core content progressed significantly, and our hc content comparison showed favorably. overall, our data suggest that the uprc curricular innovations resulted in process as well as content growth. there are several study limitations where future research could guide further conversation. qualitative survey data from the student and faculty perspective suggesting that there was intentionality with our student-guided process and content quantitative changes would be beneficial. having information about the perceived usefulness of each lo after iq sessions would also help identify which process or content variables were most related. further, our uprc vs. hc and literature-derived verb quality comparisons are imperfect proxies rather than pure control groups, and a robust experimental study could strengthen our conclusions. our curriculum was created using the principles of design thinking, an intentional and iterative process of meeting with stakeholders, constructing and trialing products, and obtaining feedback to repeat the cycle.29 positive outcomes for the iq process and early immersive clinical experiences might be of benefit for other programs interested in implementing similar curricular dynamics. as we all find ourselves in the midst of pandemic-related curricular transition and a newfound focus on virtual learning, programs may find themselves looking for curricular adaptation. we believe pursuing student-generated lo may be one such curricular innovation that can spark engagement and learning in these unprecedented times. further, with the upcoming changes to a pass/fail usmle step 1 exam for our students, we believe the such student created los allows for a more learning-centered orientation which aligns with a pass-fail exam. in our experience, studentgenerated lo addressed sufficient and appropriate content. promoting contextual, learner-driven session framing may help to support retention and transfer of knowledge and skills to the clinical environment. references 1. mager rf. preparing instructional objectives. 3rd ed. london, uk: atlantic books; 1998. 2. liaison committee on medical education. lcme functions and structure of a medical school: standards and accreditation of medical education programs leading to the md degree 2021-2022. lcme. https://lcme.org/publications/#standards. published march 2020. accessed august 2, 2020. 3. accreditation council for graduate medical education. milestones by specialty. acgme. https://www.acgme.org/what-wedo/accreditation/milestones/milestones-byspecialty. published november, 2020. accessed december 3, 2020. journal of regional medical campuses, vol. 4, issue 2 original report 4. 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medical education forty years on: a review of its effects on knowledge and clinical performance. medical principles and practice. 2009;18:1-9. 18. tange hj, hasman a, de vries robbe pf, schouten hc. medical narratives in electronic medical records. international journal of medical informatics. 1997;46:7-29. 19. penn state college of medicine. our vision. penn state college of medicine. https://med.psu.edu/md. accessed august 2, 2020. 20. utica college. blooms taxonomy of measurable verbs. utica college. https://www.utica.edu/academic/assessment/ne w/blooms%20taxonomy%20-%20best.pdf. accessed august 2, 2020. 21. penn state college of medicine. competencies and subcompetencies for graduation. penn state college of medicine. https://students.med.psu.edu/mdstudents/medical-student-competencies-andsubcompetencies-for-graduation/. published august 24, 2017. accessed august 2, 2020. 22. penn state college of medicine core competency list [internal communication]. 23. penn state college of medicine up50 [internal communication]. 24. phillips r, randhawa ap, randhawa v. blackbook. 12th ed. calgary, can: university of calgary; 2020. 25. yeo s. an analysis of verbs used in the course outcomes of outcome-based integrated courses at a medical school based on the taxonomy of educational objectives. korean j med educ. 2019;31(3):261-269. 26. saeed t, khan s, ahmed a, gul r, cassum s, parpio y. development of students’ critical thinking: the educators’ ability to use questioning skills in the baccalaureate programmes in nursing in pakistan. journal of pakistan medical association. 2012;63(3):200203. 27. sellappah s, hussey t, blackmore am, mcmurray a. the use of questioning strategies by clinical teachers. journal of advanced nursing. 1998;28(1):142-148. 28. lord t, baviskar, s. moving students from information recitation to information understanding: exploiting bloom’s taxonomy in journal of regional medical campuses, vol. 4, issue 2 original report creating science questions. journal of college science teaching. 2007;36(5), 40-44. 29. thoring k, muller rm. understanding design thinking: a process model based on method engineering. international conference on engineering and product design education. 2011;493-498. microsoft word mainandregionalcampusarticle.docx published by university of minnesota libraries publishing main and regional campus assessments of applicants to a rural physician leadership program: a generalizability analysis terry stratton, clarence kreiter, phd, carol elam, edd doi: https://doi.org/10.24926/jrmc.v2i1.1981 journal of regional medical campuses, vol. 2, issue 2 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc terry stratton clarence kreiter, phd carol elam, edd all work in jrmc is licensed under cc by-nc volume 1, issue 6 (2019) journal of regional medical campuses original reports main and regional campus assessments of applicants to a rural physician leadership program: a generalizability analysis terry stratton, clarence kreiter, phd, carol elam, edd introduction at its most basic level, the selection of qualified candidates remains a defining characteristic of any profession.1 in medicine, emphasis has shifted in terms of the desired qualities of future physicians2 and the means to assess those qualities.3-5 for example, holistic approaches advocate consideration of multiple factors other than academic performance,6-8 including an individual’s “fit” with a medical program’s social mission.9-10 yet, underlying most selection criteria or methods are individual ratings or judgments of some personal quality, aptitude, or behavior11 is information limited by the reliability of the ratings and the representativeness of the encounter.12,13 for programs with specific foci, such as those accepting applicants directly into rural paths, tracks, or concentrations, the admission process may accommodate supplemental values, interests, or stakeholder perspectives. as such, training targeted to certain practice locales (e.g. rural or underserved),14-16 medical specialties (e.g. primary care),15,16 or career interests (e.g. physician scientists)17 may demand an expanded approach to selecting qualified applicants for a specific programmatic fit. a changing dimension of the admission process, and the academic qualifications, personal qualities, and/or demographic considerations it entails, is the increasing presence of regional medical campuses (rmcs). rmcs are defined as “campuses of medical schools at which a portion of pre-clinical or clinical education of medical students occurs”,18 and play a significant role in calls for increased enrollment.19-20 rmcs are classified into 4 models (basic science, clinical, longitudinal, and combined) based on curricular years taught and/or type of training provided18 and can target a specific mission, demographic, specialty focus, and/or delivery model (e.g. community-based care). while rmcs may provide all aspects of medical training, they are usually considered extensions of the main or “parent” program with selection decisions made by a single, overarching admission committee. located in the southeastern united states (us), the rural physician leadership program (rplp) was created in 2008 at the university of kentucky college of medicine (ukcom) to attract and train applicants interested in practicing rural medicine, ideally in the state of kentucky.21 located in a city of approximately 320 000, students’ pre-clerkship training (years m1-m2 in our program) occurs at the main urban campus, while their clinical instruction and leadership training (years m3-m4) is completed at a smaller, rural (population ~7,500) medical campus about one hour away. ten students are admitted annually, with preference given to applicants with rural backgrounds, interests, or experiences. like their main campus counterparts, rplp students are free to pursue any medical specialty. rplp admissions process while myriad factors underlie the selection of applicants to medical school,22 the challenge for more focused programs like the rplp is twofold: to gauge preparedness for and fit within the medical profession, and to discern interest in rural medical practice.23,24 with final admission decisions made by a single committee, regional input into these assessments was deemed essential. to compliment applicants’ written responses to items contained on our secondary form, semi-structured, face-toface interviews are conducted with applicants meeting certain academic standards. interviews typically last between 30-45 minutes and are conducted by a wide range of individuals including active and retired faculty, administrative staff, community members, and current medical students and residents. interviewer assignment is not systematic, though specific individuals may be paired with applicants with similar personal (e.g. geographic area) or professional (e.g. medical specialty or research area) backgrounds. standardized training includes a review of program missions, the admission process (including instrumentation), and interview protocol. over 2 consecutive days, rplp applicants complete interviews at both main and regional medical campuses. at each site, 2 interviewers with access to standardized applicant data (e.g. prior academic performance, standardized test scores, demographic characteristics, residency status, relevant activities/experiences, and letters of evaluation) independently offer subjective, narrative assessments of applicants’ backgrounds and qualifications as well as a global (overall) assessment. this assessment is assigned a 1-7 numeric rating ranging from “unacceptable” to “outstanding, clearly superior”. using a scale from 0 (“no chance”) to 100 (“absolute certainty”), interviewers at both sites are also doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports asked to estimate the likelihood that the rplp applicant will ultimately practice in rural kentucky. several differences between main and regional campus selection procedures are worth noting. first, unlike the review of applications to the regular md track – which occurs on a “rolling” basis throughout the academic year – all rplp interviews, as mentioned, are conducted during 3 dedicated, 2-day periods. all decisions to admit or reject interviewed rplp candidates are made by the main campus admission committee with input from an appointed and voting rplp faculty member who summarizes the opinions of the regional campus’ interview board. accepted rplp candidates are granted admission to the regional campus program. rplp candidates who are either placed on hold for comparison or rejected due to lack of programmatic “fit” may be considered for main campus admission. second, the disparate numbers of applicants to the rplp versus the “regular” md program, along with the local populations from which to draw interviewers, caused interviewer pools to vary in size. indeed, across the 9-year study timeframe, the mean number of unique interviewers for rplp candidates was 24.3 (median = 22.0, sd = 5.2) and 17.8 (median = 18, sd = 3.9) on the main and regional campuses, respectively. admission interviewers at both campuses consisted of ukcom faculty and administrators, community members (including practicing and retired physicians), and current medical students. the main campus interviewers also included active and emeritus basic science faculty. third, although key metrics and rating scales were identical, variations in the narrative portions of the semi-structured interview forms reflected rplp interests specific to rural medical practice. for example, whereas main campus interviewers were guided to discuss applicants’ general experience/knowledge of the profession and thought into choice of medical schools, rplp forms prompted interviewers to explore applicants’ understanding of rural culture/people and thought into physician/patient relationships. with raters tasked to assess applicants’ qualifications for admission to medical school and fit with the regional campus’ rural focus, the guiding research questions were: 1) what is the reliability of ratings issued by regional and main campus admissions interviewers? 2) what contribution is made by regional interviewers to the overall reliability of admission ratings? and 3) what are the optimal numbers of raters at one or both locations? methods the study protocol received institutional review board approval to use preexisting data from 232 rplp applicants who, from 2009-2017, completed admission interviews. from the 22 re-applicants who interviewed in multiple years, initial rating data were used. interviews were granted via an internal screening process which included a holistic review of each applicant but tended to emphasize measures of cognitive ability and geographical background of applicants. of those rplp applicants interviewed during the 9-year study period, 90 were accepted for admission and subsequently enrolled in the program. interviewer ratings of likelihood of rural practice and overall applicant acceptability were examined separately using a generalizability framework. developed by cronbach25 and refined by brennan26 and others,27 this method uses analysisof-variance techniques to partition variance into multiple sources, or measurement facets. for any given facet, the resulting variance components (vcs) reflect how much of the total score variance can be attributed to that source. these facets can be crossed or nested, depending on whether or not all conditions of one facet are observed with all conditions of another facet.28 based on whether or not the results are intended to generalize beyond the observed conditions, facets are also designated as random or fixed.29 fixing a facet will typically increase the estimated reliability since it limits the range over which scores are generalized. for the designated object of measurement, the resulting “universe score” is akin to “true score” variance in classical test theory. the generalizability framework can be used in retrospective (g study) or prospective (d study) applications. in the latter, hypothetical vcs and statistics can be generated based on systematic manipulations of key measurement facets, much in the way that predicted exam reliability can be examined by altering the number of test items. whereas g studies document what is observed in practice, d studies suggest what is theoretically possible. multivariate g studies allow the calculation of separate (multiple) universe scores for each level of a univariate fixed facet,29 in this case, main and regional campus ratings. following the convention of similar studies,30 brennan’s notation26 is used to represent these models: a solid (●) or empty (○) circle indicates whether a facet is crossed or nested within the multivariate variable, respectively. the resulting notation of the complete multivariate model for this study of main and regional campus admissions ratings, then, is (r○ : p●). descriptive statistics are generated using ibm spss statistics for windows (version 24). univariate and multivariate g and d studies were conducted using genova (version 3.1)27 and mgenova (version 2.1),31 respectively. composite (combined) universe scores were based on equal a priori weights for main and regional medical campus ratings. results descriptive statistics complete sets of ratings (2 x 2 = 4) for overall acceptability and likelihood of rural in-state practice were available for 211 and 174 rplp applicants, respectively, due primarily to main campus interviewers’ failure to consistently rate the latter. applicants with incomplete rating data did not differ significantly by race, gender, or geographic origin. the doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports proportion of cases excluded due to missing data varied by year, but followed no discernible pattern. since these represented key variables of interest, and because sample sizes remained sufficient, cases with missing data were excluded rather than substituted with imputed values. mean ratings of applicants’ overall acceptability were 5.27 (median = 5.50, sd = 0.98) and 5.35 (median = 5.50, sd = 1.20) for main and regional campus interviewers, respectively. for the likelihood of practicing in rural kentucky, mean ratings were 77.7% (median = 87.5%, sd = 20.4%) and 78.5% (median = 85.0%, sd = 19.8%) for main and regional campus interviewers, respectively. ratings of applicant acceptability and likelihood of rural in-state practice were not significantly correlated for main (rs = 0.04, p = .61) or regional (rs = 0.09, p = .25) campus interviewers. univariate g study results table 1 displays univariate g study results [r : (p x c)] of overall applicant rating and likelihood of rural in-state practice. as shown, the percentages of “true score” variance associated with the object of measurement (p) were 36% and 51%, respectively. compared to likelihood of rural practice, the variation in ratings attributable to the person-by-rater (pr) and person-by-campus (pc) interaction was notably larger for overall applicant rating (53% versus 44% and 11% versus 5%, respectively). table 1. univariate mixed model g study results [r : (p x c)] results from a corresponding d study for the [r : ( p x c)] mixed model with campus fixed are shown in figure 1. for overall applicant acceptability, one admissions interview conducted on each of the 2 campuses resulted in an observed reliability of 0.57 which increased to 0.73 when doubled to 2 interviews per campus. ratings of rplp applicants’ likelihood of practicing medicine in rural kentucky tended to be more reliable: the reliability of 2 interviews, one on the main campus and one the regional medical campus, was 0.70 and rose to 0.82 when increased to 2 interviews per campus (4 in total). for both measures, the effects on reliability of increasing the number of interviews beyond the present configuration of 2 were modest. figure 1. univariate mixed model d study results: [r : (p x c)] multivariate g study results table 2 displays the multivariate g study results in a matrix format, with vcs for applicant acceptability ratings and likelihood of rural practice reported by campus on the diagonals of each of the 2 matrices (p, r:p). as shown in the left matrix, the proportion of variance attributable to systematic differences in applicants (p) is considerably greater for regional campus interviewers (53% of the total variance) than their main campus counterparts (30% of the total variance). this implies that the reliability of a single interview is 0.30 for the main campus and 0.53 for the regional campus. the average reliability of one interview across the 2 campuses is 0.42. the relationship between campuses, reflected in the observed covariance (0.56), is reported in the lower left cell of the p matrix. however, more readily interpretable is the universe score correlation (0.83) shown in the upper right cell – which, again, is synonymous with “true score” correlation in classical test theory. this universe score correlation indicates a strong positive relationship between interviewer ratings of overall applicant acceptability at main and regional campuses, suggesting that raters on the 2 campuses were assessing similar but not identical applicant characteristics. table 2. multivariate g study (r ○: p ●) with 2 levels (main and regional campus) doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports in the right matrix, similar results are presented for rplp applicants’ likelihood of rural in-state practice. compared to overall applicant acceptability, the proportion of “true score” variance attributable to applicants (p) is somewhat greater and less disparate for both main and regional campus interviewers (49% and 61% of the total variance, respectively). the universe score correlation (0.91), listed in the upper right cell of the top matrix, indicates that raters on the 2 campuses were assessing very similar aspects in arriving at their judgments regarding applicants’ likelihood of practicing medicine in rural kentucky. since raters were nested within persons, it was not possible to disentangle the specific error attributable to the rater-person interaction and systematic rater stringency. hence, in this study, the r : p vc reflected the sum of the interaction and systematic vcs. multivariate d study results figures 2 and 3 present multivariate d study results, by campus, for each of the measures collected in the rplp admissions process: overall applicant acceptability and likelihood of rural in-state practice, respectively. in addition, composite estimates are presented which combine information on interviewer ratings from both main and regional campuses. estimated reliability is projected for up to 4 interviews per campus and, correspondingly, 8 total interviews per applicant. in figure 2, the g coefficients corresponding to our current protocol of 2 independent raters (one per interview) from each campus are 0.46 (main) and 0.69 (regional) which, respectively, would increase incrementally to 0.56/0.77 and 0.63/0.82 with an additional 2-3 interviews per campus. with main and regional campus ratings weighted equally, the composite reliability averaged across 4 interviews (the current configuration) is 0.73 and would increase to 0.84 if doubled to 8 total interviews (4 per campus). figure 2. multivariate d study results: overall rplp applicant acceptability figure 3 plots comparable generalizability estimates for applicants’ likelihood of rural in-state practice. here, ratings are both more reliable and more comparable, with g coefficients for 2, 3, and 4 interviews being 0.66, 0.74, and 0.79 for main campus interviewers and 0.76, 0.82, and 0.86 for their regional counterparts. composite reliabilities, again weighted equally across campuses, are 0.82 (4 total interviews), 0.87 (6 total interviews), and 0.90 (8 total interviews) – good to excellent for most purposes. figure 3. multivariate d study results: likelihood of rural instate practice discussion as the growth of regional campuses continues, admission committees may seek to expand or better formalize the roles played by these partner programs. especially where such programs have uniquely-targeted (e.g. rural) missions, the need may exist to access specific expertise or incorporate local stakeholders in selecting qualified candidates. coordinating this process in a logistically and psychometrically optimal fashion requires a robust plan for establishing and monitoring this process. this study examined admission interview ratings from a regional campus which, via a rural physician leadership program, provides clerkship training to 10 uk com students interested in rural medical practice, preferably in rural kentucky.21 established in 2008, this “clinical model” rmc18 is an extension of the “parent” academic medical center located doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports about one hour away, which retains ultimate authority for all enrollment under a single, centralized admissions committee. however, primary feedback from rplp stakeholders is routinely provided through a parallel process in which each applicant, over a 2-day period, meets independently with 2 interviewers at each campus. this structure allowed reliability of interviewer assessments to be examined using a generalizability framework. weighted equally and averaged across campuses, combined reliabilities of both overall rplp applicant rating (0.73) and likelihood of rural practice (0.82) were adequate for the purposes at hand. however, main campus assessments tended to contain more error variance for both measures, particularly overall applicant acceptability. while effects of alternative weighting schemes on overall reliability were not formally examined, slight improvements appear possible by assigning a greater contribution to regional campus ratings. several possible explanations exist for the observed variation in main and regional campus reliabilities. first, as previously mentioned, the regional campus interviewer pool is smaller and more homogeneous in term of program knowledge and focus; that is, most interviewers are intimately familiar with the rplp history, curriculum, and objectives. in contrast, main campus interviewers reflect a much broader array of backgrounds, expertise, and interests reflective of an academic medical center. second, while the association between applicants’ overall acceptability and likelihood of rural in-state practice varied somewhat by campus, it tended to be weak: applicants’ academic qualifications were largely unrelated to raters’ judgments about their propensity to eventually practice medicine in rural kentucky. due to confounding factors, the data collection design was unable to accommodate occasion and rater as separate random facets. however, the observed results are fairly consistent with other reports on admission interview reliability.13,32,33 further, these findings support the utility of having rplp candidates interview at both the regional campus and main campus. in this study, the observed interview reliability effectively comprised 4 interviews per applicant, the likely reason for the reliable mean interview scores. in addition, results show little benefit to expanding the rplp admission process beyond 2 interviews per campus. while the medical school personal interview (mspi) remains part of the admissions process, it is only one source of data considered in committee assessments of applicant qualifications and professional/program fit.34 with rare exceptions,35,36 how this and other information is used in committee deliberations or weighted in decisions to accept, reject, or hold applicants has not been widely examined.13 holistically, mspi ratings are considered part of applicants’ overall “dossier”, but no algorithm or guidelines standardize their role or degree of influence. as such, it is unknown whether their use consistently constitutes a “high stakes” application, which has obvious implications for the level of rigor required in their collection and measurement. in a holistic review of applicants, a low rating of overall acceptability, based in part on face-to-face interviews, could prove detrimental to admission. the study objective was not to establish the superiority of a single approach to assessing applicant fit, but rather to empirically explore the apparent tension between the diversity of stakeholder input and the reproducibility of resulting scores. indeed, recent research suggests a hybrid model containing selected elements from various approaches might be optimal.33,37 predicting future events, be it academic performance, specialty choice, or eventual practice locale, remains an inexact science22 involving both tangible38 and intangible39,40 considerations. from prior research on rural medical practice, considerable attention has been paid to applicants’ related backgrounds, interests, and experiences.4143 indeed, of the 107 (38.8%) rplp applicants not invited for interviews during the study time frame, most lacked meaningful rural experience and/or sufficient academic performance.23 since the overriding goal of the rplp is to recruit and train physicians who will practice medicine in rural kentucky, a shared understanding of program goals is essential. in the case of the rplp, this was explicit – incorporating the major program outcome (practicing in rural kentucky) into the actual interview process. the purpose was not to develop a precise measure, but rather to help direct focus on the task at hand. whether this was effective or caused rplp interviewers to cognitively approach the process differently is a question for future research. the meager correlation of this measure with overall acceptability suggests interviewers were able to discern between them. these findings are limited by several factors. first, this study is based on a singular rural track training program at one us institution. as a result, how widely these findings may generalize beyond this context is unknown. second, although all interviewers follow the same semi-structured format, there is some flexibility in the specific questions that can be asked. moreover, regional campus interviewers used a slightly different interview narrative form. lastly, interviewers on both campuses were guided by “rural qualities” gleaned inductively via a nominal group process – not a standardized, demographic definition of “rural”. while by design, this more qualitative operationalization was likely implicated in interviewers’ assessments of likelihood of rural practice. another issue worth mentioning is the potential disconnect between the composite reliability estimates averaged across campus and, in actual practice, the disaggregated use of interviewer ratings by the admissions committee. that is, the informal assessment of agreement made by committee members in their review and comparison of individual interviewer ratings,some of which, not being anonymous, may be afforded more credence than others. conclusion dedicated rural medical tracks or programs have been shown to be effective strategies in producing primary care physicians doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports for practice in rural, often underserved areas,42 especially when provided in settings (like rmcs, for example) that offer meaningful learning experiences outside the larger, urban environment.44 key to the success of these efforts is the selection of candidates most qualified to meet programmatic goals. in kentucky, the rplp was designed to meet this need by admitting applicants who prefer rural practice and training them in settings with appropriate physician and community role models. study results found composite (combined) reliabilities of rplp applicants’ overall acceptability and likelihood of rural in-state practice to be encouraging. on both measures, however, ratings from regional campus interviewers tended to have less error variation than their main campus counterparts. it is possible that better training and calibration, perhaps combining interviewers from both campuses, might narrow the observed differences in reliability. mean ratings, it should be noted, did not differ between campuses. various weighting schemes could, in concert with the number of interviews, be more closely examined as a means of maximizing overall reliability. this study highlights a methodology for developing and monitoring the inclusion of additional stakeholders to the admission process, and may prove useful for programs seeking to strategically tap a wider range of perspectives – especially as they relate to a specific, targeted mission. in the present context, eliciting input from interviewers with complimentary backgrounds resulted in more reliable composite ratings of applicants’ acceptability and likelihood of practicing in rural kentucky. in addition to estimating the reliabilities of these combined scores, the multivariate approach allowed estimation of the relationship between the 2 groups of interviewers. while broadening the universe of generalization is typically associated with reduced reliability, in this application, the increase in reliability from additional interviews was found to outweigh these effects. put another way, the addition of regional stakeholders to the pool of potential interviewers may not necessarily result in a less reliable composite measure. as regional campuses proliferate, the use of multivariate generalizability approaches to examine assessments of applicants or students at multiple “fixed” locales may hold promise. future studies should include a focus on the validity of interviewer ratings. that is, whether or not assessments validly reflect applicants’ academic success or eventual likelihood of practicing in rural kentucky, for example. although early data appear encouraging, a continued followup of rplp graduates will help determine the accuracy of these long-term projections made during admission into the profession. on a broader scale, studies may wish to explore underlying differences and similarities in determining the psychometric impact of expanding stakeholder input. references 1. freidson e. profession of medicine: a study in the sociology of applied knowledge. chicago, il: university of chicago press, 1970/1988. 2. monroe a, quinn e, samuelson w, dunleavy dm, dowd kw. an overview of the medical school admission process and use of applicant data in decision making: what has changed since the 1980s? 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colleges (aamc). aamc statement on the physician workforce. washington, dc: aamc, 2006. 21. arnett pk, stratton td, weaver ad, elam cl. university of kentucky rural physician leadership program: a programmatic review. journal of regional medical campuses (online). 2018;1(3): doi: 10.24926jrmc.v1i3262. 22. benbassat j, baumal r. uncertainties in the selection of applicants for medical school. advances in health sciences education. 2007;12(4):509-521. doi: 10.1007/s10459-007-9076-0. 23. elam cl, weaver ad, whittler et, stratton td, asher lm, scott kl, et al. discerning applicants’ interests in rural medicine: a textual analysis of admission essays. medical education online (online). 2015;20:27081. doi: 10.3402/meo.v20.27081. 24. mason pb, cossman js. does one school’s admission policy help a rural state “grow their own” physicians? journal of the mississippi state medical association. 2012;53(9):284-286,288-292. 25. cronbach lj, glaser gc, nanda h, rajaratnam n. the dependability of behavioral measurements: theory of generalizability of scores and profiles. new york, ny: john wiley & sons, 1972. 26. brennan rl. elements of generalizability theory. iowa city, ia: american college testing program, 1983. 27. crick ge, brennan rl. genova: a generalized analysis of variance system. dorchester, ma: university of massachusetts at boston, 1982. 28. shavelson rj, webb nm. generalizability theory: a primer. newbury park, ca: sage, 1991. 29. kreiter cd. generalizability theory. in: sm downing, r yudkowsky (eds); assessment in health professions education. london: routledge, 2009; 75-92. 30. kreiter cd, ferguson kj. an investigation of the generalizability of medical school grades. teaching and learning in medicine. 2016;28(3):279-285. doi: 10.1080/10401334.2016.1154859. 31. brennan rl. manual for mgenova: version 2.1. iowa city, ia: iowa testing programs, 2001. 32. axelson rd, kreiter cd. rater and occasion impacts on the reliability of pre-admission assessments. medical education. 2009;43(12):1198-1202. doi: 10.1111/j.1365-2923.2009.03537.x. 33. hanson md, kulasegaram km, woods nn, fechtig l, anderson g. modified personal interviews: resurrecting reliable personal interviews for admission?academic medicine. 2012;87(10):13301334. doi: 10.1097/acm.0b013e318267630f. 34. o’neill ld, korsholm l, wallstedt b, eika b, hartvigsen j. generalizability of a composite student selection program. medical education. 2009;43(1):58-65. doi: 10.1111/j.13652923.2008.03247.x. 35. elam cl, stratton td, wilson jf, scott kl. how admission committees decide: influence of committee members’ experience and applicants’ academic characteristics. academic medicine. 2002;77(10 suppl):s26-s28. 36. elam cl, johnson mms. an analysis of admission committee voting patterns. academic medicine. 1997;72(10 suppl):s72-s75. 37. bibler zaidi nl, santen sa, purkiss ja, teener ca, gay se. a hybrid interview model for medical school interviews: combining traditional and multisampling formats. academic medicine. 2016;91(11):15261529. doi: 10.1097/acm.0000000000001218. 38. daniels zm, vanleit bj, skipper bj, sanders ml, rhyne rl. factors in recruiting and retaining doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports professionals for rural practice. journal of rural health. 2007;23(1):62-71. doi: 10.1111/j.17480361.2006.00069.x. 39. cutchin mp. community and self: concepts for rural physician integration and retention. social science and medicine. 1997;44(11):1661-1674. 40. hancock s, steinbach a, nesbitt ts, adler sr, auerswald cl. why doctors choose small towns: a developmental model of rural physician recruitment and retention. social science and medicine. 2009;69(9):1368-1376. doi: 10.1016/j.socscimed.2009.08.002. 41. greer t, kost a, evans dv, norris t, erickson j, mccarthy j, et al. the wwami targeted rural underserved track (trust) program: an innovative response to rural physician workforce shortages. academic medicine. 2016;91(1):65-69. doi: 10.1097/acm.0000000000000807. 42. florence ja, goodrow b, wachs j, grover s, olive ke. rural health professions education at east tennessee state university: survey of graduates from the first decade of the community partnership program. journal of rural health. 2007;23(1):77-83. doi: 10.1111/j.1748-0361.2006.00071.x. 43. roseamelia c, greenwald jl, bush t, pratte m, wilcox j, morley cp. a qualitative study of medical students in a rural track: views on eventual rural practice. family medicine. 2014;46(4):259-266. 44. brokaw jj, mandzuk ca, wade me, deal dw, johnson mt, white gw, et al. the influence of regional basic science campuses on medical students’ choice of specialty and practice location: a historical cohort study. bmc medical education (online). 2009;9:29. doi: 10.1186/1472-6920-9-29. microsoft word covid-19 impact on regional article.docx published by university of minnesota libraries publishing covid-19 impact on regional medical campus education: student perspectives obed barkus, bgs; dorothy hughes, phd, mhsa doi: https://doi.org/10.24926/jrmc.v4i3.3903 journal of regional medical campuses, vol. 4, issue 3 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc obed barkus, bgs; university of kansas school of medicine – salina dorothy hughes, phd, mhsa; departments of population health and surgery, university of kansas school of medicine – kansas city corresponding author: obed barkus, bgs ku school of medicine-salina health education center 138 n. santa fe salina, ks 67401 785-822-0400 obarkus@kumc.edu all work in jrmc is licensed under cc by-nc volume 4, issue 3 (2021) journal of regional medical campuses original reports covid-19 impact on regional medical campus education: student perspectives obed barkus, bgs; dorothy hughes, phd, mhsa abstract due to social distancing precautions and the desire to protect clinical learners, the covid-19 pandemic forced medical schools everywhere to implement more distanced and virtualized learning in their educational curriculums. more specifically, at the university of kansas school of medicine-salina, a regional medical campus, the impact of some of these changes were also seen and felt. the purpose of this study was to investigate the downstream effects of these curriculum changes from the perspectives and opinions of medical students attending a regional medical campus. to explore the study purpose, a mixed-methods, cross-sectional study that used an online survey with closed and open-ended questions was used. additionally, because of unique curriculum characteristics depending on the year of the student, first and second year students (phase i) were asked slightly different questions than students in their third and fourth years (phase ii). closed-ended questions asked students about lecture experience, clinical learning development and time, study time, exam performance, collaborative learning experiences, and socialization/interactions with colleagues. students answered in range of -3 to +3, negative numbers meaning a detrimental impact (or decrease in study time), and positive numbers being beneficial impact (or increase in study time). open-ended questions asked students about improvements that could be made, unique class circumstances during the pandemic and any other relevant impact not covered in closed-ended questions. for phase i students, lecture experience, study time, and exam performance resulted in no impact. however, collaborative learning and socialization with colleagues did result in a detrimental impact that was significant. for phase ii learners, clinical skills development, time spent in clinical skills development, and socialization with colleagues were detrimentally impacted. however, the amount of time spent on studying increased and exam performance benefited. these findings suggest that pandemic-related curriculum changes impact learners differently depending on the phase of medical they are in. introduction the covid-19 pandemic affected the experiences of medical students across the world. at a regional campus like university of kansas school of medicinesalina (kusm-salina), the effects of the pandemic varied among students, and varied from the school’s other 2 campuses. we approached this study from the perspective that the standard medical school curriculum should be constantly evaluated, much like the continuous quality improvement cycle used commonly throughout healthcare. when curricula are under constant constructive scrutiny, educators may also be able to better understand how crises – like pandemics – may impact them. we agree with previous work that take this same perspective and asserts that the experiences of the medical students should be incorporated in this process as well.1 a majority of us medical schools follow a 4-year model consisting of 2 initial preclinical years (phase i) and the last 2 years focusing on clinical medicine (phase ii).2 students in the preclinical years watch lectures, participate in anatomy labs, attend collaborative learning sessions with their fellow students, and take exams over the material from those lectures and group sessions. over the years at kusm there has been a transition to more group, case-based, collaborative, and flipped-classroom learning, in contrast to more traditional lecture-based learning.3,4 phase i students tend to be at school more often, and clinical experiences are kept to a minimum. on the other hand, phase ii students are focused on their clinical skills acquisition and total knowledge of medicine. students in phase ii spend most of their time in the clinic and hospital learning alongside physicians, residents, and other health care doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports professionals. they also attend clinical learning activities at their respective institutions for supplemental clinical experience and formative and summative feedback. because of the differences in clinical experiences between the 2 phases, the covid19 pandemic may affect students in each phase differently. during the severe acute respiratory syndrome (sars) outbreak in 2003, medical schools in hong kong and canada were forced to cease in-person learning, leading to medical schools transitioning to videotaped vignettes, audiotaped recordings or online chat rooms and webcasting in place of clinical experiences.5 similarly, in the covid-19 pandemic, there has been a cessation of in-person lectures and an increase of recorded lectures and/or livestreams across the country.6 collaborative learning sessions have also been transitioned to webinars or teleconferences; as a result, these changes have led to less real-time feedback and have made back and forth discussion difficult.6 furthermore, second year medical students at the end of phase i were preparing for the united states medical licensing exam (uslme) step 1 when these curriculum changes were first implemented, creating an unprecedented circumstance for second year students. first-year students were finishing up their last modules for the academic year while third-year students completed their clerkships. when covid-19 first significantly affected the us in march 2020, the aamc released guidelines recommending at least a 2-week suspension of any student clinical activities involving patient contact in order to mitigate virus spread and protect learners (aamc, 2020). guidelines in april 2020 suggested a lengthened suspension in accordance with local, state, and national guidelines and that medical students not be involved in any direct patient care activities (aamc, 2020).5 at a regional medical campus like kusm-salina, greater hands-on clinical experience and an emphasis on rural medicine are often reasons students choose to attend. however, the pandemic presented a significant obstacle to those foci. at the start of the covid-19 pandemic, kusm-salina cancelled and/or moved some large-group interactive sessions and small-group collaborative learning sessions to an online, synchronous format, while lectures and supplemental clinical activities were transitioned to an asynchronous online format. synchronous sessions were held online using blackboard collaborate or zoom, and exams were taken online at home. phase ii students were pulled from clinical rotations at hospitals and clinics as well as in-person, school-sponsored clinical learning sessions; these experiences were replaced by online clinical simulations and other asynchronous learning activities. because students were forced to be at home, they were not able to interact in-person with their fellow classmates, colleagues, faculty, and attending physicians. these pandemic-induced curriculum changes affected students, administrative personnel, and instructors. this study focuses on the students at our regional medical campus kusm-salina, seeking to understand their perspectives on the effects of the covid-19 pandemic on their medical education experience. with this knowledge, educators at our schools and schools similar to ours may be able to make improvements to their curricula and to their contingency plans for future crises. methods to understand the impact of the pandemic on medical students attending a regional campus, this mixed-methods, cross-sectional study utilized an online survey with openand closed-ended questions asking about major components of the curriculum and effects on their academic experience. students were eligible to participate if they attended kusmsalina during the spring semester of 2020 (januarymay). a link to the redcap survey was emailed to all eligible students. the first question asked what phase the student was in during spring 2020, and then respondents were directed to the set of questions relevant to their phase: i or ii. we asked a few phasespecific questions to better understand the effects experienced. for a list of the closed-ended questions used for the survey to help answer the research question see table 1 below. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports table 1. closed-ended questions and mean, median, and range responses closed-ended survey items used a -3 to +3 scale, with negative numbers representing a detrimental or harmful impact, zero indicating no impact, and positive numbers representing a beneficial or positive impact on the experience in question. for study time, the positive numbers indicated increases in study time, and negative numbers indicated decreases. these quantitative data were analyzed using stata se/15. we calculated summary, descriptive statistics, including frequencies, proportions, means, and ranges. because of the small sampling frame and number of respondents, more advanced statistical analysis was not used. the resulting qualitative data from these open-ended questions were summarized inductively. we also asked open-ended questions about factors impacting the medical training experience. for the list of open-ended questions used on the survey for both phase i and ii students see table 2. table 2. open-ended questions: results quantitative findings out of 32 students (8 in each class), 18 (56%) students responded. there were 13 (72.2%) from phase i and 5 from phase ii (27.8%). phase i students were asked about the impact of the pandemic on their lecture experiences using the -3 to +3 scale described in methods. the mean rating was 0.46 (range -2 to +1). with respect to study time, phase i student responses had more variability. the mean was -0.44 (range -3 to +3). for covid-19 impact on exam performance among phase i students, the mean was -0.46 (range -2 to +1). with respect to collaborative learning experiences during phase i, the mean was -1.38 (range -3 to +3). finally, we asked about the impact of the pandemic on socialization with classmates and colleagues as it pertained to their medical education experience. for phase i students, the mean response was -2.3 (range 3 to -1). all who responded felt there was a negative impact on socialization and interactions with classmates during pandemic-related curriculum changes. the means of all responses for phase i questions are found in table 1. phase ii students were asked about unique aspects of their curriculum that were impacted by the covid-19 pandemic, either positively or negatively, similar to the phase i students. however, phase ii students numbered only 5. we asked phase ii students about the pandemic’s impact on clinical skills development. the mean response was -2.6 (range -3 to -2), indicating all who responded felt a negative impact. regarding study time, conversely to phase i students, all 5 phase ii students answered +3, indicating an increase in study time. regarding impact on exam performance, the phase ii mean was 1.4 (range +1 to +2). overall, phase ii students experienced an increase in study time and a beneficial impact on exam performance. phase ii students were also asked about the impact of the pandemic on time for clinical skill learning activities and events. similar to clinical skills development, the impact on clinical skill activities and events had a mean of -2.2 (range -3 to -1). the social aspect of medical school was also explored with phase ii students. the mean was -1.4 (range -3 to +2). the means of all responses for phase ii questions are found in table 1. qualitative findings in the qualitative data, many different perspectives were brought to light about covid-related curriculum changes at our regional medical campus. we present the questions with summaries of the responses to each and select representative quotations. due to our small sample size, we are not presenting all doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports qualitative responses in their entirety to protect student confidentiality. question: what aspects of covid-related curriculum changes need improvement? for phase i students, online, prerecorded lectures were difficult for some who preferred that “more lectures could be live-streamed” because “lectures could be improved to be more interactive.” students often brought up the fact that online webinars for collaborative and problem-based learning sessions did not compare in quality to the interactions and discussions experienced in their previous, in-person versions. in addition, one student felt “some recorded lectures seem slightly outdated”. on a smaller regional campus like kusm-salina, where there are only 8 students per class, many students felt that social distancing along with appropriate face masks and personal hygiene should have been reasonable measures that would have allowed for the continuation of in-person sessions. the students expressed that kusm-salina’s unique campus circumstance perhaps should have been allowed different guidelines from the other, larger campuses where 30 to 100+ students would have been asked to congregate. for example, one student said: “i feel that with the proper safety precautions implemented we would be able to do some in-person learning activities. personally, i learn best with in-person interactions and hands-on learning and when those aspects of the curriculum were taken away during covid modifications i definitely missed them!” for phase ii students, many wished they could have stayed in clinics and hospitals to acquire clinical medical knowledge and physical exam techniques. for example, a student stated: “there is no substitute for real experience. i missed out on surgeries and physical exam maneuvers that i likely will not have repeat exposure to but will be expected to know in residency.” the students reported understanding this was a difficult situation to predict and prepare for, and they understood alternative simulated activities were an appropriate response. question: do you have any reason to believe that your class’s experience has been unique from other classes? why or why not? as mentioned previously, first-year medical students were finishing their last 2 modules of their academic year whereas second year medical students were reviewing for the uslme step 1 to complete phase i; therefore, these differences must be taken into consideration when reviewing student perspectives. first-year students reported the biggest impact on their medical educational experience was not getting to directly collaborate, learn, and socially interact with their colleagues. some even stated concerns about how the pandemic would “affect [their] bonding”. many second-year students expressed concerns about experiencing step 1 test date delays while also having to deal with being forced to study at their homes, not having as much interaction, and coping with the stress of preparing for a high-stakes exam. one student stated: “[t]here had been significant anxiety around the issue which, more likely than not, affected peoples’ focus on studying.” in addition, multiple second-year students reported 1 to 2-week delays in taking step 1 and at the time feared it would result in a delay starting phase ii. the phase ii students similarly brought up concerns about not only having shortened in-person clinical experiences, but also the fact that they would not able to travel for externships and clinical rotations at potential residency locations. for instance, a student stated: “[w]e do not get to travel for interviews fourth [year], meet our future colleagues, or see the towns/cities we will spend the next 3-5 years in. we also do not get to participate in externships which greatly influence the likelihood of getting an interview and residency spot.” question: have covid-related curriculum changes affected your medical school experience in ways not represented by the survey? many of the phase i students explained that having to learn to study at home instead of their usually study space at school was an environmental change, rather than a curriculum change, and it had in fact affected their medical education experience and performance. for example, one student stated: “studying at home was more of a challenge for me. i did well enough but i wasn't as productive as i would have been at school.” other students mentioned feeling “disconnected” from their colleagues. phase i students mentioned missing exposure to supplemental clinical knowledge that they believed they would have gained from either enrichment activities or hands-on cadaver anatomy doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports activities that help build on theoretical knowledge learned from lectures and text books. phase ii student responses varied, with some feeling isolated from colleagues and patients and others being happy to have a chance to step away from the rigorous schedule of medical school and focus on other aspects of life, with one student stating: “yes, i was able to get a very nice breath of fresh air and spend a great deal of quality time with my immediate family. overall, this was a great benefit to my physical and mental health, despite the deficits in my education.” question: do you have any additional comments you feel are relevant? phase i students had no additional input. phase ii students mentioned that implementing a standard telehealth clerkship would be beneficial, with one student stating: “honestly, i think they should make a telehealth rotation. . . this would give us experience with the ‘new age of medicine’ tech.” lecture experience, study time, and exam performance were either not impacted or slightly negatively impacted for phase i students, while collaborative learning sessions and socialization were. clinical knowledge, skill development, and socialization with colleagues and attendings were negatively impacted for phase ii students. positive impacts for phase ii students included study time and exam performance. there were some differential effects of curriculum changes based on phase of medical school, which were detailed in the qualitative data as well. discussion natural disasters and worldwide pandemics have affected medical institutions and their students. the lessons from these events do not come from the disasters themselves but from the responses and corresponding changes medical institutions had to make to mitigate the impacts on the educational experiences of their students. due to hurricane katrina in 2005, tulane university school of medicine in new orleans relocated its education programs to houston, texas, and used baylor university facilities. along with partnering with other schools, this school cited having key back-up technology infrastructure as a major reason for why the school was able to be functional again after only a month.7 like the current covid-19 situation, the sars outbreak of 2003 in hong kong led to the closure of medical schools and universities located there. those institutions responded by implementing information technology systems so that students could maintain social distancing and prevent the spread of the virus.8 in looking at the covid-19 pandemic and its impact on us undergraduate medical education, medical schools have acted in accordance with aamc recommendations and in similar ways to their katrina and sars responses, integrating more remote learning through technology.5 the responses to these disasters and pandemics were able to keep medical education afloat, but better understanding the ramifications of these responses for students is the value of this study. regional medical campuses differ from larger, urban campuses in that there are fewer students. kusmsalina uses a significant amount of real-time telecommunication technology, such as lecture streaming.9 students at salina perceive – in contrast to more metropolitan campuses – they have more opportunities for immersive, hands-on clinical experiences due to the more intimate educational setting.1 another factor to consider is interpersonal dynamics. because of the smaller class size, students often know each other more personally and have ample opportunities to socialize through schoolsponsored specialty interest groups.1 the largest proportion of phase i students felt that their lecture experience was not impacted; however, the average showed a slight detrimental impact because the next-largest proportion did not report a negative impact. this finding is supported by our analysis of free-text responses. students mentioned that pre-recorded lectures diminished the quality of the original live-streamed interaction and discussion with faculty and fellow classmates, possibly supporting why we see the slight detrimental impact. nevertheless, phase i students felt no impact overall, but if there was one it was only a slight detrimental impact. study time for phase i students had no uniformity in the responses. this differed markedly from the experiences of their phase ii counterparts, which were relatively positive. the impact on study time for phase i students may vary per student due to personal characteristics such as study habits, personal stressors, anxiety, individual motivation, and doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports other external factors, as suggested by looyeh et al.10 furthermore, research has shown that study time alone has no direct relationship with performance; it is the interaction of motivation and ability along with study time that influences academic performance.11 personal factors like study habits have a definite role in time spent studying,12 which may influence these findings. with our data, we cannot separate these individual-level factors from the effects of covid-19related curriculum changes. students largely reported no pandemic impact on exam performance, but a few reported a minor detrimental impact. this could mean that curriculum changes may not have had as detrimental an impact as educators may have originally feared.13 although one study supports that students learning in the classroom is associated with better performance on essay-style exams, this same study showed no difference in multiple choice (medical school exams) exam performance between online and classroom learners.14 in fact, in a study that explored whether online learning platforms contributed to higher exam performance, researchers found that the use of webbased platforms had a positive correlation with the percentage of correct answers in medical exams.15 another study suggests that online learners may achieve more than classroom counterparts,16 further supporting that the virtualization of the curriculum due to covid had less of a negative impact than expected. however, reasons why some students may have felt a harmful impact to their exam performance may be related to reasons given in open-ended responses: receiving less feedback and interaction with faculty and colleagues and having to transition to less productive learning environments.17 most students indicated that collaborative learning activities in small group sessions were negatively impacted by the pandemic. because curriculum changes were transitioned to more individualoriented online settings and did not involve as much direct communication with and visualization of colleagues, these difficulties were predictable. in previous research, collaborative learning activities have been proven to stimulate learning.3 however, with covid associated distance learning, transitioning medical school to the home setting may disrupt home-work boundaries, isolate students, and increase the use of email,19 possible reasons why students indicated negative effects related to smallgroup learning in our survey. one study that explored graduate student perceptions of online learning found that technical issues, a perceived lack of belonging to a group, difficulty in understanding objectives without other students, and time constraints are impediments to the online classroom,20 also consistent with sentiments expressed by kusm-salina students. with the transition to more online learning experiences, phase ii students at kusm-salina felt the pandemic negatively impacted their clinical experiences. conversely, previous research has shown virtual patient learning may not have a detrimental impact on the quality of education. in a study investigating the use of a “low-fidelity simulator”, virtual patients were deemed a valuable and useful tool for the development of clinical reasoning and history taking skills.21 therefore, even though students may perceive that that their educational experience has suffered, their actual learning and acquisition of skills may not have been compromised with the use of virtual alternatives. in a virtual radiology clerkship, researchers found that final exam scores were similar in the virtual version compared to the in-person version, but students revealed that didactic lecture content felt more advanced and opportunities to build professional connections with faculty physicians were more limited.22 lack of rapport with teaching physicians and a decrease in patient contact are prominent features in how students perceived the impact on the clinical portion of their education. the social aspect was important to investigate because peer and classmate interactions may affect one’s medical education.17 in our study, the majority of students felt socialization with peers as it related to their medical school experience suffered because of covid-related changes. for our phase ii students, the ability to socialize with colleagues, faculty, and attending physicians was also negatively affected, a result seen in other studies as well. in a study looking at student satisfaction and learning outcomes, withdrawal rates and exam scores were similar between in-person and online instruction. however, online students tended to be less satisfied with instructor rapport, course excellence, peer interaction, and self-perceived knowledge gains.23 in addition to learning and student satisfaction implications, social interactions with colleagues also doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports matters to mental health. it is well known that social isolation is linked to behavioral health disorders in healthy individuals but especially those with existing mental health conditions.24 therefore, the social aspect should be considered in any holistic discussion of medical education. in contrast to phase i students, the topics of study time and exam performance for phase ii students were more uniform. however, there were only 5 respondents in this category. phase ii students experienced not only an increase in study time across the board, but also a slight benefit to their exam performance. a study at the university of belgium looked at the relationship between study time investment and academic performance in higher education. for most courses, study time predicted academic performance more reliably then student characteristics;25 therefore, the association between increased study time and improved exam performance is not a new concept. for covid-related curriculum changes in this context, increased study time and exam performance may be due, in part, to the way phase ii clerkships and clinical rotations are designed. traditionally in phase ii, more time is allocated to learning on the wards via real-world clinical encounters.2 one study looking at a psychiatry clerkship’s active learning activities (team-based learning and clinical simulation) and their effect on student performance on the standardized nbme subject exam in psychiatry, concluded that increasing active learning did not improve student exam performance.26 therefore, if traditional clinical active learning may not benefit student performance on exams, removing it (during the pandemic) may not be detrimental to student performance as well. if students, however, have less time in clinic, this could potentially increase time spent studying material specifically relevant to national exams, resulting in higher exam performance. some studies have suggested that students sometimes prefer online learning modules rather than a traditional inperson didactic due to less travel, thereby increasing attendance if one is able access online lectures from one’s own home.27 additionally, phase i students that have reduced contact with colleagues and instructors could be more susceptible to burnout because of the work load compared to phase ii students.27 this potentially contributes to the differences in findings between phases i and ii seen in our survey. a confounding factor on our results on exam performance, however, is that performance on clerkship exams typically increases as the year progresses.28 with that said, the differences between phase i and ii student study time and exam performance provide evidence that the effects of covid-related curriculum changes may affect students differently depending on their phase of medical school. future implications. past work has focused on the response of medical institutions and the reconstruction of the medical school curriculum in response to disasters. however, there is less literature on the opinions of students – particularly those on smaller campuses – about these changes. this study detailed how students perceived such impacts on their educational experience. with this knowledge, in the wake of future disasters or pandemics, educators may make changes to current approaches or choose different curriculum adaptations entirely. limitations. due to our small campus size and rural location, the sample size for this study is limited and therefore cannot be generalizable to other medical campuses in the country. additionally, many phase ii students at kusm-salina did not respond to the questionnaire. because of the survey method, there is inherent selection bias that must be taken into account. however, we are confident these results are relevant to other, similarly-situated regional campuses with small class sizes located in nonmetropolitan areas. in the future, there would be value in replicating this across all campuses and across regional campuses. future studies could potentially quantify the relationship between study habits and exam performance as well as the direct relationship between the covid-19 pandemic and examination scores. conclusion throughout history, medical institutions have adapted their curricula in response to disasters by implementing more technology-based, distanceoriented learning infrastructures. these adaptations have achieved continuity in medical education. curriculum changes should constantly be evaluated, though, to allow for further improvement and innovation. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports when investigating covid-19 impacts on the regional medical school experience, the 2 phases of medical school should each be considered. for phase i students, lecture experience, study time, and exam performance were either not impacted or slightly negatively impacted. aspects that were more clearly negatively impacted were collaborative learning sessions and socialization. for phase ii students, clinical knowledge and skill development and time/activities relevant to this component were negatively impacted, as well as socialization with colleagues and attendings. however, unlike phase i students, phase ii students felt their study time and exam performance increased or was slightly positively impacted, respectively. this indicates study time and exam performance may suffer or thrive depending on the phase of medical school a student is in when pandemic-related curriculum changes occur. in the covid-19 pandemic, students’ perspectives on curriculum changes have not thoroughly been investigated. this study aimed to do so on a small regional campus and provide further information useful to educational system improvements. references 1.cathcart-rake w, robinson m, paolo a. from infancy to adolescence: the kansas university school of medicine-salina: a rural medical campus story. academic medicine : journal of the association of american medical colleges. 2017;92(5):622-627. 2.alman ba, purtill jj, pellegrini vd, scoles p. the fourth year of medical school: time for reassessment: aoa critical issues. j bone joint surg am. 2017;99(13):e72. 3.bonaminio ga, fontes jd, doolittle g, shaw p, moser s, robinson m. the university of kansas school of medicine. acad med. 2020;95(9s):s184-s187. 4.gaur u, majumder maa, sa b, sarkar s, williams a, singh k. challenges and opportunities of preclinical medical education: covid-19 crisis and beyond. sn comprehensive clinical medicine. 2020:1-6. 5.akers a, blough c, iyer ms. covid-19 implications on clinical clerkships and the residency application process for medical students. cureus. 2020;12(4):e7800. 6.ferrel mn, ryan jj. the impact of covid-19 on medical education. cureus. 2020;12(3):e7492. 7.krane nk, kahn mj, markert rj, whelton pk, traber pg, taylor il. surviving hurricane katrina: reconstructing the educational enterprise of tulane university school of medicine. acad med. 2007;82(8):757-762. 8.patil n, yan ych. sars and its effect on medical education in hong kong. medical education. 2003;37(12):1127. 9.cathcart-rake w, robinson m, owings s, kennedy m, paolo a, chumley h. the birth of a rural medical school—the university of kansas school of medicine-salina experience. medical science educator. 2012;22(4):250-258. 10.rezaie looyeh h, seyed fazelpour sf, reza masoule s, chehrzad mm, kazem nejad leili e. the relationship between the study habits and the academic performance of medical sciences students. journal of holistic nursing and midwifery. 2017;27(2):65-73. 11.nonis sa, hudson gi. academic performance of college students: influence of time spent studying and working. journal of education for business. 2006;81(3):151-159. 12.marpa e. correlation among time management, study habits and academic achievement of the math major students. in:2014. 13.ahmed h, allaf m, elghazaly h. covid-19 and medical education. the lancet infectious diseases. 2020;20(7):777-778. 14.parkhurst r, moskal bm, lucena j, downey gl, bigley t, elber s. engineering cultures: comparing student learning in online and classroom based implementations. the international journal of engineering education. 2008;24(5):955-964. 15.bientzle m, hircin e, kimmerle j, et al. association of online learning behavior and learning outcomes for medical students: large-scale usage data analysis. jmir medical education. 2019;5(2):e13529. 16.thirunarayanan mo, perez-prado a. comparing web-based and classroom-based learning. journal of research on technology in education. 2001;34(2):131-137. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports 17.glass al, sinha n. classroom instruction results in better exam performance than online instruction in a hybrid course. journal of general psychology. 2018;145(4):362-376. 18.carstensen ss, kjaer c, möller s, bloksgaard m. implementing collaborative, active learning using peer instructions in pharmacology teaching increases students' learning and thereby exam performance. european journal pharmacology. 2020;867:172792. 19.rose s. medical student education in the time of covid-19. jama. 2020;323(21):21312132. 20.song l, singleton es, hill jr, koh mh. improving online learning: student perceptions of useful and challenging characteristics. the internet and higher education. 2004;7(1):59-70. 21.isaza-restrepo a, gómez mt, cifuentes g, argüello a. the virtual patient as a learning tool: a mixed quantitative qualitative study. bmc medical education. 2018;18(1):297. 22.durfee sm, goldenson rp, gill rr, rincon sp, flower e, avery ll. medical student education roadblock due to covid-19: virtual radiology core clerkship to the rescue. academic radiology. 2020;27(10):1461-1466. 23.hale ls, mirakian ea, day db. online vs classroom instruction: student satisfaction and learning outcomes in an undergraduate allied health pharmacology course. journal of allied health. 2009;38(2):e36-42. 24.sharma d, bhaskar s. addressing the covid-19 burden on medical education and training: the role of telemedicine and teleeducation during and beyond the pandemic. frontiers in public health. 2020;8(838). 25.masui c, broeckmans j, doumen s, groenen a, molenberghs g. do diligent students perform better? complex relations between student and course characteristics, study time, and academic performance in higher education. studies in higher education. 2014;39(4):621-643. 26.crisafio a, cho sh. impact of varying active learning time on student performance on a standardized exam in the psychiatry clerkship. academic psychiatry. 2020;44(2):196199. 27.sani i, hamza y, chedid y, amalendran j, hamza n. understanding the consequence of covid-19 on undergraduate medical education: medical students' perspective. annals of medicine and surgery. 2020;58:117119. 28.reteguiz j-a, crosson j. clerkship order and performance on family medicine and internal medicine national board of medical examiners exams. family medicine-kansas city. 2002;34(8):604-608. microsoft word jrmc_articletemplate.docx all work in jrmc is licensed under cc by-nc volume 3, issue 1 (2020) journal of regional medical campuses message from the editor-in-chief: it is with great excitement that i share with you that we have added an associate editor to our journal, dr. peter nalin, chair and professor of family medicine and biobehavioral health at the university of minnesota medical school, duluth campus and associate dean for rural medicine for the university of minnesota medical school. dr. nalin has published in our journal and is well positioned to assist with our ongoing growth and development. many thanks to dr. alan johns who served in this role and helped to launch the journal. we will continue to honor his contributions by naming him as our associate editor emeritus. many thanks to our editorial board and their ongoing oversight and contributions to our journal. we invite you to consider submissions related to the covid-19 pandemic and its impact on your campus. we have one perspective to share in this issue and would like to have an upcoming issue focused on covid-19 impact. be safe. regards, paula m. termuhlen, md editor-in-chief, journal of regional medical campuses microsoft word celebratingthevaluearticle.docx published by university of minnesota libraries publishing celebrating the value of learners for teaching faculty in regional medical education kathryn martin, phd, mph; ashley saucier, md z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc kathryn martin, phd, mph; associate dean for regional campuses, medical college of georgia at augusta university, email: katmartin@augusta.edu ashley saucier, md; associate professor, department of family medicine, assistant clerkship director, department of family medicine, medical college of georgia at augusta university, email: asaucier@augusta.edu all work in jrmc is licensed under cc by-nc volume 2, issue 3 (2019) journal of regional medical campuses abstract celebrating the value of learners for teaching faculty in regional medical education kathryn martin, phd, mph; ashley saucier, md topic: character limit: (2000 characters, including spaces) teaching medical students in a busy private practice can be daunting – taking too much time away from patients, giving feedback, completing evaluations, and the like. however, there is much value to be obtained from the experience of young learners. with competing agendas in today's corporate healthcare arenas, there are benefits from teaching for both the physician and the hospital that oftentimes go unnoticed, unrecognized, and unappreciated. short description: a fun-filled participatory session, reminding us of the value of teaching medical students using the “pictionary” game format and small group discussion. participants will explore and discuss different roles that medical students can play as learners in their environment that add value to the healthcare system or clinical setting. participants will also discuss how to use these “value-added roles” to recruit and retain community based clinical faculty. (up to) four questions that were posed to/considered by session participants: 1) in what ways to medical students add value to your practice? 2) are there new and innovative ways you can incorporate the discussed medical student roles into your teaching methods with medical students? 3) how can you use this information as a way to recruit or develop community based clinical teaching faculty? three take home points from our session: 1) medical students can function in the health care setting in various ways that optimize productivity and increase the quality of patient care. 2) defining ways medical students can add value to the clinical setting can serve as a tool to recruit and develop community based clinical faculty. 3) thinking outside the box for ways medical students can play roles that add value to the clinical setting has the potential to increase students’ understanding of the healthcare team and methods to promote quality patient care. microsoft word inoculatingtraineesupstreamarticle.docx published by university of minnesota libraries publishing inoculating trainees upstream: what distressed providers wished they'd learned in medical school linda l.m. worley, md, faclp z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc linda l.m. worley, md, faclp; associate regional dean, university of arkansas for medical sciences northwest campus college of medicine, professor of psychiatry and obstetrics and gynecology, uams, adjunct professor of medicine, vanderbilt center for professional health, worleylindal@uams.edu all work in jrmc is licensed under cc by-nc volume 2, issue 3 (2019) journal of regional medical campuses abstract inoculating trainees upstream: what distressed providers wished they'd learned in medical school linda l.m. worley, md, faclp topic: deciphering the secrets for preventing burnout, distressed, disruptive physician behavior and the tragic of loss of life to suicide couldn't be more important for the overall health of our nation than now as we face an increasingly critical physician shortage. physicians mandated to attend the vanderbilt center for professional health, distressed physicians' course often as a result of their disruptive behavior offer invaluable lessons underlying the core drivers beneath their distress. armed with these insights, it is possible to design and implement upstream educational curricula for medical students, residents, and early career faculty to inoculate them proactively to better navigate the challenges in medicine today. short description: the stressors in medicine today are palpable. record numbers of physicians report significant symptoms of burnout with approximately 400 physicians per year choosing to end their lives by suicide. inner distress often manifests outwardly through disruptive behavior potentially jeopardizing the overall safety and functioning of the healthcare team. the vanderbilt center for professional health distressed physicians' course remediates physicians who are referred as a result of their disruptive, distressed behavior. the physicians referred to the course are highly skilled, productive physicians who graduated near the top of their class matching into highly competitive specialties. they offer invaluable insights into the shortcoming of their medical training. course faculty member and associate regional dean of uams northwest college of medicine, linda l.m. worley, md, is infusing this missing curriculum into the training of regional medical students, residents and staff. four questions that were posed to/considered by session participants: 1) how many physicians will we be short when looking ahead to the projected needs by 2030? 2) what are the stressors driving physician burnout, early retirement, and suicide? 3) what are distressed-disruptive physician behaviors and how do they negatively impact the performance of the healthcare team? 4) what are the essential skills physicians in training need to master in order to avoid becoming a distressed, disruptive provider? three take home points from session: 1) physicians mandated to attend a course for distressed-disruptive behavior reported minimal prior training in team behavior, managing stress and burnout, conflict management, mindfulness, and emotional intelligence. 2) disruptive physician behavior is unacceptable; it decreases patient satisfaction, increases the frequency of medical errors and litigation, creates a toxic workplace with costly turnover, and contributes to low morale and difficulty recruiting. 3) physicians have exceedingly high standards and struggle when others fail to live up to their expectations. they are highly skilled, productive, driven, and dedicated to perfection in patient care. building leadership skills of self-awareness, selfcontrol, and empathy, including an ability to effectively listen and resolve conflict while still in training, will prepare them to more effectively navigate the stressful healthcare environment without becoming a distressed-disruptive provider from the editors published by university of minnesota libraries publishing why the journal of regional medical campuses? why now? paula m. termuhlen, md, alan johns, md, med doi: https://doi.org/10.24926/jrmc.v1i1.1004 journal of regional medical campuses, vol. 1, issue 1 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc https://doi.org/10.24926/jrmc.v1i1.1004 https://pubs.lib.umn.edu/index.php/jrmc/index doi: https://doi.org/10.24926/jrmc.v1i1.1004 journal of regional medical campuses, vol. 1, issue 1 volume 1, issue 1 (2018) journal of regional medical campuses perspectives why the journal of regional medical campuses? why now? paula m. termuhlen, md and alan johns, md, med editors-in-chief there has never been a better time for us to start a journal that reflects the innovation and flexibility of the regional medical campus. for those of us who serve on regional campuses in the roles of faculty, staff, administrators, and students, we know why we came, who we are and what we do. however, for many in the medical education community, little is known about the 115 regional campuses in the united states and canada. the jrmc was born out of a need to tell our stories and share our unique perspectives and challenges. over half of the medical schools in the united states and canada have regional campuses that are often mission focused with various numbers of students at various stages of their medical school careers. just like our institutions where “when you’ve seen one medical school, you’ve seen one medical school”, our associated regional campuses each have their own unique culture and processes. the jrmc is our opportunity to enhance the academic environments of our campuses by creating a home for the scholarship produced on our campuses. the richness of our work is reflected in the thoughtful writing of our students and faculty. basic and translational research that emphasizes our locales and missions needs a place to be shared. discussions of operational challenges such as those associated with admissions processes and faculty development across campuses also needs a place where others can learn of best practices and lessons learned. our contributors deserve a quality open-access, on-line venue for their valuable scholarship that will be indexed in medline. our readers need to know published articles have been peer-reviewed by editors and reviewers from many regional medical campuses. in the spirit of open-access publishing, we offer to you our first issue of the jrmc which includes work from across the us and canada. we want to thank the university of minnesota libraries for providing the opportunity for us to lead this effort from the university of minnesota medical school, duluth campus. we want to thank our editorial board and reviewers from across north america who are helping to shape the launch of this journal. we also want to thank the aamc group on regional medical campuses for providing support and sharing information to help our future readers learn about our journal. our goal is for the jrmc to become the preeminent place for scholarship produced on regional campuses. join us! https://doi.org/10.24926/jrmc.v1i1.1004 microsoft word thenewregionalmedicalcampusarticle.docx published by university of minnesota libraries publishing the new regional medical campus: a practical guide ralitsa akins, md, phd, michael flanagan, md, lanita carter, phd, & katherine mcowen, msed doi: https://doi.org/10.24926/jrmc.v2i4.1769 journal of regional medical campuses, vol. 2, issue 4 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc ralitsa akins, md, phd michael flanagan, md lanita carter, phd katherine mcowen, msed corresponding author: ralitsa akins, md, phd; email for correspondence: ralitsa_akins@yahoo.com all work in jrmc is licensed under cc by-nc volume 2, issue 4 (2019) journal of regional medical campuses original reports the new regional medical campus: a practical guide ralitsa akins, md, phd, michael flanagan, md, lanita carter, phd, & katherine mcowen, msed abstract there is a paucity of published literature related to new regional medical campuses. the authors, members of the association of american medical colleges (aamc) and its group on regional medical campuses (grmc), offer a historical perspective on the role of regional medical campuses (rmcs), and provide a roadmap for establishing a new rmc, including logistics, resources, curriculum development, student services, faculty, affiliations, and networking within the community. a checklist designed to support leadership decision-making is also included. the rmc is an efficient model for increasing opportunities for clinical training, accommodating expansion of graduate medical education, and offering a cost-effective solution to train future physicians. introduction and history: why start a new regional campus? a regional medical campus (rmc) is a location separate from the main campus of a medical school offering one or more full years of the institution’s medical education program, but not independently accredited by the liaison committee on medical education (lcme). while a few rmcs in the united states existed before the middle of the last century, the rmc model fully emerged in the 1970s with the establishment of 35 campuses between 1970 and 1979 as a way to increase learner enrollment and diversify learner clinical experience.1 from 1980 until the mid-2000s the number of medical schools as well as rmcs remained stable with relatively few new institutions or rmcs being created. this changed in 2006 when the association of american medical colleges (aamc) issued a call for a 30% increase in u.s. medical school enrollment by 2015, grounded in a projected physician shortage.2 the aamc administers an annual survey to all medical schools regarding current and future rmcs. data from the aamc national survey shows that in academic year 20152016, 51 u.s. medical schools out of 142 who participated in the survey had at least one rmc, which amounted to 40% of the institutions surveyed.3 this was a significant proportion of all medical schools at the time of the survey and was recognized as a growing trend, since over the 5-year period preceding the survey between 2011 and 2016, the number of medical schools with an rmc increased from 34% to 40%. in 2016 alone, 16 new rmcs were created, 8 schools expanded already existing campuses, and 15 schools increased the number of students within existing campuses.4 the percentage of medical schools reporting intentions to create a new rmc, expand an existing rmc, or increase the students at an already established rmc has remained stable over the last decade, at about 21% of all schools.5 therefore, the creation of an rmc is not unique, but is rather a commonplace approach embraced by medical schools often in response to a need for increased student enrollment to address a regional projected physician shortage. the aamc survey also inquired about the reasons for starting rmcs. medical schools identified the following as compelling reasons for considering a new rmc: serving state needs – typically expressed as a legislative mandate addressing physician workforce needs; serving local needs – typically expressed as a need to attract high-quality physicians to rural areas; institutional commitment to a distributed educational model – allowing students to be trained in a variety of settings while providing them access to different patient populations; institutional need to increase class size, typically expressed as a need to increase the physician workforce in underserved areas of the state, and sometimes aligned with rural rmcs; collaboration between the institution and resourcerich regional community systems, building mutually beneficial relationships; need for student exposure to different practice types – intercity/suburban/rural; increasing clinical teaching capacity in general; addressing healthcare needs of communities; expansion of academic medical centers into community settings. fulfilling the mission of the medical school6 and meeting increased demands for physicians in rural areas7,8 are consistent factors cited for establishing new rmcs in the existing literature. rmcs offer states and institutions a costeffective model for medical student education, while providing comparable educational benefits in geographically new territories.9 doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports little is published in the literature specifically regarding the implementation and development of new rmcs. most of the current literature discusses rmcs created within a new medical school, focusing on the start of the medical program at the central campus, and not on details about the rmc. the macy foundation published 2 reports on new and developing medical schools.10,11 major factors in planning included the positive impact that medical schools have on the universities that initiated the new schools, advantages for the hospitals and health systems that assisted in the school’s establishment, and benefits to the community such as provision of primary care and local economic growth. whitcomb9,10 suggested that a feasibility analysis is a major part of the decision to start a medical school and such analysis could be time-consuming and lengthy. space allocation, availability of faculty, and the overall ability to ensure quality student education are critical. the reports noted that some of the rmcs established as 4-year or 2-year campuses over time became self-sustaining, separate medical schools. of the 15 new schools described in the 2013 macy report,11 8 (53%) were originally established as rmcs. hays12 suggested that successful educational innovation in the development of regional medical education is based on 10 principles, including strong community support, development of an appropriate structure to deliver the mission, and recruitment of faculty who are positive role models. coleman et al.13 and siegrist14 used spatial accessibility analysis, utilizing geographic information system mapping technology (gis), to define areas of physician need. beckett & morrison15 outlined a model for identifying the location for development of a new medical school based on the economic concept of physician demand, rather than the social concept of need, and suggested that this may be a better approach to addressing the physician shortfall. they noted that physicians trained locally may likely be retained instate to meet the physician demand. in 2010, smego et al.16 published a chronicle on the development of the commonwealth medical college that started with 3 rmcs in pennsylvania. the school’s purpose was to increase physician numbers, thereby decreasing a physician shortage in the northern part of the state. prior to its development, considerations were given to financial planning, clinical site availability, accreditation requirements, and stability of the local practice environment in supporting student training. fogarty et al.17 described the start of the florida state university college of medicine, created to meet health care needs outside the academic medical center, in ambulatory settings. this community-based school started as 6 rmcs and 2 rural sites that were spread across the state. central oversight of curriculum and student affairs required faculty development at all sites, and an online evaluation system was imperative for the school to meet its mission. in the future, overall physician demand will be impacted by a variety of societal forces, such as changes in healthcare delivery, increasing patient populations, and an aging physician workforce.18 states are faced with changing their approach to medical education to meet this growing need. there are several options to consider, which include: 1) establishing new medical schools; 2) increasing the capacity on current campuses of private and public medical schools; and 3) establishing one or more rmcs at existing medical schools. the cost of building new medical schools is at times prohibitive10 and might decrease the financial resources available to meet the clinical, service, and research missions of existing medical schools. moreover, limited resources at established academic medical centers (amcs), where physicians are often already stretched thin with clinical responsibilities, can make expansion of current medical schools a less attractive option. consequently, expanding the class size of existing medical schools by establishing rmcs that incorporate existing educational and/or clinical facilities in outlying communities and drawing on expertise of local practicing physicians becomes an attractive solution to educating medical students. starting a new medical campus: logistics and resources the logistics of starting an rmc can be daunting at the outset for those with insight into the number of elements that should be addressed proactively. alternatively, for those without experience, the magnitude of the undertaking may only become apparent well into the process. starting a new rmc should be a decision well planned and broadly discussed, with completion of a needs assessment, a feasibility study, and strategic planning. there are essential areas that deserve initial consideration, discussion, and definition prior to launching a new rmc. there are a variety of resources available to the institution that should be consulted before deciding on models, financial agreements, or any formal infrastructure development. due diligence is certainly one of the most important factors in building a successful rmc reliant upon successful regional partnerships. consultation consulting with one or more experts on the structural design of the rmc and the requirements for successful lcme accreditation are time and money well-spent. following a thoughtful plan that identifies specific areas for accomplishment will provide useful guidance that can help to ensure both early and long-term success. before a decision to start a regional campus is made, consultation with the following collaborators should be considered: 1. the lcme secretariat – the ex officio staff of the lcme at the aamc and the ama offer their services in consulting about rmc-related requirements and have seen both successful and unsuccessful examples of implementation. they provide valuable doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports advice about cost, possible educational pitfalls, and planning for necessary institutional agreements. 2. others who have started rmcs in the last decade – contacting those institutions (both main and regional campuses) that have implemented a new rmc in the last decade is probably the most important action of the information gathering phase. if possible, also talk with schools that ended up choosing not to start an rmc, or schools that chose to pursue a new medical school instead. while this requires a little research, it will serve to identify successes and mistakes from past rmc implementation, as well as possible consultants who may be of assistance in determining financial feasibility. joining a networking group like the aamc’s group on regional medical campuses (grmc) is an excellent way to develop the personal relationships necessary to get the real backstory about successes, and more importantly, failures. 3. the local community – through collaborations with local civic groups like the chamber of commerce and ongoing discussions with community health leaders, develop relationships that might transform into resourceful future partnerships. do not underestimate the value of an academic institution to a regional health system which can often provide valuable resources, as well as strong brand recognition, and therefore greater community buyin. needs assessment and financial structure while national data have established the overall need for training medical students, a needs assessment specific to the academic medical center (amc) and local community will help to define goals and objectives. a commitment to ensure financial sustainability is necessary. is there a source of institutional, state, or outside funding? has the potential for local philanthropy been explored? will student tuition be used directly, indirectly, or not at all at the rmc? while the lcme requires that tuition be the same at both the amc and all affiliated rmcs, is the overall cost of attendance at the main and regional campuses comparable, and how will student debt be addressed at the rmc? frequently, providing a path for reduced student debt at the rmc can be a strong incentive for students to train at a newly launched rmc without an established track record. an important consideration is whether the new campus would expand the class size or serve as an additional venue for clinical opportunities. it is also necessary to assess the locally available physician workforce, including number of physicians, range of specialties, interest in teaching, as well as the number of physicians needed for delivering the curriculum and for student advising. furthermore, the possible physician recruitment challenges facing specific communities should be a part of the needs assessment. feasibility assessment identifying funding sources is only one step in determining the feasibility of establishing an rmc; other important questions also require answers. for example, are there already established clinical affiliations, or are new ones needed? what is the vitality of local healthcare institutions, and are they able to provide adequate teaching venues for medical students? are bed-size, patient mix, utilization rate, and annual admissions able to provide quality education related to the student curriculum, (in other words, are there adequate numbers of patients and a diversity of cases to support training)? are there available experienced administrators to support the start and development of the new rmc, or is new recruitment needed? is the local community supportive of establishing a new campus? establishing, nurturing and preserving clinical partnerships is a pivotal factor in a school’s ability to establish a new clinical campus.20 working with hospital leadership is not a “one and done” endeavor. successful partnerships require thoughtful and continued communication, inclusion in decision making, a collaborative approach to student teaching, and continued community engagement.21-23 giving serious consideration to facility availability is critical for an rmc launch. an advantage to the rmc is that established facilities at regional medical centers can often be utilized for teaching medical students, obviating the need for new and costly construction. in addition to clinical facilities, the lcme requires dedicated space for small group learning, self-directed learning, and individual and group study, a student lounge, call-room space, as well as student housing. consequently, each of these facility resources should be identified. both immediate and future facility needs should be considered from the start. strategic planning short and long-term planning is necessary to envision and implement the new campus. strategic planning includes each area of the school’s vision and mission supported by the rmc (e.g. education, service, and research). furthermore, such planning requires an assessment of resources needed for implementation, establishment of goals, and identification of measures of success. formal analyses, such as swot (strengths, weaknesses, opportunities, and threats) and/or pest (political, economic, socio-cultural, and technological factors) support effective planning. in addition to community-based rmcs, such as those at fsu,17 several programs have targeted specific needs in the communities they serve. the importance of integration into local communities to improve outcomes has been clearly identified.24-26 this is particularly important in addressing the needs of rural and remote communities. similar issues have doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports been identified in the development of rmcs in other countries; lawrenson, et al.27 highlighted the need for training physicians in the country versus importing physicians who will care for underserved communities. organizational structure defining the model for regional expansion will help to guide subsequent decisions in other areas. there are several distributed models employed at different schools, each customized to fit the amc’s needs and resources. the most common model offers basic science instruction at the main amc, with clinical clerkships and perhaps electives at the rmc. south dakota school of medicine and florida state university college of medicine are examples of this approach.28 a flipped approach, with basic science instruction delivered at an rmc and clerkships provided both regionally, and centrally at the amc, is another less traditional design that has been used at indiana university.28 some programs, such as the campus de l'université de montréal en mauricie, located in quebec, combine the resources and facilities of 2 distinct universities and several independent regional medical centers to provide all 4 years of instruction. when an area has a critical need for more physicians, this can take precedent over other competing missions. a creative design, such as that used by the university of washington’s wwami program provides an example of 5 western u.s. states collaborating to use resources most efficiently. first-year basic sciences are offered at the amc in seattle or at one of the 5 rmcs, followed by the second year with all students training at the seattle campus, and third and fourth year students rotating in either seattle or at one of the rmcs spread across washington, wyoming, alaska, montana and idaho.28 typically, decisions about the type of rmc are determined by institutional mission, existing resources, available sites, and regional culture. governance medical schools use various models for governance to ensure clarity of structure. a clearly defined structure and organizational chart with reporting lines is essential in guiding the decisions made at the rmc. one study suggests that the most successful models are based on a shared vision as well as clear lines of communication between the main campus and rmc. such models also emphasize greater reliance on local decision making at the rmc to address challenges that arise during program implementation.19 typically, the rmc will operate with a separate faculty and administrative staff who handle day-to-day issues.10 many rmcs have a campus dean who provides oversight for the rmc and reports to leadership at the main campus. however, though many rmcs are managed locally with some coordination from the main campus, others are run entirely from the main campus.20 other models exist and vary considerably by geographic location and engagement with the local community. one approach is the use of a balanced matrix organization with dual reporting responsibilities to both the main medical school and local partners, addressing the issues of comparability.21 affiliation agreements with local health systems where instruction, learning, and clinical rotations will occur are critical to ensure a stable teaching environment and are required by the lcme. the support of the broader community at a new rmc is a key element of success for the campus. engaging local community leaders through participation on committees or in fund raising efforts can contribute to the support of the broader mission long-term. leadership governance and leadership of rmcs depend on the local context and institutional relationships. as a result, the role of the regional dean could combine aspects of student, educational, and academic affairs. there are valid arguments for recruiting an experienced rmc dean to provide visionary leadership and assistance with navigating the sometimesturbulent waters of a newly launched rmc. alternatively, recruiting local physicians with well-established community contacts as campus leaders can provide critical buy-in from potential teaching-physicians in the community. a combination of both leader types with distinct but complimentary roles can reap the benefits of both approaches. the experts’ advice: areas to consider regardless of financial models or governance structures, a primary factor in building a successful rmc is to engage in a sincere effort to create and maintain lasting fruitful working relationships between campus, institutional, and community leaders. this defines the rmc’s place in the success of the institutional endeavor while allowing the institution to utilize the benefits of a distant site. those rmcs that are most successful value the leadership of the rmc and consider it a pivotal part of the institutional academic community. comparability assessment between the main campus and the rmc should involve curriculum, student support services,22 technology,23,24 and availability of scientific labs.25 it is important to understand that the rmc is an extension or a complement to the main campus, rather than a competitor. admissions medical schools assign students to rmcs in a variety of ways with a centralized admission process a common approach. relying on the established admissions process at the main amc conserves significant amounts of time and resources. a centralized admissions process is often utilized with campus visits during the first year, after which students submit their campus preference.19 this approach optimizes the greatest number of student preferences while respecting space doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports limitations. other programs utilize student site preference at the time of admission to make campus assignments.26 a secondary application for students already accepted to the main campus offers a more manageable and creative campus selection process for a defined and usually limited number of students to attend the rmc. the final campus assignment may be based on both student preference and space availability. medical schools that have track-specific programs on their regional campuses will often utilize a specific admissions process for that track.27-28 this approach can support those students who wish to remain in or near their home communities during medical school. a heightened sense of reasoning in assigning students to a specific campus may be helpful in recruiting and producing practitioners through primary care and rural tracks. curriculum while local resources at the rmc may differ significantly from those at the main campus, the curriculum at both the regional and main campus of the same medical school must be comparable to comply with liaison committee on medical education (lcme) standards. however, this does not mean the curricula must be identical, and frequently the available teaching faculty, clinical facilities, and educational space will be substantially different between campuses helping to guide thoughtful curriculum development. as medical education has moved toward competency-based assessment, ensuring that student cohorts at both the regional and main campus are achieving expected milestones and ultimately the corresponding competencies has become a common goal. more than 100 years ago in 1910, abraham flexner established the basis for the traditional medical school curriculum, where 2 years of basic science are followed by 2 years of clinical learning experiences. medical education is now moving toward more innovative curricula that better prepare physicians for practice in the twenty-first century, where electronic resources abound for teaching and assessment, as well as diagnosis and treatment. these new approaches to medical pedagogy are often more easily piloted at rmcs, which are commonly smaller with less faculty, staff, and students overall. this smaller size often translates into a campus that could be flexible and nimble in pursuing new initiatives. it may also allow curricular change to be implemented and adjusted in real time more easily and help determine best practices that could eventually be rolled out at the larger main campus. innovations in medical education can include longitudinal integrated clerkships, rather than block rotations to better embrace current knowledge on spaced learning and interleaving. in addition, earlier exposure to patient care and case-based learning in teams is being introduced at many institutions. incorporating inter-professional learning into medical training mimics the real world and facilitates the type of effective team-based care that is now common. furthermore, at many schools there is an emphasis on health system science, including value-based care and evidencebased practices.29 in addition, shorter times to completion of training, such as 3+3 programs, and a greater focus on new technology, such as point-of-care ultrasound, are being incorporated into innovative medical school curricula. jointdegree programs, such as md/mba, md/phd, and md/mph programs can be created to train physician leaders and researchers for the future, especially when the rmc is in close proximity to a collaborative university or college. such educational innovations may often be more easily introduced, modified, and fine-tuned at the rmc. student services student services on rmcs are often offered by a variety of campus leaders who may or may not be student affairs professionals. often rmc deans serve as curriculum, student affairs, and faculty affairs leaders all at the same time. regardless of staffing, rmc students require access to all services available to main campus students. this need can be fulfilled using technology to connect learners with the main campus or non-traditional leaders with additional duties in support of learners. many of the necessary support services for students at an rmc may be initially provided through an established office of student affairs at the main campus. this is especially true for traditional models, where the first 2 years are spent on the main campus followed by clinical rotations at the rmc. there are several services that students will require regardless of rmc design. dedicated staff are needed to address the following: student health; mental health and wellness support; student safety and sharps injury guidance; student space and housing oversight; financial aid and debt literacy; career and academic advising; community service-learning opportunities; it support and connectivity to the amc; administrative support for course selection; scholarly and research opportunities; management of cross functional academic environments; oversight of course schedules and clerkship rotations, and library resources. students at rmcs often have the benefit of direct access to faculty mentors from early clinical experiences, which may not be as readily available on the main campus. building student-teacher relationships early-on could be beneficial in providing career guidance and specialty choice. student organizations doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports first and second year medical students frequently become involved in a number of institutional organizations that provide career guidance, such as specialty interest groups. in addition, community service opportunities allow students to gain leadership experience and demonstrate altruism, which can be highlighted on a cv as well as residency applications. administrative support, when needed, helps to facilitate these activities. testing, evaluation, and learner support exponential growth of scientific knowledge has required current medical students to become critical thinkers mastering the practical application of ever-increasing knowledge. with the emergence of competency-based medical education, confirming the acquisition of identified competencies and the milestones toward achieving them is essential to ensure that all students reach the expected performance level for graduation.30 the evaluation of medical students and residents along this competency-based continuum can be assessed in a number of ways. using the rime (reporter-investigator-manager-educator) framework is one approach that can be used to effectively describe professional growth.31 a single dean for evaluation and assessment can oversee this ongoing evaluative process at both the main and rmc campuses. however, modes of assessment at the rmc must integrate into online tracking software used at the main campus allowing medical schools to demonstrate compliance with lcme standards. both formative and summative assessments are necessary at all medical training sites. traditional standardized testing, as well as direct observation in the clinical setting and through objective structured clinical exams (osces) are used similarly at both main and regional medical campuses. faculty trained to facilitate and evaluate students through direct observation and osce exams are necessary regardless of where these sessions are held. osce exams also require trained standardized patients, who may assist with the evaluative process. likewise, certified proctors are necessary for more traditional standardized testing. learning support staff are a necessity for all medical schools and may often be extended from the main campus through regular visits to the rmcs, as well as through electronic connectivity via audio-visual platforms. in contrast, a medical librarian is becoming a more essential member of the educational support staff at the rmc due to the increasing reliance on electronic resources for learning and scholarly work. faculty faculty recruitment should be undertaken with a deliberate approach, based on the specific curricular needs of the campus, with a goal to provide the diversity of specialists that are necessary to meet instructional needs. therefore, before starting faculty recruitment, completing an “inventory” of faculty needs would be wise, and this should be correlated directly with the number of students planned for the rmc. such an approach will allow an assessment of the number of teaching physicians required to effectively deliver the curriculum, provide for student advising and mentoring needs, and support both inpatient and outpatient clinical services. several questions should be asked when conducting a faculty needs assessment: • does the college of medicine have an affiliation agreement with the facility where the faculty will practice? what will be the employment relationship of the new faculty members? do they work for the college of medicine, the health system, or an affiliate hospital? who would need to approve faculty accepting students? agreements about who will teach and when often must be made with the health system or employer rather than with the individual physician. a physician may agree and want to accept students, yet other circumstances and requirements at the workplace may prevent this. a hospital’s educational office will often manage more than one group of learners and will assign preceptors based on availability and service schedules. for example, one facility may have requests to accommodate allopathic and osteopathic medical students, resident rotations, clinical experiences for nurses, physician assistants, physical therapy students, and students in other clinical specialties. with the expansion of clinical programs across the country, this scenario is more common than not, and it is rare for a school to have an agreement with a local healthcare institution for exclusive teaching of their students. therefore, the process for obtaining approval for a physician to teach, and for scheduling individual students, may be beyond the “power” of an individual physician. • are faculty members remunerated by their current employer? if the medical school is not planning to monetarily compensate faculty time, reluctance may emerge based on the cost to the preceptors, e.g. the need for producing work relative value units (rvus).32 remuneration models may vary and create competition for availability of “teaching slots” in a given hospital. rural hospitals tend to be smaller and this issue may, therefore, be exacerbated, especially when multiple groups of learners need to be accommodated. whether there are payments or not, and whether the remuneration is to the hospital or to the physician, depends on agreements and hiring models. in some agreements, the medical school or rmc may provide additional staffing (e.g. a coordinator paid by the school and located at the hospital) to offset logistics in student scheduling rather than compensation to individual physicians. in other models, the institution employing the community teaching physicians may receive remuneration for the services provided and decide how those funds are distributed and used. to date, many schools compensate for student rotations based on number of students taught per week, or per semester. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports • will the faculty be engaged in required clerkships or in electives? if a preceptor will be teaching an elective rotation to a limited number of students in a small private practice, an affiliation agreement may not be expected, and likely the practitioner will be remunerated directly if they are paid. for required clerkship rotations, however, an affiliation agreement will be needed, and various ways for monetary compensation may be invoked. • who controls the faculty schedule? this is especially important for “volunteer” faculty who may or may not accept students at times when the students are scheduled to receive their clinical experiences. • who appoints faculty and what is the process for promotion (if one exists)? the answers to these questions vary widely between institutions. traditionally, faculty are assigned to departments associated with the main campus, and if the medical school is a part of a larger university, the rules for faculty assignments stem from a centralized office, such as the office of the provost or the vice president for academic affairs, and the university faculty organization and its committee on promotion and tenure. such centralized bodies may vary by organization, function, and authority. how faculty nomenclature is designed, also varies widely, most often having a “clinical” qualifier in the faculty’s title (e.g. clinical assistant professor). other nomenclature could include “adjunct faculty”, “volunteer faculty”, and other titles, some of which are and some of which are not eligible for promotion. in addition, the expectations for clinical faculty promotion may vary significantly between institutions when they exist at all. more often than not, clinical faculty are not considered eligible for tenure, and some medical schools have moved away from offering tenure altogether. therefore, it is important to enter discussions about faculty recruitment at a new site with clarity about options for faculty assignment and rank, including expectations for promotion. answers to the questions noted above will allow careful planning for faculty recruitment. it is important to include hospital/practice leadership in faculty recruitment and a designated office of medical education or equivalent should be involved in student placement. while affiliation agreements do provide some assurances, these are not contractual relationships and could potentially degrade with a change in hospital leadership, hospital profitability, competing priorities, or new partnerships. schools need to remain vigilant and intentionally nurture relationships with clinical partners, especially in a community-based setting. the overwhelming majority of faculty at rmcs are volunteer community faculty. as a result, faculty development is a primary concern, particularly with new faculty who may not have had teaching responsibilities since residency. teaching and assessment methods are rapidly changing and preparing faculty to provide the best educational interactions for learners is an increasing challenge, particularly with the move toward competency-based medical education, an entirely new assessment model. recruiting local physicians who have established positive relationships with other community practitioners is a critical step in identifying and credentialing prospective teaching physicians. providing adequate faculty development to physicians who may have limited teaching experience, and perhaps no academic exposure since medical school, is an important support service that should not be overlooked. consideration should be given to remuneration of volunteer faculty or provision of alternative incentives, such as access to library resources, gym facilities, etc. ninety-five out of 136 schools participating in an aamc survey on faculty retention (70%), noted increasing difficulties in recruiting and retaining volunteer faculty at clinical campuses, listing a variety of reasons, including: increased student enrollment leading to increased demands on faculty; local faculty participating in the training of students from more than one medical school or health professions program; new medical programs in the area of the campus creating increased competition for resources; inability of the medical school to appropriately compensate physician preceptors. such issues should be considered, and possible solutions identified, prior to committing to the start of a new regional medical campus. library resources while the services of a librarian may initially be provided by the local affiliate medical center librarian, a dedicated librarian will become an essential resource for the more established rmc, especially if firstor second-year students are training there. a medical librarian affiliated with the amc and located at the rmc will provide students with reference services, research consultation such as guiding pubmed searches, coordination of study spaces, and informatics instruction. moreover, a medical librarian can become indispensable to the rmc faculty by providing the above services, as well as literature searches for scholarly work, curricular support, coordination of services with the amc library and support in preparing library and information technology sections during lcme reviews. a checklist to assist decision making for a new regional campus table 1 presents a summary of considerations for starting a new rmc and offers medical school leadership and collaborators a systematic model for decision-making and planning a rmc. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports table 1. actions, considerations, and resources in deciding whether to start a new regional campus conclusion doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports while this practical guide is not intended to be a compendium of all information needed to successfully create a new rmc, the authors have summarized the cornerstones and necessary steps in bringing a new campus to life. starting a new rmc – from creating the concept, to applying due diligence in feasibility and planning, to operations implementation, is a thoughtful, deliberate, and extensive process, which if carefully completed, would yield a smoother accreditation process and faster implementation. a deliberate approach to planning will benefit both the rmc and the community that hosts it. the timeline for this process is framed by accreditation requirements for review and approval, as well as by having a dedicated team to complete the necessary steps. it is important that the whole organization – from the university president to the university chief academic officer, to the college dean, to the campus dean and the college and campus administration are all committed to the process of establishing a new rmc, actively participating in decisions and securing resources for a successful launch. it is equally important that the local community is engaged in the planning process from the very start becoming an active partner in decision-making and rmc design. continued communication and consultation with the accrediting body from the first inception of the idea for a new rmc is critical to successfully building a new rmc. developing a financial proforma to guide expectations for resource allocation, revenues, and expenditures will ensure shared understanding among university school of medicine, college campus, and community leadership. the rmc model is efficient for providing increased opportunities for clinical training expansion. the creation of rmcs in association with established amcs, is a cost-effective and realistic approach to efficiently train new physicians. rmcs therefore, present a viable solution to meet the need for training healthcare providers in the immediate future. about the authors ralitsa akins, md, phd joined the group on regional medical campuses in 2005 and has served on its planning committee. she has also served as the associate dean of faculty affairs at elson s. floyd college of medicine, a newly-accredited medical school that started on 4 regional campuses. dr. akins was previously the associate dean of academic affairs at the binghamton campus of suny upstate college of medicine, overseeing curriculum, student affairs, faculty affairs as well as all clerkship and elective rotations on 2 campus locations, binghamton, ny and sayre, pa. in addition, she was on the team that achieved accreditation of the el paso regional campus of the texas tech health sciences center school of medicine as the new 4-year paul l. foster school of medicine. dr. akins is currently the provost of des moines university. michael flanagan, m.d., faafp, has been at the penn state college of medicine university park campus for 23 years, where he serves as vice-chair and professor of family and community medicine, professor of humanities, and medical director. a member of the group on regional medical campuses since 2013, he currently serves as the assistant dean for student affairs at the university park campus, and previously filled the role of interim associate dean for education from 2015-2016. dr. flanagan was an integral member of his rmc’s leadership team that transitioned the campus from an affiliate site to an accredited 4-year rmc. he is a member of the admissions committee at the penn state college of medicine hershey campus, as well as at the rmc. in addition, dr. flanagan has previously served as the family medicine clerkship director and helped develop the humanities curriculum at the rmc. he is the editor-in-chief for a new book on regional medical campuses, published in 2018. lanita carter, phd is the immediate past chair of the group on regional medical campuses. she has been active in the grmc since 2003 and joined the steering committee as the southern region representative in 2013, later serving as program chair. for the past 15 years, dr. carter has worked with the uab school of medicine huntsville regional medical campus as director of medical education and student services. she has served on the uab admissions committee for 14 years and was an interim leader of the admissions committee in 2016-2017. katherine mcowen, msed is the senior director of educational affairs in medical education at the aamc. she has served as a staff leader for the grmc for the last 10 years. ms. mcowen collaborates with aamc staff and constituents across the continuum of medical education to plan and deliver a variety of programs supporting the development of educational initiatives, administrative innovations, and scholarly activity in the united states and canada. all authors currently serve on the editorial board of the journal of regional medical campuses. disclosures acknowledgements none funding/support not applicable conflict of interest none other disclosures none treatment of human subjects and treatment of animal subjects not applicable disclaimers none previous presentations not applicable doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports references 1. cheifetz c., mcowen k., gagne p., wong j. regional medical campuses: a new classification system. acad med. 2014; 89(issue 8): 1140-1143. 2. association of american medical colleges. aamc 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(2012). medical students on long-term regional and rural placements: what is the financial cost to supervisors? microsoft word imaginationarticle.docx published by university of minnesota libraries publishing imagination, the first virtual meeting anna wirta kosobuski, edd and richard g. melvin, phd journal of regional medical campuses, vol. 3, issue 3 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc anna wirta kosobuski, edd; university of minnesota medical school duluth campus, duluth, mn richard g. melvin, phd; university of minnesota medical school duluth campus, duluth, mn corresponding author: anna wirta kosobuski, edd assistant professor, department of biomedical sciences university of minnesota medical school duluth campus 1035 university drive duluth, mn 55812 email: awirta1@d.umn.edu cell: 715-817-4995 all work in jrmc is licensed under cc by-nc volume 3, issue 3 (2020) journal of regional medical campuses imagination, the first virtual meeting anna wirta kosobuski, edd and richard g. melvin, phd abstract two regional medical school faculty have a meeting of the minds as they seek ways to stop the spread of covid-19. a combination of expertise and imagination resulted in entertaining kid-friendly information to promote covid-19 awareness and prevention practices. what started as a seemingly small health promotion project for children quickly blossomed into an impactful, far-reaching venture that cuts across distance, cultures, and disciplines as the resources travel regionally and internationally, are translated to multiple languages, and evolve into new, cutting edge covid-19 research and innovative methods of providing supportive services for youth in a native american community. what can we do to help? a question that we’ve heard time and again since march 2020, when it became clear that covid-19 had crept its way to the united states, making its presence known by turning so many of our societal norms upside down and sideways. we were hit by a ton of bricks then tossed into the middle of a hurricane. for the past couple of years, the 2 of us enjoyed the balance our areas of expertise brought to projects. an internationally trained evolutionary geneticist and an ojibwe/finnish woman whose winding path led her to a late-in-life education doctorate, but both with a deep-seated love of learning and sharing the captivating world of science with native american kids. and that was our common ground, the root of what in the eyes of some might be an unlikely partnership. both of us care deeply about using and sharing our professional knowledge in ways to assist those who want what we have to offer. we hope that by providing people with the information that they request we can help make a real difference in their lives and those of people their communities. we have been able to do this “as 2 complementary alleles”, quips the geneticist. like so many other people around us, one day we asked one another, what can we do to help others in these unsettled times? we turned to our common, complementary strength and simply asked, what would help the kids? and so, it began. in the middle of the torrential chaos of finding our entire nation in need of toilet paper, hand sanitizer, and face masks, layered upon temporary school and business closures, shifting work schedules or in some cases, all out loss of work, our fear was that children might be lost in the shuffle. we thought, if grown-ups are finding themselves without all the tools they need to fully cope and adjust, how about the little ones? believing that children were trying to make sense of all that was going on, and that they too were trying to make decisions, we began to think about our experiences during some of our past activities with kids when we help them see how science deepens the fascinating nature of our everyday lives. the kids usually ask questions fueled by equal parts understanding and imagination. we asked ourselves, what are some of the questions they ask? and specifically, if we were talking about covid-19, what would be some of their questions? presenting and discussing the topic was out of the question. moreover, school leaders were in the midst of trying to find a workable recipe for effective methods of delivering daily core classroom requirements and certainly didn’t need us in their way to top off their already wildly stressful days. we decided to take the route of creating short, informational covid-19 resources that presented the topic in eye-catching, kidfriendly formats. now, if this is our goal, just what does covid-19 look like? to fully flesh this out we pulled together our project team, including the gifted artist with an uncanny knack of turning all things to magic, and worked furiously over the next couple of weeks to turn out the materials in time so schools could get them in the hands of the kids. what followed was nearly as unexpected as the pandemic itself. our resources, germs! germs! germs! and covid-19? answers for kids provided overviews of the virus and pandemic using an imaginative approach that depicted the virus as a stubborn creature with its hands poised on its waist, steadfast on world domination unless we face and fight it. knowing from experience not everyone has the means for journal of regional medical campuses, vol. 3, issue 3 or even the desire of internet access, we sent paper copies to native american community partner schools for dissemination. the school, kids, and entire communities loved them, and it was clear that the need was there. we had them set up for digital download to allow ease of access and expansive dissemination. we spread the word to professional and community contacts. the news snowballed as people shared them far and wide on facebook and throughout their own networks. before we knew it, they were national, and then international as they traveled on up to canada and via twitter to colleagues and teachers as far away as australia and yorkshire, england. very quickly, the request came that our covid-19 resources be made available in additional languages as communities throughout minnesota were in dire need of digestible resources but had few options other than the cold hard and uninterpreted facts provided by the centers for disease control literature and website. a quick search for translators and soon we had somali, hmong, and spanish versions of our work. requests for materials and printed copies for dissemination kept coming. interestingly, though the english-versions of printed copies ran out fast, we were over the top with excited delight when those prepared for somali communities were requested even more quickly. we are now on our third order of reprints of both versions. the demand for materials and the outpouring of feedback told us not only how desperately trustworthy and accurate community resources were needed, but also how much people enjoyed our creative, friendly presentation of covid19 information. we were urged to expand our project. time for round 2. we partnered up with a fellow faculty member who shares our ideal of putting knowledge and expertise to use to empower communities. the next set of materials spun off on subtopics of the first: one on face masks and social distancing, whiz kidz! amazing facts about covid-19 face masks and social distancing, and a second, covid-19, clean hands mythbusters that addresses the efficacy of wearing gloves to help stop covid-19’s spread. in addition to these, we put the daily news updates of the virus spread to work by placing it at the center of a fun mathematics lesson, flatten the curve, that translates the real-life experience of covid19’s spread into problem solving and graphing. we plan to use this lesson in our future activities with children and make it publicly available to teachers for use in their classrooms nationwide. like the covid-19, what started out as our little project soon took on a life of its own and has evolved and presented new and sometimes unexpected scenarios. dr. melvin thinks of the images of the virus that were conjured up by artist, when he is talking to community officials about the presence of the virus in wastewater and at public beaches. he finds community communication of the information in covid-19 graphs is more accessible through imagining the virus as a character in our story with its own motives and flaws. dr. wirta kosobuski called on her newfound knowledge and incorporated ideas born in the deluge of community feedback and identifications of priority needs regarding covid-19 education to design a new project that expands her longstanding partnership with an area tribal community in exciting directions. in a similar vein as our materials for kids, the new community project is in response to the impact of covid-19 on young people. dr. wirta kosobuski and her community partner dreamed up and implemented an innovative, holistic, culturally based virtual mental health group support program for native american adolescents. what’s next? nobody knows, but what is certain is that we’ll meet whatever life throws us with our same unwavering love of the adventures of learning and our shared tendency to, at times, think, imagine, and laugh like kids. whether you find yourself interested or even mildly curious, all of our covid-19 materials for kids can be viewed and downloaded at https://conservancy.umn.edu/. search wirta kosobuski or melvin. acknowledgements: we would like to thank and acknowledge our fellow faculty member, glenn simmons, jr., team member rachel kingsiert, and illustrator, jordan rodgers. microsoft word reflecting on the advantages article.docx published by university of minnesota libraries publishing reflecting on the advantages of longitudinal integrated clerkships and covid-19 kyle geiger, bs; jaime bowman, md, faap; dawn e. dewitt, md, msc, macp, fracp doi: https://doi.org/10.24926/jrmc.v4i2.3492 journal of regional medical campuses, vol. 4, issue 2 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc kyle geiger is fourth year medical student, elson s. floyd college of medicine, washington state university, spokane, wa. jaime bowman is an associate clinical professor and director longitudinal integrated clerkship, year 4 associate director, elson s. floyd college of medicine, washington state university, spokane, wa. orcid: https://orcid.org/0000-0001-7301-1999 dawn e. dewitt is professor and senior associate dean, inaugural year 4 director, elson s. floyd college of medicine, washington state university, spokane, wa. corresponding author: kyle geiger e-mail: kyle.geiger@wsu.edu all work in jrmc is licensed under cc by-nc volume 4, issue 2 (2021) journal of regional medical campuses perspectives reflecting on the advantages of longitudinal integrated clerkships and covid-19 kyle geiger, bs; jaime bowman, md, faap; dawn e. dewitt, md, msc, macp, fracp abstract the emergence of coronavirus disease 2019 (covid-19) has dramatically changed the landscape of medical education. the novel experience of pandemic disruptions to clinical training revealed advantages of longitudinal integrated clerkships that emerged during the covid-19 outbreak. while there is emerging literature regarding online learning during the pandemic, to our knowledge there is no literature highlighting how longitudinal curricular approaches insulated students from pandemic disruptions. these insights may be useful as medical schools contemplate potential future disruptions to clinical training. students in our longitudinal, integrated clerkship (lic) enjoyed several advantages compared to students training in traditional block models. advantages of an lic model include a relatively even exposure to specialties across the clerkship year, discipline specific assessment information despite an early truncation of clinical activity, and a seamless transition to integrated online learning, as a single integrated virtual clerkship model for the entire cohort. lic students avoided consequences seen in traditional clerkships such as missing entire core-clerkship rotations between march and june, 2020. our lic assessment program assesses competencies through ongoing, cumulative direct observation of skills (e.g. history and physical examination) across specialties. this facilitated final overall clerkship assessments, by competency rather than by specialty, in time for the medical student performance evaluation (mspe) to be submitted to residency programs. finally, pre-existing relationships with preceptors facilitated ongoing contact during virtual clerkships and opportunistic clinical experiences once students re-engaged in clinical activities. clinical education crisis the emergence of coronavirus disease 2019 (covid-19) has dramatically changed the landscape of medical education. logistical challenges continue to emerge as we focus efforts on training the next generation of doctors. the initial shortage of personal protective equipment (ppe), combined with the possibility that students might become infected and/or asymptomatically spread the virus, has significantly influenced the role of medical students world-wide. most schools followed the association of american medical college’s (aamc) recommendation to suspend all student clinical rotations in spring, 2020.1 our students were in the eighth month of the 10 month lic at this time. the aamc revised its guidance on august 14, 2020 for medical students to include direct clinical activities with patients with and without known or suspected covid-19, if the necessary precautions can be adhered to and the care facility agrees. medical education has been forced to respond to rapidly changing circumstances, not knowing when health systems might request that students pause or re-engage in clinical learning. these challenges, along with nation-wide calls for social distancing, have changed the way medical schools are delivering education. these pandemic disruptions have revealed advantages of longitudinal integrated clerkships (lics). this viewpoint highlights the advantages of an lic model during the covid-19 pandemic. these advantages suggest that the lic might be a more robust model if another situation requires suspension of clinical training (with patient care), at an individual medical school or on a worldwide basis, such as student illness, another international pandemic, or “waves” of covid-19. journal of regional medical campuses, vol. 4, issue 2 perspectives longitudinal integrated clerkships (lic) unlike traditional block clerkships in which year 3 and 4 students focus on specific specialty experiences for 4-6 weeks, the lic model aims to integrate specialty experiences with faculty and patients over the clerkship year in a continuity-centered model. for example, students at our institution experience internal medicine one week, surgery the next, and circle back to internal medicine 4 weeks later, with some weeks integrating multiple specialty experiences during a single week. while lic models vary to some degree across medical schools, foundational principle of longitudinal integrated clerkships (lics) is continuity; students have continuity with both preceptors and patients during the entirety of the core clerkship year.2 learners in the lic model spend an extended time in a clinical setting to allow student continuity with patient care across both health system and community settings, cultivating clinical and cultural learning.3 by 2018 as many as 69 medical schools across the us had adopted the lic model in some form.4 in 2019, the washington state university elson s. floyd college of medicine (esfcom) launched one of the first ever “all-in” lic models in the world, where 100% of students participate in the lic, delivered at 4 community-based washington state clinical campuses. in the esfcom lic model, third year students have exposure to core specialties including medicine, obstetrics–gynecology, surgery, psychiatry, family medicine, and pediatrics in an integrated fashion across the entire clerkship year. through patient continuity experiences, esfcom students quickly become experts on their patients’ health while developing strong relationships with them. one example would be following a pregnant mother from her 8-week ultrasound to birth and subsequent first visit with a pediatrician. continuity with preceptors over many months builds mentoring relationships and entrustment. the curricular and operational advantages of the lic in the traditional “block” model of medical education, students rotate within a specific specialty for 6 to 12 weeks. pandemic “closures” disrupted the traditional core clerkship year, derailing scheduled rotations and leaving students with little to no clinical experience in some specialties. there is currently only speculation on how the disruption to clinical learning will ultimately impact student competence and residency match outcomes. the potential gaps in a student’s knowledge and skills, and the disruption of relationships with preceptors, may significantly affect the reliability of clerkship assessments and the quality of letters of recommendation. a core benefit of the lic model is the opportunity for students to build meaningful relationships across time with patients and preceptors. the integrated nature of lic significantly mitigated the impact of the covid-19 pandemic time loss across all specialties rather than eliminating exposure to entire disciplines. our students also had well-established relationships that facilitated their ability to obtain detailed letters of recommendation. lic models generally incorporate opportunities for “selfdirected learning” (sdl). in our program each student has one dedicated sdl half-day per week. students are encouraged to connect with continuity patients but may also use some of this time to explore sub-subspecialty interests.4 in the traditional clerkship model, subspecialty electives and exploratory experiences are scheduled only in the final year. our students were also less impacted by cancellations of specialty elective opportunities, in part because established longitudinal relationships with preceptors, through self-directed days and continuity experiences, opened doors to further clinical opportunities. this is relevant as accessibility to away rotations are currently limited nationwide.5 lic schedules generally ask students to switch clinical learning environments frequently, but when students return, they are a known team member. the lic facilitates opportunities for students to practice and transfer skills across “specialty” settings, and to further improve their skills when returning to a particular service. the lic model also decreases experience gaps such as seasonal clinical experiences (i.e. doing pediatrics in the summer when respiratory illnesses are less common) and diminishes the effects of early performance limitations that affect learning outcomes (i.e. students may have vastly different experiences if completing surgery as their first verses their last clerkship rotation). this model also shows promise to be better structurally suited than the traditional model to aid students’ learning. in the lic model, students may naturally engage in spaced retrieval and repetition of material. there is evidence in the literature to support that retrieval and repetition based learning is a superior journal of regional medical campuses, vol. 4, issue 2 perspectives method.6 block models promote massed retrieval (cramming) as students prepare for end-of-block subject exams. while it could be argued that the spaced repetition seen in the lic allows for more effective learning, allowing students to accomplish in 9 months what others would achieve in 12 months, there is currently limited data in the literature and within our program to further support this claim. because students were not on a traditional “block schedule” of 6 weeks, the transition to week-by-week online virtual clerkships was seamless. importantly, the lic structure enabled the faculty to work together to create an integrated virtual clerkship with much less effort than needed by faculty in traditional models. for example, given a gap of 6 weeks, each clerkship discipline only had to contribute one week of virtual clerkship curriculum rather than each clerkship group having to provide 6 weeks of material for a subset of rotating students. since schedule principles used for the live lic were also used to build the virtual experiences, moving in and out of virtual experiences, and returning to clinical patient care were particularly agile. faculty from the lic were asked to join the virtual lic, which facilitated engagement and ongoing student-mentor contact when clinical time was not available. in our virtual lic, students used a combination of online cases and modules through aquifer7 and wise-md8 as a substitute for real patients. students connected via zoom9 with attendings in small groups (4-5 students). students presented and discussed patients, and completed simulated clinical “tasks” such as transfer of patient care, and subspecialty consults. because the faculty were creating a single integrated virtual experience, with a smaller number of experiences required in each specialty, we were also able to design and incorporate standardized patient interviews that emphasized advanced skills (given that the students were late in the clerkship year) while incorporating specialty-specific knowledge. assessment our lic assessment program emphasizes longitudinal skill development and utilizes many small moment-intime “workplace-based assessments” of performance on individual tasks. preceptors provide feedback and assess students in real time. workplace-based-assessments (wbas) are based on direct observation and assess one skill at a time, e.g. physical examination or oral presentation, referencing entrustable professional activities (epas).10 unlike traditional end-of-rotation assessments, students trigger an assessment form immediately upon completion of a skill and debrief with their preceptor at the time. importantly, because our program already has significant entrustability information on every student across every discipline, the lic model continued to support a robust cross-specialty assessment of skills as well as information on disciplinespecific knowledge and experience. the virtual-lic preceptors were able to continue using wba tools during the virtual lic. thus, our students’ experience and assessment are fully comprehensive despite the interruption in direct patient care. this is in contrast to the limitation of the many students nationwide who are lacking experience, skills and assessment information in one or more specific core clerkship disciplines. conclusions the lic model generated unanticipated advantages for students in the setting of a significant disruption in clinical learning due to an international pandemic. while the esfcom experience is limited to the inaugural cohort of one new medical school, our participation in national and international conversations with colleagues have confirmed that our experience is not unique.11 other medical schools may want to strongly consider the lic model advantages that have become more obvious during the covid-19 pandemic. these advantages include: 1) relatively even learning and experience across multiple specialties; 2) the availability of discipline specific assessment information across all specialties despite an early truncation of direct patient care learning activities; 3) a relatively seamless transition to integrated online learning for an entire class using a single integrated virtual clerkship model (that was also less work for each individual specialty); and 4) the advantages of pre-existing relationships with preceptors and patients that facilitated engagement in ongoing contact through opportunistic clinical experiences now that it is safe to re-engage in clinical activities. while the last was primarily due to the fact many of our preceptors from the third year clerkship elected to continue participation in the lic via online learning, the limited time commitment required from each specialty facilitated ongoing engagement. the lic has coincidentally resulted in a robust clinical education assessment that has distinct advantages compared to journal of regional medical campuses, vol. 4, issue 2 perspectives the traditional “block learning” during a period of unprecedented disruption to clinical learning for medical students. this experience has led us to believe that the lic model is preferable to block rotations if and when other individual, local, or global interruptions occur during clinical training references 1. important guidance for medical students on clinical rotations during the coronavirus (covid-19) outbreak. aamc. accessed april 16, 2020. https://www.aamc.org/news insights/press-releases/important-guidance medical-students-clinical-rotations-during coronavirus-covid-19-outbreak 2. worley p, couper i, strasser r, et al. a typology of longitudinal integrated clerkships. med educ. 2016;50(9):922-932. doi:10.1111/medu.13084 3. ogur b, hirsh d, krupat e, bor d. the harvard medical school-cambridge integrated clerkship: an innovative model of clinical education. acad med. 2007;82(4):397-404. doi:10.1097/acm.0b013e31803338f0 4. gheihman g, jun t, young gj, et al. a review of longitudinal clinical programs in us medical schools. med educ online. 2018;23(1). doi:10.1080/10872981.2018.1444900 5. medical student away rotations and in-person interviews for 2020-21 residency cycle. aamc. accessed june 19, 2020. https://www.aamc.org/what-we-do/mission areas/medical-education/away-rotations interviews-2020-21-residency-cycle 6. karpicke jd. retrieval-based learning: a decade of progress.; 2017. doi:10.1016/b978-0-12809324-5.21055-9 7. aquifer | your trusted source for clinical learning virtual patient cases. aquifer. accessed june 19, 2020. https://aquifer.org/ 8. wise-md » the web initiative for surgical education. accessed june 19, 2020. http://wise md.med.nyu.edu/init.action 9. video conferencing, web conferencing, webinars, screen sharing zoom. accessed june 19, 2020. https://zoom.us/ 10. chen hc, van den broek wes, ten cate o. the case for use of entrustable professional activities in undergraduate medical education. academic medicine. 2015;90(4):431–436. doi:10.1097/acm.0000000000000586 11. dewitt, dawn. personal communication, online meetings with the american association of medical colleges group on regional medical campuses (aamc grmc) and the consortium of longitudinal integrated clerkships (clic). march to november, 2020. microsoft word family medicine preceptorships article.docx published by university of minnesota libraries publishing family medicine preceptorships for first year medical students: durable educational value amid healthcare transformation james boulger, phd and emily onello, md doi: https://doi.org/10.24926/jrmc.v1i3.1102 journal of regional medical campuses, vol. 1 issue 3 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc james boulger phd, professor, department of family medicine and biobehavioral health, university of minnesota medical school, duluth regional campus emily onello md, assistant professor, department of family medicine and biobehavioral health, university of minnesota medical school, duluth regional campus all work in jrmc is licensed under cc by-nc volume 1, issue 3 (2018) journal of regional medical campuses original report family medicine preceptorships for first year medical students: durable educational value amid healthcare transformation james boulger phd and emily onello md abstract the required family medicine preceptorship in the first-year curriculum at the duluth regional campus of the university of minnesota medical school has existed for decades and has provided students with opportunities to work with regional family physicians. exposing medical students to excellent primary care of patients early in the curriculum remains an educational priority. this time series analysis examines physician willingness to participate along with the teaching physician practice structure (physician-owner versus employed physician). a downward trend in the percentage of physicians agreeing to serve as preceptors is reported (1992 at 83.6%, 2002 at 71%, 2012 at 61.2%, and 2017 at 47.9%). the data reflects a transition from independent practice to larger health systems. percentages of physicians in large health systems were 8.3% (1992), 28.8% (2002), 64.3% (2012), and 61.9% (2017). this time series analysis also provides comparative data summarizing student evaluations of the family medicine preceptorship experiences from the years 1993, 2014, 2015, 2016 and 2017. despite changes in practice structure and fewer physicians agreeing to precept, the data demonstrates consistently high ratings by medical students over time. the authors do not report any conflicts of interest. introduction in the current context of grave physician shortages1 and health care transformation, there is a nationwide recognition of the value of family medicine. early and formative medical student experiential sessions with family physicians are vital and support the selection of family medicine as a specialty choice. such sessions have been documented as one of the determinants reinforcing career choices2-6. the duluth regional campus’ curriculum and the efforts to admit the ‘right’ students for family medicine remains resoundingly successful – with 46.7% (n = 953 of 2042) of graduates entering family medicine residencies since 1976. a critical component of the university of minnesota medical school duluth campus curriculum is a robust family medicine preceptorship in place since 1972. the required course has existed in a similar format for the past 45 years, pairing all first-year students ‘one-onone’ with community family practitioners. students join local family physicians for half-day sessions scattered throughout the entire first year of medical school. this research summarizes the student perceptions of the preceptor experience over 24 years. longitudinal data presented are unique and have not been presented before. during this same time period, we have also witnessed the transition from the ‘private practice’ model to the health systems care model. this research examines the willingness of family physicians to serve as preceptors amid medical organizational change. physician resources have been stretched by increasing numbers of students and increasing demands on communitybased offices for implementation of electronic medical records, demonstration of quality measures, and fulfillment of insurance requirements for payment. therefore, identifying and recruiting preceptors to serve as teaching sites has become increasingly challenging in recent years7,8. to investigate the question of whether the ongoing health system changes have affected student ratings of the preceptorship, medical journal of regional medical campuses, vol. 1, issue 3 original report student opinions of the family medicine preceptorship experience are reviewed. has the loss of practice ‘ownership’ and autonomy accompanied a change in the willingness of community physicians to participate in a medical school teaching program? have student evaluations of the program changed over the recent decades? can we continue to expect our local family physicians to find time for our medical students? methods this is a time series analysis of preceptor ratings over more than 2 decades. the university of minnesota institutional review board has exempted from review studies of educational processes. following the conclusion of the family medicine preceptorship, each first-year medical student completes a written evaluation form. completion of the evaluation form is required of all students, however the form itself is not graded. the information provided by the medical students is not shared directly with the local family physicians. instead, it provides course faculty with valuable information on the student learning experience. during the study period, the class size at the duluth regional campus ranged from 51 to 65 students. this form includes a number of likert scale items and space for individual comments. the same form was used throughout the study timeframe. responses to the evaluation from the years 1993, 2014, 2015, 2016, and 2017 are analyzed and compared. researchers selected 1993 as a base reference point from 25 years ago, a time prior to significant local health system changes. the 1993 data is compared with the most recent 4 years of student ratings. the 4 academic years of 2014-17 were selected to provide an optimal characterization of current student responses. doi: https://doi.org/10.24926/jrmc.v1i3.1102 the authors have also examined rates at which the local family medicine doctors have agreed to participate. rates from the years 1992, 2002, 2012, and 2017 are compared. these years were selected because they represent appropriate decade-long intervals and the most recent year to ascertain trends. local family physicians invited to serve as course preceptors include community physicians as well as residents in second and third years of their 3-year training. the duluth family medicine residency program remained at 10 residents per year until 2014 at which time it decreased to 8 residents per year. nearly all of the local family medicine physicians are invited to precept, excepting those who have verbalized a strong desire not to do so. records have been kept of the community physicians’ responses to this call for volunteers. all preceptors are unpaid by the medical school. responses of ‘yes’, ‘no’, and the absence of a response were compiled. finally, physician practices were categorized by type. the practice was defined as ‘solo/small’ if it had fewer than 9 family physicians and was independent of a larger health network. otherwise, the practice was categorized as a ‘system’. additionally, the investigators defined a ‘system’ practice as having both a formal affiliation with a local hospital and having 2 or more primary care clinic sites that share the same affiliation name. physicians who were still in residency were given a separate category, ‘residents’. results data on the student ratings of the family medicine preceptorship program activities are presented for student cohorts of 1993, 2014-17. the rating scales (1 = never/negative to 5 = always/positive) used over this period provide an absolute comparative figure for student perceptions and satisfaction. in all categories and years, the modal response was ‘5’. the response rate for students was 100% in all journal of regional medical campuses, vol. 1, issue 3 original report years since the evaluation form was required. figure 1 illustrates that there has been no decrement in the student ratings of the family medicine preceptors’ performance as teachers over the years (chi square testing did not show any statistical difference in the rating categories over time). preceptor performances continue to be highly lauded and perceived as presenting a realistic view of practice to their students. they are highly rated as clinical teachers. figure 1 as seen in figure 2, the proportion of solicited family physicians in practice who have assented to be clinical preceptors in the community has diminished over the past 25 years. in 1992, 83.6% of physicians agreed to precept, but by 2017 only 47.9% did. the numbers of physicians solicited were 61 (1992), 75 (2002), 96 (2012), and 132 (2017). the increasing number of solicited physicians was due to several factors including the expanding student class size as well as diminishing proportion of favorable responses from physicians. resident physician responses were analyzed separately to ascertain if this cohort differed from the physicians in community practice. the decreasing trend was the same for both groups. doi: https://doi.org/10.24926/jrmc.v1i3.1102 figure 2 an added consideration, mentioned earlier, is the transformation of physicians’ practices over the past 25 years. in order to assess these changes, a retrospective analysis of practice type was performed. preceptors were classified as being in a small/solo practice or in a practice which is a part of a healthcare system, or whether the preceptor was a resident in training at the time of serving as preceptor. the results of this analysis are shown in figure 3. figure 3 demonstrates that the practice types in which the medical students train have changed markedly over the past 25 years. the proportion of preceptor physicians in solo/small practices has diminished (60.4% to 15.9%) while the proportion practicing in health ‘systems’ has increased significantly (8.5% to 61.9%). the proportion of resident physicians who engaged in preceptorship teaching has varied somewhat over the timespan (31.3% in 1992 to 22.2% in 2017). journal of regional medical campuses, vol. 1, issue 3 original report figure 3 discussion the standardized student evaluation data, collected within a single medical school course over several decades, are unique and have not been presented before to our knowledge. regardless of the practice site type to which the student is assigned, student evaluations are almost universally positive. typical comments can be found it the 2015 assessment: “seriously, she was incredible across the spectrum of assessment. i’ll probably continue to observe throughout the summer.” “i really liked having dr. a as my preceptor and am a little sad that the year is over.” “the preceptorship was excellent! i was hopeful it would take place next year as well. dr. r is a natural teacher and an enthusiastic physician.” “rating is 10 on a scale of 5! he was an amazing preceptor.” “i thought this was a good match. dr. n was very friendly and helpful. she was very open to my questions and let me gain hands-on experience whenever possible.” doi: https://doi.org/10.24926/jrmc.v1i3.1102 the occasional comments of concern by students are followed up individually and privately to ascertain whether this was an anomalous comment or reflective of a more serious and permanent problem with the site, the preceptor, or the student. as medical practice, specifically urban family medicine practice, has transformed from a private and physician-owned and directed model to a systems-based multi-specialty large organization model, the content of the office-based practice has also altered. today, many fewer urban systembased family physicians deliver full-scope, broad spectrum medical services. the attempt to link medical organizational changes over the past 25 years to the willingness of family physicians to serve as mentors with this program is data-driven and worthy of discussion. the data indicates that it is more difficult to get practicing physicians to serve as preceptors today when contrasted with 25 years ago. one of the reasons for the decrement in interest may be an indirect measure of practice satisfaction, ‘busy-ness’, etc. reasons that physician preceptors chose to precept, or decline the opportunity, are not studied here. future inquiry in this area could be informative. pressures on doctors’ time include declining reimbursement rates, decreasing duration of typical office visit, uninsured patients, and transitions to electronic health records.7-11 the effects of the affordable care act are still emerging today, but it is clear that increasing the number of insurance covered individuals will lead to even more stresses on a system that is understaffed in primary care and family medicine. correspondingly, within the medical education framework, added pressures have increased on the community physicians who generously support student learning. decades ago, community family physicians were asked to participate only in journal of regional medical campuses, vol. 1, issue 3 original report teaching of medical students. today, there are a great many more learners who desire the tutelage of the community physician. students in advanced practice nursing, physician assistant programs, premedical ‘prep’ programs, etc. all demand more of the physician’s time than in the past. family physicians, by dint of their scarcity and versatility, are particularly in demand for both their clinical teaching skills and their ability to model excellent care. how does this increasing demand mesh with the demands of a busy practice? what factors can support and sustain teaching excellence going forward? this study did not assess all parameters that could impact the physician’s decision to teach (i.e. competing teaching demands from other health professions, age or gender of preceptor, etc.). given the declining number of physicians who volunteer to teach medical students found in this study, it is likely that more focused and concerted efforts by the medical school to engage with community physicians will be necessary. from the medical school side of the equation, there is increasing demand for structure and support of community-based teaching. clinical training sites should be formally affiliated with specific educational agreements. training and compliance with hipaa regulations, non-existent some years ago, now are necessary at both the medical school and the clinical sites. while previous engagements with community physicians were quite informal, today’s health system and hospital regulations need be formalized. what are the results of these requirements? implications for other schools and future directions. discussion of the elements that make the duluth family medicine preceptorship program successful and sustainable should be of interest to schools and regional campuses that are contemplating the introduction or revision of current curricular doi: https://doi.org/10.24926/jrmc.v1i3.1102 offerings. additionally, the presence of this model which has been sustained and strong for 40 years can serve to assuage the concerns of academic institutions that these efforts may be ‘risky’ ventures into which funding should be directed. student specialty choices are made earlier than in the past, so it is imperative that good models and information be given to students early enough to enable continuance and reinforcement of their interest in family medicine12-15. as the fiscal and human resources for new program development in academia are limited, this cost-efficient model is certainly worthy of study and emulation. future directions for this program include an increasing emphasis on faculty development with our community colleagues. currently, all preceptors are provided with a gratis subscription to the online journal teaching physician, offered by the society of teachers of family medicine (stfm). upwards of 40-plus hours of continuing medical education (cme) credits may be earned through teaching physician. additionally, course faculty continue to make site visits to each training site in our community and explore new ways to offer faculty development programming and support physicians who have a talent for teaching. the questions raised earlier are complex, and the answers to many of these questions are multidimensional and speculative at this point. it is hoped that data-driven small studies such as this will enable all of us to better design programs that reinforce the interest in family medicine and primary care in our students. references 1. association of american medical colleges. the complexities of physician supply and demand: projections from 2013 to 2025: final report. washington, dc: aamc;2015. 2. mcclure e, black l. the role of the clinical preceptor: an integrative literature review. j nurs educ. 2013;52(6):335-341. doi: https://doi.org/10.24926/jrmc.v1i3.1102 journal of regional medical campuses, vol. 1, issue 3 original report 3. bergman ea. be a preceptor: create tomorrow's leaders. journal of the academy of nutrition and dietetics. 2013;113(4):493. 4. stagg p, prideaux d, greenhill j, sweet l. are medical students influenced by preceptors in making career choices, and if so how? a systematic review. rural and remote health. 2012;12:1832. 5. ogrinc g, eliassen ms, schiffman js, et al. preclinical preceptorships in medical school: can curricular objectives be met in diverse teaching settings? teach learn med. 2006;18(2):110-116. 6. corbet ec, jr., owen ja, hayden gf. effect of a second-year primary care preceptorship on medical students' career plans. south med j. 2002;95(7):691-694. 7. christner jg, dallaghan gb, briscoe g, et al. the community preceptor crisis: recruiting and retaining community-based faculty to teach medical students-a shared perspective from the alliance for clinical education. teach learn med. 2016;28(3):329-336. 8. latessa r, beaty n, colvin g, landis s, janes c. family medicine community preceptors: different from other physician specialties? fam med. 2008;40(2):96-101. 9. pawlson lg, watkins r, donaldson m. the cost of medical student instruction in the practice setting. j fam pract. 1980;10(5):847-852. 10. doyle ga, patricoski ct. costs of teaching for community teachers of family medicine. fam med. 1997;29(1):12-13. 11. vinson dc, paden c. the effect of teaching medical students on private practitioners' workloads. acad med. 1994;69(3):237-238. 12. rohan-minjares f, alfero c, kaufman a. how medical schools can encourage students' interest in family medicine. acad med. 2014. 13. avery dm, jr., wheat jr, leeper jd, mcknight jt, ballard bg, chen j. admission factors predicting family medicine specialty choice: a literature review and exploratory study among students in the rural medical scholars program. j rural health. 2012;28(2):128-136. 14. stagg p, greenhill j, worley ps. a new model to understand the career choice and practice location decisions of medical graduates. rural remote health. 2009;9(4):1245. 15. scott i, wright b, brenneis f, brett-maclean p, mccaffrey l. why would i choose a career in family medicine?: reflections of medical students at 3 universities. canadian family physician medecin de famille canadien. 2007;53(11):19561957. original report published by university of minnesota libraries publishing effect of regional medical campus education on student pursuit of primary care specialties casey p. collins, john f. mccarthy, md doi: https://doi.org/10.24926/jrmc.v1i1.1002 journal of regional medical campuses, vol. 1, issue 1 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc https://doi.org/10.24926/jrmc.v1i1.1002 https://pubs.lib.umn.edu/index.php/jrmc/index mr. collins is a third year wwami student in spokane, wa, university of washington school of medicine, seattle, wa. dr. mccarthy is assistant dean for rural programs, university of washington school of medicine, seattle, wa. correspondence should be addressed to mr. collins, telephone: (360) 305-8026; email (caseyc24@uw.edu) and dr. mccarthy, uw at schoenberg center, gonzaga university, 502 e boone ave, spokane, wa 99258; telephone: (509) 313-7916; fax: (509) 313-7930; email (mccajf@uw.edu). all work in jrmc is licensed under cc by-nc volume 1, issue 1 (2018) journal of regional medical campuses original report effect of regional medical campus education on student pursuit of primary care specialties casey p. collins john f. mccarthy, md abstract purpose to investigate whether education at a regional medical campus (rmc) affects the likelihood of university of washington school of medicine (uwsom) students choosing a primary care specialty. method two approaches were taken to answer the study question. first, the percentage of uwsom students who matched to a primary care residency program between 1996-2016 was compared between two groups of students: those educated at an rmc and those educated at the academic medical center (a non-rmc). second, physician specialty data was obtained from the ama physician masterfile for uwsom graduates from 1996-2011. physicians were again split into rmc and non-rmc groups, and the percentage of primary care physicians was compared between the two groups. this study was completed in 2016. results among graduates from 1996-2016, 33% (564/1707) of those educated at an rmc were matched to a primary care residency program compared to 39% (787/2003) of students educated at the non-rmc (p < 0.001). graduates from 1996-2011 had similar likelihoods of becoming a primary care physician regardless of first year education site (37% [395/1078] versus 39% [551/1403], p = 0.18, figure 2). conclusions the results of this study did not support the hypothesis that the wwami rmcs produce more primary care physicians than the non-rmc. a greater percentage of students who attended the non-rmc matched into a primary care residency program compared to the rmc group, while the percentage of students who ultimately chose a primary care specialty was quite similar. financial support: mr. collins was supported in part for this study by the smith family endowed chair in medicine. ethical approval: the university of washington institutional review board approved the acquisition and analysis of subject data. application #52065. approval date 5/24/2016. keywords: key words: primary care; regional medical campus; wwami; university of washington; medical education introduction in 2006, the aamc’s statement on the physician workforce requested medical schools expand enrollment by 30% from the 2002 level. in large part, this recommendation was fueled by projections of a future physician shortage, particularly among primary care specialties.1,2 the primary care shortage was particularly concerning, as the supply of primary care physicians (pcps) has been associated with improved health outcomes, including all-cause, cancer, heart https://creativecommons.org/licenses/by-nc/4.0/legalcode doi: https://doi.org/10.24926/jrmc.v1i1.1002 journal of regional medical campuses, vol. 1, issue 1 original report disease, stroke, and infant mortality; low birth weight; life expectancy; and self-rated health.3 medical schools responded to the aamc’s recommendation, and enrollment is projected to reach the 30% goal by 2017-18.4 as part of this expansion, the number of regional medical campuses (rmcs) has increased substantially since 2006.5 an rmc may be broadly defined as a campus geographically distinct from its parent institution that offers at least 6 months of medical education.6 the number of rmcs within the us increased to 98 as of may, 2013, and as of 2015, 35% of lcme accredited medical schools offer all or some of their curriculum at an rmc.7,8 the development of rmcs has become an attractive option to medical schools interested in expanding enrollment due to their cost-effectiveness and potential to improve health care access in areas of need.9,10 the university of washington school of medicine (uwsom) has long been recognized as one of the nation’s leaders in producing primary care physicians. additionally, it was one of the earliest adopters of the rmc education model in the early 1970’s when the washington alaska montana idaho (wami) program was first conceived, with the addition of the wyoming campus in 1996 to form the wwami program.11 the program includes rmcs in each of the five states and the non-rmc in seattle, an academic medical center. historically, students accepted to the uwsom completed their first year of basic science education at either an rmc or the non-rmc, followed by a second year of basic science education at the nonrmc. students complete clerkships during the third and fourth years through the wwami region. it is possible that rmcs may be more effective at producing pcps than non-rmcs due to their community-based nature, favorable interactions with primary care physicians, and missions emphasizing aspects of medicine such as rural health or longitudinal care.12,13 however, little research has been done that evaluates career outcomes of students who are educated at rmcs. two studies have been performed that compare family medicine match rates between rmcs and non-rmcs within the us, but to our knowledge no study has specifically compared primary care career outcomes.14,15 thus, the purpose of this study was to analyze whether uwsom students educated for their first year at an rmc campus are more likely to enter a primary care specialty such as family medicine, general internal medicine, adolescent medicine, geriatrics, pediatrics, or medicine/pediatrics compared to those educated at the non-rmc. method we took two approaches to evaluate the study question. for the first approach, we obtained match results for graduates of the university of washington school of medicine from 1996-2016 directly from the university. we then classified graduates from the regional campuses (wyoming, spokane/pullman, alaska, montana, and idaho) into an rmc group, and graduates from the seattle campus into a non-rmc group. we considered students who entered a pediatrics, family medicine, or internal medicine-primary care residency program to have matched to a primary care residency program and all others to have matched to non-primary care programs. we excluded students who deferred enrollment or did not match. we then compared the percentage of students who chose a primary care residency program between the rmc and non-rmc groups. for the second approach, we obtained current specialty information for graduates from 1996-2011 from the ama physician masterfile. we created rmc and non-rmc groups in the same manner as the match results. we excluded those without a known first year campus. we classified physicians practicing in family medicine, general internal medicine, adolescent medicine, geriatrics, pediatrics, or medicine/pediatrics as pcps. we then compared the percentage of pcps between rmc and non-rmc groups. we used a pearson’s 2 test with a statistical significance threshold of p < 0.05 to perform both analyses. the university of washington institutional review board approved the acquisition and analysis of subject data. https://doi.org/10.24926/jrmc.v1i1.1002 doi: https://doi.org/10.24926/jrmc.v1i1.1002 journal of regional medical campuses, vol. 1, issue 1 original report table 1 number of graduates from each uwsom campus gathered using match lists from 1996-2016 and the ama physician masterfile from 1996-2011. campus no. matched graduates no. deferred no. without match or unknown no. physicians spokane/pullman 491 8 3 284 montana 405 9 2 291 idaho 366 4 0 254 alaska 259 6 1 147 wyoming 186 1 2 102 unknown na na na 28 all rmc 1707 28 8 1106 non-rmc 2003 57 8 1404 all 3710 85 16 2510 results the match lists from 1996-2016 included 3811 graduates. of those subjects, 85 students deferred residency matching and 16 had an unknown or no match. the rmc group included 1707 graduates while the non-rmc group included 2003 graduates (table 1). analysis of primary care match frequency between the two groups revealed a 6% (787/2003 versus 564/1707) greater primary care match frequency among non-rmc graduates compared to rmc graduates (p < 0.001, figure 1). current practice information was available for graduates from 1996-2011 and included 2510 physicians. of those subjects, 28 did not have a known first year campus. the rmc group included 1106 physicians while the non-rmc group included 1404 physicians (table 1). this data set demonstrated a similar percentage of physicians practicing in primary care between the two groups (37% [395/1078] versus 39% [551/1403], p = 0.18, figure 2). figure 1 percentage of rmc medical school graduates versus non-rmc graduates who were matched to a primary care residency program (1996-2016). *p < 0.001 33 * 39 0 5 10 15 20 25 30 35 40 45 50 rmc non-rmc % g ra d u a te s e n te ri n g p ri m a ry c a re r e si d e n cy p ro g ra m s https://doi.org/10.24926/jrmc.v1i1.1002 doi: https://doi.org/10.24926/jrmc.v1i1.1002 journal of regional medical campuses, vol. 1, issue 1 original report discussion the results of this study did not support the hypothesis that the wwami rmcs produce more primary care physicians than the non-rmc. a greater percentage of students who attended the non-rmc matched into a primary care residency program compared to the rmc group, while the percentage of students who chose a primary care specialty was quite similar. the contrast between the results of our two approaches suggests that graduates from the nonrmc who attend a primary care residency program are more likely to choose a non-primary care specialty at some point during residency. there are many characteristics of primary care residency programs that could influence a resident’s choice to pursue further specialty training. for example, some primary care residency programs are run by academic medical centers which value further specialty work. it is important to note that the above conclusion remains speculation because the data collected from the match lists and ama physician masterfile are not directly comparable. the current practice information from the masterfile could only reliably be collected through 2011 as more recent graduates may still be in a residency or fellowship program. the masterfile data itself has well known limitations and only includes approximately 83% of graduates within the given timeframe compared to the match lists which accounts for a higher percentage of graduates. there are many other limitations to this study, primarily in the form of confounding variables. although pediatric and internal medicine residents may become primary care physicians, many pursue further specialty training. approximately 20-25% of internal medicine residents and 40% of pediatric residents choose primary care.16-17 also, choosing a specialty is a complicated decision, and many variables have been associated with that decision making process. some variables include gender, preference for rural or urban areas, socioeconomic background, rural background, specialty preference prior to medical school, and specialty-specific characteristics such as technical skills, income, lifestyle, or patient interaction.18-20 additionally, there are characteristics intrinsic to the uwsom and wwami program that may influence the results. for instance, even though a significant proportion students spend their first two years at the non-rmc in seattle, many of those students choose to 37 39 0 5 10 15 20 25 30 35 40 45 50 rmc non-rmc % p ri m a ry c a re p h y si ci a n s figure 2 percentage of rmc medical school graduates versus non-rmc graduates who chose a primary care specialty (1996-2011). https://doi.org/10.24926/jrmc.v1i1.1002 doi: https://doi.org/10.24926/jrmc.v1i1.1002 journal of regional medical campuses, vol. 1, issue 1 original report complete their clinical clerkships at one or more of the 170 available community education sites.10 the uwsom is also notable for its implementation of the colleges system, a system of mentorship through which a small group of students is mentored by a physician, typically in a primary care specialty, with the goal of developing clinical skills.21 this system likely has an influence on specialty choice, as exposure to role models has been shown to strongly associate with residency program choice among medical students.22 finally , the uwsom has a number of specialty programs designed to attract students to primary care and rural practice which many of the non-rmc graduates participate in: wwami rural integrated training experience (write), which is a longitudinal integrated clerkship in a rural community for 6 months of third year; targeted rural underserved track (trust), through which students continually return to a regional site for clinical education throughout their training; the rural/underserved opportunities program, a one-month primary care experience in a rural community; and track, which enables students to complete some or all of their clinical training in a particular regional location.11,23,24 incorporation of similar programs may improve primary care match frequencies among existing medical schools, although their effects on specialty choice have yet to be determined. the above aspects of uwsom education are reflective of its mission which emphasizes the importance of primary care and delivering care to underserved areas in the region. the rmcs do not have distinct missions from the main campus, which is in contrast to other schools or schools missions.25 thus, the success of the uwsom in producing primary care physicians at both rmcs and its academic medical center is in all likelihood a result of a collective effort to address the health needs of the wwami region. while medical school expansion appears to be on track to meet future physician demand, in part due to implementation of rmcs, it is unclear whether the physicians produced by these campuses will address an equally critical problem of specialty maldistribution. this information is an important step toward understanding how the rapidly expanding rmc educational model affects student specialty choices. we consider this information valuable to policymakers and university administrators considering medical school expansion. rmcs have become a widespread option, but there are many different types of rmcs to consider. only recently have rmcs been defined and divided into distinct classifications: basic science, clinical, longitudinal, and combined models.6 the university of washington school of medicine utilizes the basic science model of rmcs, where students spend a portion of their basic science education at one of the wwami locations. for policymakers and university administrators considering medical school expansion via rmcs, this study provides valuable information about how the basic science model rmc may affect specialty choice of future students. further investigation of rmcs must be done in order to assess their current and potential impact on physician workforce and distribution. studies of individual rmc programs may be useful, as those successful at producing physicians that meet local and national workforce needs can be emulated by future medical school expansions. ideally, these studies would control for variables that have been shown to have an effect on specialty choice. largescale studies of specialty choice that include many rmcs would also be valuable, particularly if they utilize the most recent rmc classification. finally, it is important to continue investigating factors which influence the geographical distribution of physicians, as inequities in distribution also contribute to inadequate supply in many regions. references 1. association of american medical colleges. aamc statement on the physician workforce. (http://www.aamc.org/download/55458/data/ workforceposition.pdf). published june 2006. accessed june 26, 2016. 2. association of american medical colleges. the complexities of physician supply and demand: projections from 2013-2025. https://doi.org/10.24926/jrmc.v1i1.1002 http://www.aamc.org/download/55458/data/workforceposition.pdf http://www.aamc.org/download/55458/data/workforceposition.pdf doi: https://doi.org/10.24926/jrmc.v1i1.1002 journal of regional medical campuses, vol. 1, issue 1 original report (https://www.aamc.org/download/426242/dat a/ihsreportdownload.pdf?cm_mmc=aamc-_scientificaffairs-_-pdf-_-ihsreport). published march 2015. accessed july 12, 2016. 3. macinko j, starfield b, shi l. quantifying the health benefits of primary care physician supply in the united states. int j health serv. 2007;37(1):111–126. 4. association of american medical colleges. results of the 2015 medical student enrollment survey. (http://members.aamc.org/eweb/upload/2015 _enrollment_report.pdf). published april 2016. accessed july 9, 2016. 5. group on regional medical campuses/ group on faculty affairs 2013 regional medical campus survey, unpublished data, march 2013. 6. cheifetz ce, mcowen ks, gange p, wong, jl. regional medical campuses: a new classification system. acad med. 2014;89:1140-1143. 7. liason committee on medical education. annual medical school questionnaire part ii, 2010-2011 through 2015-2016. (https://www.aamc.org/initiatives/cir/406434/ 13a.html). accessed june 27, 2016. 8. association of american medical colleges. official list of regional medical campuses. (https://www.aamc.org/members/grmc/32653 6/grmc_launches_2013_regional_medical_cam pus_survey.html). updated may 2013. accessed june 27, 2016. 9. hurt mm, harris jo. founding a new college of medicine at florida state university. acad med. 2005;80:973–979. 10. norris te,coombs jb, house p, moore s, wenrich md, ramsey pg. regional solutions to the physician workforce shortage: the wwami experience. acad med. 2006;81:857– 862. 11. ramsey pg, coombs jb, hunt dd, marshall sg, wenrich md. from concept to culture: the wwami program at the university of washington school of medicine. acad med. 2001;76:765–75. 12. mavis b, sousa a, osuch j, arvidson c, lipscomb w, brady j, green w, rappley md. the college of human medicine at michigan state university: expansion and reinvention. acad med. 2012;87:1705-1709. 13. rackleff lz, o’connell mt, warren dw, friedland ml. establishing a regional medical campus in southeast florida: successes and challenges. acad med. 2007;82:383-389. 14. liaw w, cheifetz c, luangkhot s, sheridan m, bazemore a, phillips r. match rates into family medicine among regional medical campus graduates, 2007-2009. am fam physician. 2012;25:894-907. 15. crump wj, barnett d, fricker s. a sense of place: rural training at a regional medical school campus. j rural health 2004;20:80–4. 16. american college of physicians. internal medicine residency match results virtually unchanged from last year. (https://www.acponline.org/acpnewsroom/internal-medicine-residencymatch-results-virtually-unchanged-from-lastyear). march 21, 2014. accessed november 18, 2017. 17. american academy of pediatrics. percent of graduating residents whose future clinical practice goal is primary care practice. (https://www.aap.org/en-us/professionalresources/research/pediatriciansurveys/documents/graduating-residentssurvey-goals-primarycarepractice.pdf). updated 2013. accessed november 18, 2017. 18. teitelbaum hs, ehrlich n, travis l. factors affecting specialty choice among osteopathic medical students. acad med. 2009;84:718723. 19. senf jh, campos-outcalt d, kutob r. factors related to the choice of family medicine: a reassessment and literature review. fam med. 2003;16:502-512. 20. dezee kj, maurer d, colt r, shimeall w, mallory r, powers j, durning sj. effect of financial renumeration on specialty choice of fourth-year u.s. medical students. acad med. 2011;86:187-193. 21. goldstein ea, maclaren cf, smith s, mengert tj, maestas rr, foy hm, wenrich md, ramsey pg. promoting fundamental clinical skills: a competency-based college approach at the university of washington. acad med. 2005;80:423–33. https://doi.org/10.24926/jrmc.v1i1.1002 https://www.aamc.org/download/426242/data/ihsreportdownload.pdf?cm_mmc=aamc-_-scientificaffairs-_-pdf-_-ihsreport https://www.aamc.org/download/426242/data/ihsreportdownload.pdf?cm_mmc=aamc-_-scientificaffairs-_-pdf-_-ihsreport https://www.aamc.org/download/426242/data/ihsreportdownload.pdf?cm_mmc=aamc-_-scientificaffairs-_-pdf-_-ihsreport http://members.aamc.org/eweb/upload/2015_enrollment_report.pdf http://members.aamc.org/eweb/upload/2015_enrollment_report.pdf https://www.aamc.org/initiatives/cir/406434/13a.html https://www.aamc.org/initiatives/cir/406434/13a.html https://www.aamc.org/members/grmc/326536/grmc_launches_2013_regional_medical_campus_survey.html https://www.aamc.org/members/grmc/326536/grmc_launches_2013_regional_medical_campus_survey.html https://www.aamc.org/members/grmc/326536/grmc_launches_2013_regional_medical_campus_survey.html https://www.acponline.org/acp-newsroom/internal-medicine-residency-match-results-virtually-unchanged-from-last-year) https://www.acponline.org/acp-newsroom/internal-medicine-residency-match-results-virtually-unchanged-from-last-year) https://www.acponline.org/acp-newsroom/internal-medicine-residency-match-results-virtually-unchanged-from-last-year) https://www.acponline.org/acp-newsroom/internal-medicine-residency-match-results-virtually-unchanged-from-last-year) https://www.aap.org/en-us/professional-resources/research/pediatrician-surveys/documents/graduating-residents-survey-goals-primarycarepractice.pdf) https://www.aap.org/en-us/professional-resources/research/pediatrician-surveys/documents/graduating-residents-survey-goals-primarycarepractice.pdf) https://www.aap.org/en-us/professional-resources/research/pediatrician-surveys/documents/graduating-residents-survey-goals-primarycarepractice.pdf) https://www.aap.org/en-us/professional-resources/research/pediatrician-surveys/documents/graduating-residents-survey-goals-primarycarepractice.pdf) doi: https://doi.org/10.24926/jrmc.v1i1.1002 journal of regional medical campuses, vol. 1, issue 1 original report 22. wright s, wong a, newill c. the impact of role models on medical students. j gen intern med 1997;12:53– 6. 23. allen sm, ballweg ra, cosgrove em, engle ka, robinson lr, rosenblatt ra, skillman sm, wenrich md. challenges and opportunities in building a sustainable rural primary care workforce in alignment with the affordable care act: the wwami program as a case study. acad med. 2013;88:1862-1869. 24. dobie sa, carline jd, laskowski mb. an early preceptorship and medical students’ beliefs, values, and career choices. adv health sci educ theory pract. 1997;2:35–47. 25. columbia university college of physicians and surgeons. columbia-bassett program. (http://www.columbia-bassett.org). accessed august 17,2016. acknowledgements the authors would like to thank douglas schaad, phd, professor of biomedical informatics and medical education, university of washington school of medicine, for his data contributions. https://doi.org/10.24926/jrmc.v1i1.1002 http://www.columbia-bassett.org/ microsoft word building novel research article.docx published by university of minnesota libraries publishing building novel research capacity in a regional medical campus emergency medicine program: 1.0 origins and partnerships shira brown, bmt md fcfp ccfp(em); karl stobbe md ccfp(em); maynard luterman ba,msc, mdcm,ccfp; suneel upadhye, md msc frcpc; christopher henderson, bsc; larry w. chambers phd, face, ffph (hon) (uk), fcahs; david heywood md ccfp(em); amber graystone md msc ccfp(em); salim ahmed md, mbbs, ccfp; corrine davies-schinkel, rn, msc; amanda bell, md, msc, ccfp, fcfp doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 3, issue 2 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc shira brown, bmt md fcfp ccfp(em) karl stobbe md ccfp(em) maynard luterman ba,msc, mdcm,ccfp suneel upadhye, md msc frcpc christopher henderson, bsc larry w. chambers phd, face, ffph (hon) (uk), fcahs david heywood md ccfp(em) amber graystone md msc ccfp(em) salim ahmed md, mbbs, ccfp corrine davies-schinkel, rn, msc amanda bell, md, msc, ccfp, fcfp all work in jrmc is licensed under cc by-nc volume 3, issue 2 (2020) journal of regional medical campuses original reports building novel research capacity in a regional medical campus emergency medicine program: 1.0 origins and partnerships shira brown, bmt md fcfp ccfp(em); karl stobbe md ccfp(em); maynard luterman ba,msc, mdcm,ccfp; suneel upadhye, md msc frcpc; christopher henderson, bsc; larry w. chambers phd, face, ffph (hon) (uk), fcahs; david heywood md ccfp(em); amber graystone md msc ccfp(em); salim ahmed md, mbbs, ccfp; corrine davies-schinkel, rn, msc; amanda bell, md, msc, ccfp, fcfp abstract the emergency medicine researchers of niagara (emron) program is an evolving research incubator with the niagara regional campus (nrc) of mcmaster university’s michael g degroote school of medicine and niagara health (nh). emron is becoming a productive research organization aligned with the strategic priorities of its partner organizations (nrc and nh). emron is committed to advancing local community health care standards and sharing best practices with provincial and national peers. currently, emron is overseeing 11 projects involving 11 clinical faculty principal investigators, 14 medical students, and one emergency medicine resident project lead. in 2018-2019, the group had 29 accepted peer-reviewed abstracts – 55% posters, 41% presentations, and 4% workshops. in its first 2 years of operation emron has achieved success in new structures, processes and outcomes that position it well to be a fulsome research organization for years to come. introduction the growth and rich development of academic programs is one of the highlights for faculty members and hospital leaders practicing community-based care. research is an important incubator for academic development,1,4,12-14,17 and community hospitals that strive for academic excellence experience unique challenges in their journeys. likewise, a regional medical campus is an important accelerator towards achieving a well-developed educational and research environment that fosters the intellectual challenge and spirit of inquiry appropriate to this academic setting.6 a researchfriendly culture is not necessarily well-established in distributed medical education programs in ontario, unlike academic health sciences centres.7,9,11 therefore, effective, innovative relationships and governance structures are important to remove barriers, such as time constraints on potential research faculty and availability of research support staff, to create a rich and fully developed community-based academic environment. a collection of emergency medicine physicians working as part of niagara health (nh), together with the leadership of the niagara regional campus (nrc) for the mcmaster university medical education program discovered an opportunity for innovation. the collaboration resulted in the development of a community-based emergency medicine (em) research program, entitled emron. this article describes the creation and evolution of our community-based em research program, focusing on foundational partnerships, funding acquisition, and governance structures. background it is helpful to understand the geographical and institutional structure of the niagara region as a basis for discussion. nh is a hospital network that serves the niagara region with secondary and tertiary care across 5 hospitals. figure 1 shows the geographical distribution of the nh sites for institutionally provided care centers. nh has 5 hospitals with 3 emergency rooms (ers), 3 intensive care units (icus), and 2 urgent care centres (uccs) serving a population of 400 000 people with 160 000 er and 40 000 ucc visits annually. the emergency departments at nh sites are staffed by approximately 70 emergency physicians. nearly 80% are doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports certified by the canadian college of family physicians (ccfp or ccfp-em) or the royal college of physicians & surgeons of canada (frcpc-em), as well as a minority of well-experienced general practitioners. with 400 clinical faculty, the nrc is home to 84 undergraduate medical students and 26 postgraduate trainees across family medicine, general surgery, and family medicine-emergency medicine. in addition, over 300 medical trainees rotate through nh each year for elective or community placements. students at the nrc rotate through all of nh’s ers and uccs as part of their core training or electives. as outlined in the canadian medical education directives for specialists (canmeds) 2015 physician competency framework, frcpc-em residents are expected to be engaged in the continuous enhancement of their professional activities through ongoing learning which includes teaching students, residents, the public, and other health care professionals, integrating best available evidence into practice, and contributing to the creation and dissemination of knowledge and practices applicable to health.10 similarly, the competency based medical education (cbme) for em residency programs in canada includes 3 specific entrustable professional activities (epas) that residents are expected to meet: 1) appraising and integrating new evidence into clinical practice, 2) advancing emergency medicine through a scholarly project, and 3) participating in a quality improvement initiative to enhance patient care.3 staffing issues in community eds the south niagara sites provide emergency and urgent care to the communities of welland (population 52 293), port colborne (population 18 306), fort erie (population 30 710) and niagara falls (population 88 071). these sites have experienced challenges recruiting adequate numbers of em specialty-trained practitioners due to the extensive human resource requirements of 4 independent sites, and the semirural nature of these service areas. over the past decade, the em physician team focused on strengthening their physician human resources. the establishment of nrc in 2009 increased local academic resources and structure. to date, there have been 229 md students trained at nrc, 112 have completed their residency programs and 18% of those have returned to the region to practice medicine. of the residents trained through the nrc, 52% of family medicine, 100% of general surgery, and 86% of family-emergency medicine residents have stayed in the region to practice. the nrc’s presence has increased local academic resources. on the heels of this momentum, the south niagara emergency medicine alternative funding arrangement physician funding groups in welland, port colborne, and fort erie sought to further develop academic activity. they did so, through their shared leadership, by partnering with the nrc and aspiring to build an em research initiative. the passion for this initiative was significant enough that the em physicians collectively voted to contribute a meaningful portion of designated physician earnings, approximately 1% to launch a research program, with a long-range view that the program would fortify academic activities and bring energy, interest, and creativity to daily work. the decision was made by the active voting membership of the physician group, as governed by the group’s bylaws, and was a unanimous decision. physicians are provided voting membership when they maintain active staff privileges at niagara health and meet a minimum shift commitment to the collective departments. the group understood their decision would improve patient outcomes and increase the brand recognition of the em group, nh, and the nrc, and would help recruit em talent to the region. as both quality improvement (qi) and health services research are strengthened by the use of rigorous and similar methods, emron embraces both types of research initiatives. emron welcomes involvement of hospital qi leads and their participation has resulted in the creation of relevant questions to improve delivery of care while aligning with nh’s strategic priorities. additionally, emron strives to enhance the scholarly activities of students within the nrc. methods the 3 south niagara site physician funding groups include a robust cost-sharing governance structure comprised of detailed bylaws that define their membership, voting, and committee mandates. within these 3 sites, the physician leadership created consensus to commit significant resources towards an em research initiative. however, it was recognized that this initiative would have far greater success by leveraging and partnering with local academic resources and leadership within the nrc. during early discussions with nrc’s leadership it became clear that for this partnership to succeed, the physician group would require an innovative relationship with nrc. the physician group was interested in becoming regional thought leaders in the field of communitybased research and wanted to maintain oversight and autonomy in the use of the partnership’s resources. simultaneously, the nrc advocated for this partnership to enhance academic offerings for niagara medical students by participating in research that would improve their clinical decision-making and strengthen their applications for limited postgraduate training positions. the creation of this partnership and the terms of reference were developed over a series of meetings between the sites’ chief, who also chaired the em alternative funding arrangements and was in partnership with the campus regional assistant dean who was supported in this effort by the academic chair of the department of family medicine in mcmaster university. building on the flexibility of the regional campus and an eager and engaged physician group, the partnership was able to craft terms of reference that allow the em physician group to collaboratively guide allocation of the financial resources over doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports time with leaders of nrc. this was an important prerequisite for stakeholder buy-in that allowed for a balance between the security of governance while retaining autonomy of resources and project development for the physician investors, many of whom would also serve as researchers. simultaneously, nrc leadership recognized the importance of mcmaster providing a tangible commitment of resources to the initiative to be a fully invested stakeholder. resources have included funding for the physician lead as well as administrative support and guidance. likewise, nh has been integral in providing infrastructure support necessary for supporting projects within the hospital settings. therefore, both partners brought forward and elevated the required resources to inaugurate the new initiative. the incoming regional assistant dean and em alternative funding arrangement chair/site chief agreed to co-chair the financial governance committee of the initiative. membership within the committee was equally balanced between members of the physician group and leadership of nrc. decisions were agreed to be made by consensus. with agreements established, the partnership was created and the funds were directed to be held in a mcmaster university program account that was administered by the nrc under the direction of the governance committee. once these basic frameworks were completed, the governance committee was in position to hire a research lead and research coordinator and to recruit the required expertise and human resources to begin this unique initiative. results at the time of inception there were approximately 50 full time em physician staff, 30 of which were involved in the sites that provide funding for emron. approximately 15 staff were involved in the “south niagara cost sharing group” which serves as a governance group among the physicians. a democratic process was used to decide about funding decisions for emron by this group and the decision to participate in funding emron was unanimous. once voted on, physicians were not able to opt out of the funding decision. while still in its early stages, emron has experienced an inspiring rate of growth and is beginning to move towards its second phase of evolution. emron allocates resources to areas of excellence with the long-term goal of creating a wellgrounded em medicine research program within the niagara region. at the time of this writing, it has been 2 years since emron first employed an external clinical faculty research lead, and 1.5 years since the hiring of the program’s nurse research coordinator. within this time, the partnership of em physician researchers from within the niagara region have worked on 11 projects which aim to have an impact the field of emergency medicine. each of the 11 projects involve 11 em clinical faculty researchers, 14 medical students, and one em resident lead project. in 2018-2019, the group had 29 accepted peerreviewed abstracts – 55% (16/29) posters, 41% (12/29) presentations and 4% (1/29) workshops. the research also resulted in 3 invited talks and 2 peer-reviewed publications.5,20 recently, the group has been awarded a national award by the annual canadian association of emergency physicians conference for their work on the choosing wisely canada guidelines. the group is participating in one phase iv pharma trial with 80% participant recruitment to date and has received over $100 000 in external grant funding. two of the hospital sites have also seen a significant increase in ministry of health revenue through pay for results from a flow and operations project. the emron initiative has enabled both the partnership and nh as an institution to recruit experts into the local em community. these additional half-dozen hires have included physicians with extensive academic careers who are supporting the partnership’s academic goals in multiple ways. emron has also become an inspiration for the potential genesis of other research groups in the niagara region. this opportunity is one that will continue to grow and flourish and has the potential to continue to raise the status of em in our region, and across canada. in collaboration with nh, nrc and other researchers in mcmaster university, emron is recruiting and supporting projects that build expertise and personnel in research across an array of topics. these projects are building the expertise and capacity of nh and nrc in advancing qi in the niagara region. furthermore, emron aims to prioritize projects that support the economic sustainability of health care and research delivery. emron has prioritized creating a research community and building a research-friendly culture within the nh emergency departments and urgent care centers. as emron matures, it will support and expand engagement with individuals and organizations, both current and potential, including, but not limited to, engaged networks of patients and learners. discussion this early initiative demonstrates that distributive medical education campuses, in partnership with their communitybased physician groups, have a unique opportunity to innovate through flexible partnerships and an unconventional mentality. further, financial resources that would be considered meager in a larger academic center can be leveraged successfully as a substantial accelerator in a regional medical campus and with a local physician group. the structures and processes of these opportunities can respond to area needs while being informed by successful existing examples. in addition, lessons learned from this organically grown and the expanding opportunities are an important resource. these initiatives can facilitate trust and growth through governance that balances the input of the doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports funders with the unique challenges and opportunities within a location. for example, the partnership has allowed emron to explore opportunities and evolve the membership, including internal medicine and other disciplines, during its first 2 years, before finalizing its terms of reference governing allocation of research resources. emron members and governance committee recognize the importance of full stakeholder engagement that are building the capacity of emron and establish its role in among its members, the em department, nh, nrc, and the community at large. future directions the next evolution of emron is to create governance over financial and human resources for allocation towards qi and other research projects. these decisions must be guided by a clear vision and mission that aligns with emron’s partners. predictably, emron has found that the demand for research resources, student engagement, and valuable collective meetings is outpacing capacity. in its broadest terms, emron’s vision is to create a rigorous and ethically conducted research program; it seeks to align with nh’s vision of “achieving ambitious results,” as part of the core nh values statement and mcmaster’s commitment to creativity, innovation, and excellence. however, adapting this vision further to personalize it for researchers within emron will become important when deciding on future resource allocation. challenges and limitations additional stakeholders will need to be engaged to inform a more mature research initiative. these stakeholders within and outside the niagara region include, but are not limited to, career academics, patients, allied health practitioners, including emergency medical services (ems), nursing, and community health providers, hospital, and community leadership. ensuring future governance provides ample opportunity for a chorus of voices to guide research that will ultimately be required to ensure a mature infrastructure warranting national and international attention the potential governance of a novel research initiative was unclear and complicated by a lack of a template for action, the unique practice requirements in the culture of community-based medicine, and the challenges specific to distributed medical education. organizational challenges requiring attention have been overcome within the partnership among the nrc, nh, and the em physician alternative funding arrangement. this partnership required creative negotiations, relationship building, transparency, and mutual trust. however, after now working through these initial challenges, this innovative model is an incubator for an enthusiastic research team who aspire to be responsible stewards of research in the niagara region, and to represent nh and nrc with high quality research, robust scholarly activity, and improved patient care. conclusions based on the progress to date, emron can be a model for other distributed campuses and community hospitals to inform their local leaders to evolve their academic offerings to students, and to enhance medical services in their own region. emron shows that community hospitals and community physician groups have the capacity to build academic resources and grow as a research entity. further, the successes experienced by emron provide evidence that structures for accomplishing a similar culture of research do not need to be overly complicated and the amount of resources required to have significant impact do not need to be extraordinary.2 references 1. bass mj. office-based research: the antidote to learned helplessness. canadian family physician. 1987 september; 33:1987-1992. 2. balanger m. implementation of a clinician and academic researcher-led funding program to stimulate research in a regional medical campus. journal of regional medical campuses 2019;2:5: doi: https://doi.org/10.24926/jrmc.v2i5.2137 3. bednarczyk j, pauls m, fridfinnson j, weldon e. characteristics of evidence-based medicine training in royal college of physicians and surgeons of canada emergency medicine residencies a national survey of program directors. bmc medical education. 2014 march 21; 14: 57. 4. bernard cd. scholarship for community physicians. canadian family physician. 2014 april: 60: 388-390. 5. brown, ns, chirico, j, hollidge, m, randall j. clinical leadership in reducing risk: managing patient airways. healthcare management forum. 2019 march; 32(2): 92-96. doi: 10.1177/0840470418810678. 6. cathcart-rake w, robinson m. promoting scholarship at regional medical campuses. journal of regional medical campuses. 2018;1:1. doi: https://doi.org/10.24926/yrmc.v1:1.999 7. council of ontario faculties of medicine. distributed medical education in ontario 2014 report: bringing care closer to home. toronto, council of ontario faculties of medicine. 2015a. https://cou.ca/wpcontent/uploads/2015/05/cou-distributed-medicaleducation-report.pdf doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports 8. council of ontario faculties of medicine. distributed medical education in ontario 2014 report: bringing care closer to home: program compendium. council of ontario faculties of medicine. toronto 2015b. https://cou.ca/wp-content/uploads/2015/05/coudistributed-medical-education-programcompendium.pdf 9. council of ontario faculties of medicine. report to council of ontario faculties of medicine (cofm) from the distributed medical education (dme) committee. scholarly activity within distributed medical education programs: reflections and recommendations. council of ontario faculties of medicine. 2019 10. feank jr, snell l, sherbino j. canmeds 2015 physician competency framework. royal college of physicians and surgeons of canada. 2015.http://canmeds.royalcollege.ca/uploads/en/fra mework/canmeds%202015%20framework_en_red uced.pdf accessed september 2019 11. gehrke p, binnie a, chan spt, cook dj, burnds kea, rewa og, herridge m, tsang jlr. fostering community hospital research. canadian medical association journal. 2019;191(35):e962-e966. doi:10.1503/cmaj.190055 12. hennen bk. the dragon research. canadian family physician.1988 june; 34: 1265, 1417. 13. hogg w, donskov m, russell g, pottie k, liddy c, johnston s, chambers lw. riding the wave of primary care research: development of a primary health care research centre. canadian family physician. 2009 october; 55: 35-40. 14. kelly l. developing a rural research project. canadian journal of rural medicine. 2008; 13(4):194-196. 15. lamphear jh, strasser r. developing partnerships for distributed community-engaged medical education in northern ontario, canada. medicc review. 2008;10(4):15-19. 16. lemky k, gagne p, konkin j, stobbe k, et al. a review of methods to assess the economic impact of distributed medical education (dme) in canada. can med educ j. 2018 mar; 9(1): e87–e99. 17. paige g, binnie a, chan spt, cook dj, burns kea, rewa og, herridge m, tsang jly. fostering community hospital research. cmaj 2019, september 3:191:e962-6, doi: 10.1503/cmaj.190055 18. royal college of physicians and surgeons of canada. canmeds: better standards, better physicians, better care. accessed july 31, 2019 http://www.royalcollege.ca/rcsite/canmeds/canmed s-framework-e 19. royal college of physicians and surgeons of canada. competence by design; 2017. available at: http://www.royalcollege.ca/rcsite/cbd/competenceby-design-cbd-e objectives of training in emergency medicine. http://www.royalcollege.ca/ 20. upadhye s, worster a, valani r. relevance of opiod guidelines in the emergency room (roger). american journal of emergency medicine. 2019 march; 37(3): 538-539. doi: 10.1016/j.ajem.2018.07.028 microsoft word creating a healthcare entrepreneurship article.docx published by university of minnesota libraries publishing creating a healthcare entrepreneurship teaching program for medical students aida ahrari, msc; pawandeep sandhu, hbsc; dante morra, md, mba; sarah mcclennan, mhsc, md; alison freeland, md doi: https://doi.org/10.24926/jrmc.v4i1.3564 journal of regional medical campuses, vol. 4, issue 1 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc aida ahrari is a medical student at the university of toronto and a graduate of the master’s degree in systems leadership and innovation at the institute of health policy, management, and evaluation, university of toronto, toronto, ontario. pawandeep sandhu is a medical student at the university of toronto, toronto, ontario. dante morra is the chief of staff at trillium health partners hospital and head of the canhealth network, mississauga, ontario. he is an associate professor in the temerty faculty of medicine and an adjunct professor at the rotman school of management, university of toronto, toronto, ontario. sarah mcclennan is the director of the mississauga academy of medicine at the university of toronto, mississauga, ontario. she is an assistant professor in the department of medicine, division of emergency medicine, university of toronto, toronto, ontario. alison freeland is the regional associate dean of education at the university of toronto, temerty faculty of medicine’s mississauga campus and vice president of education, academic affairs, and patient experience at trillium health partners, mississauga, ontario. she is an associate professor in the department of psychiatry, university of toronto, toronto, ontario. corresponding author: dr. alison freeland, office of the regional vice dean, university of toronto, trillium health partners, clinical administrative building, 15 bronte college court, 4th floor, mississauga, on, l5b 0e7; telephone: (905) 848-7580 ext. 2209; email: alison.freeland@thp.ca; twitter: @drafreeland. all work in jrmc is licensed under cc by-nc volume 4, issue 1 (2021) journal of regional medical campuses original report creating a healthcare entrepreneurship teaching program for medical students aida ahrari (msc), pawandeep sandhu (hbsc), dante morra (md, mba), sarah mcclennan (mhsc, md), alison freeland (md) abstract introduction: the future of healthcare hinges on effective adoption of innovative solutions. arguably, physicians are ideally positioned to propel clinical innovation given their firsthand experience with healthcare challenges; however, physicians often lack the necessary skills in innovation development and implementation methodology as it related entrepreneurship. the gap is partly a result of the paucity of exposure to entrepreneurship concepts within medical education and postgraduate training. to address this gap, the university of toronto’s distributed medical education campus in mississauga created a novel teaching initiative designed to impart themes of healthcare entrepreneurship to early stage medical learners. methods: to inform the design of the program, the authors conducted a series of semi-structured interviews with key stakeholders, including physician entrepreneurs, innovation leaders, curriculum specialists, and medical students. using thematic analysis, key recommendations were extracted regarding learning objectives, approach to program delivery, and anticipated outcomes. a wellestablished entrepreneurial teaching model, the mars entrepreneurship framework, was adapted to frame the curricular content to the needs of medical learners. the resulting educational product consisted of 6 sessions, taught by subject matter experts, which outlined a methodological approach to the development of a medical start-up as a means of launching an innovation. results: from november 2019 to may 2020, six sessions were held with a total of 37 unique attendees. the authors found that the series generated interest in entrepreneurship among medical students while fostering an appreciation for the basic principles of entrepreneurship. conclusion: the next stage involves further program evaluation to guide the next iteration of the program. potential avenues for growth include delivering the series virtually to support greater student accessibility. future considerations include incorporating entrepreneurship into core undergraduate medical curricula and creating a dual degree program in medicine and entrepreneurship that cater to students with a deep interest in the field of healthcare entrepreneurship. disclosure: the authors have no conflict of interest to declare. as all data were completely anonymized and no patients were involved, this was not reviewed by an ethics board introduction background the future of healthcare involves leveraging innovation to solve healthcare challenges. while other industries are applying technology to improve operations, healthcare has traditionally proven more resistant to change.1 to address the pressing challenges facing our healthcare system, we need individuals who are able to design and implement patient-centered solutions to complex problems.2 to this end, physicians who experience health systems challenges are ideally positioned to create innovative solutions. equally important is the ability of innovators to operationalize novel ideas, which requires skills grounded in the field of entrepreneurship. not surprisingly, a study investigating patent application patterns for medical devices found that major incumbent medical device firms were more likely to incorporate information from physician-founded start-ups than non-physician-founded start-ups, as physicians can often provide important insight to ensure that products address real healthcare challenges and are intuitive for the endusers.3, 4 yet, few medical schools in canada actively encourage students to pursue innovation and entrepreneurship during their formative years of training, and as a result, the number of physician entrepreneurs in canada journal of regional medical campuses, vol. 4, issue 1 original report has been limited.5 given the recent increased interest and productivity of physicians in developing new devices, software, and services to improve patient outcomes, training future physicians to innovate healthcare is a logical next step. medical schools across the country continue to expand education of students beyond the traditional clinical expertise to include other important areas of development such as leadership, advocacy, and quality improvement. broader expertise in the aforementioned areas is an important aspect of ensuring optimal human health at both the individual and population level.6 innovation and entrepreneurship are key domains in which clinicians can generate solutions with a broad impact on patient outcomes. currently, the lack of formal education on entrepreneurship in medical school means that aspiring physician entrepreneurs are often left to learn important skills, establish networks, and acquire resources on their own.7 we believe that medical schools should do more to supplement medical education with entrepreneurial exposure in order to inspire medical trainees to consider entrepreneurship as a viable avenue for developing healthcare solutions. innovation and entrepreneurship are central to many of the clinical and educational activities of the mississauga region, both at the university of toronto’s distributed medical education campus in mississauga, as well its community hospital partner, trillium health partners (thp). as the clinical teaching site of the mississauga distributed medical campus, thp is a leader in the canadian innovation and entrepreneurship landscape. thp leads an acclaimed pancanadian initiative, the coordinated accessible national (can) health network, which coordinates an integrated and receptive marketplace for canadian health technology startups. given the mississauga academy of medicine’s culture of innovation and entrepreneurship, students and faculty alike were driven to leverage their regional strength and offer healthcare entrepreneurship teaching to medical students. herein, the regional medical education campus of mississauga led the creation of the entrepreneurship in healthcare seminar series. environmental scan and needs assessment we conducted an environmental scan and needs assessment to gather information about existing entrepreneurship teaching programs within the medical education space in canada and the united states. our initial needs assessment revealed a gap in opportunities for training medical learners in entrepreneurial skills, particularly in canada. a brief review of the literature highlighted the sparsity of publications in this area, emphasizing that, despite a growing culture of entrepreneurship, medical education has failed to adapt and offer students training in this important field. this is slowly changing, with a number of training programs in innovation and entrepreneurship beginning to emerge. one such doi: https://doi.org/10.24926/jrmc.v4i1.3564 initiative is a certificate degree program for medical students in healthcare delivery science, management and policy distinction by carver college of medicine at the university of iowa. established in 2016, the program offers students a dedicated block on the topics of innovation and entrepreneurship, and involves the completion of 9 education blocks over 3.5 years.8 similarly, a landscape review from 2016 found 13 schools with innovation and entrepreneurship teaching streams catered to medical students, all of which were based out of the united states (table 1).2 of those, 9 programs spanned all 4 years of medical school and 10 programs required a capstone project.2 programs were led by faculty from diverse professional backgrounds, and all awarded formal recognition to graduates. these programs accepted a median of 13 new medical students per year, which compromised of approximately 7% of the student body.2 prominent educational themes included entrepreneurship, innovation, and technology. within canada, similar programs were exceedingly rare, with our review of the canadian medical schools’ official websites finding just 2 such programs: university of alberta’s faculty of medicine and dentistry offering a health entrepreneurship stream for their md/mba and md/phd students, and mcmaster university delivering a healthcare innovation, commercialization, and entrepreneurship program for select md and phd graduates.7, 9 given that interest in healthcare entrepreneurship is rapidly expanding, we anticipate a growing number of similar programs will emerge from the medical education space in the near future. table 1. innovation and entrepreneurship programs at us medical schools, as identified by a 2016 structured internet search reported by niccum et al.2 journal of regional medical campuses, vol. 4, issue 1 original report methods stakeholder consultations in the first phase of program development, we engaged key stakeholders to obtain expert perspective regarding the program feasibility, curriculum design, and best practices for delivering this training. we consulted with 6 renowned physician entrepreneurs in the forefront of canadian healthcare innovation and 4 experts in the field of entrepreneurship education design and delivery. we also consulted with 9 key university of toronto faculty thought leaders with tremendous experience in curriculum design. furthermore, we sought out the user perspective by consulting with 8 medical students at the university of toronto. all consultations were conducted in the form of semi-structured interviews and written consent was obtained. interview data was assessed by 2 reviewers (a.a., p.s.) who coded the transcripts; disagreements were discussed with other members of the group (s.m., a.f., d.m.) and consensus was reached. we adopted braun and clarke’s validated model of thematic analysis with a 6-phase approach to generate, review, and define themes within the interview transcripts. recurrent themes were extracted and subsequently informed the design of the program regarding the structure, mode of delivery, and synthesis of the series’ learning objectives. program design the entrepreneurship in healthcare seminar series was designed as an extracurricular program to introduce medical students to the fundamental principles of entrepreneurship in healthcare. the seminar series was established at the university of toronto’s distributed medical education campus in mississauga, home to the mississauga academy of medicine, where 216 students per year complete their medical training. the program committee developed the initiative between may 2019 to september 2019 and the series was rolled out in the 2019-2020 academic year. the seminar series consisted of 6 sessions, each approximately 2 hours in duration, delivered from november 2019 to may 2020. five out of 6 sessions were held in person at the distributed medical education campus in mississauga and all students from both campuses, st. george (toronto) and mississauga, were invited to attend. one session was delivered virtually due to social distancing restrictions of the current pandemic. a panel of renowned physician entrepreneurs and innovation experts taught the sessions. six out of 7 speakers were physicians, of which 4 were physician entrepreneurs and 2 of which held leadership roles within healthcare innovation and entrepreneurial ventures. one of the speakers was an expert in healthcare innovation and not a physician. the style of teaching involved didactic lectures doi: https://doi.org/10.24926/jrmc.v4i1.3564 followed by a rich discussion among students and subject experts (table 2). students who attended 4 out of the 6 sessions were awarded a certificate of completion, granted by the leadership team at the mississauga academy of medicine. the value of offering this certificate was twofold. first, it presumably increased student interest in the initiative, as there was a tangible recognition associated with participation. this was particularly important as this was the first iteration of the series and many students had not been previously exposed to healthcare entrepreneurship. second, the certificate served to encourage longitudinal participation in the program, which would allow us to obtain constructive feedback and informed program evaluations. in refining the series’ learning objectives, we looked to mars institute, a north american leader in entrepreneurship. the series’ learning objectives were modelled after the mars entrepreneurship 101 framework, a validated approach to teaching entrepreneurial concepts, and adapted to the needs of medical students.10 mars entrepreneurship 101 course developers granted us written permission to utilize their course outline to inform the development of our seminar series’ learning objectives. students began by learning about the types of innovation in healthcare and subsequently covered topics pertaining to the development of a start-up, from ideation to implementation (table 2). each speaker curated a lecture based on the outlined learning objectives and included anecdotes from their personal entrepreneurial journey. as an addition to the series, we developed an optional selfpaced longitudinal project to help guide students engage in what they were learning in a practical way. the longitudinal project prompted students to identify a healthcare challenge, develop a solution, and subsequently bring the solution to market. the primary goal of the longitudinal project was to evaluate student interest and uptake for such an exercise. the secondary goal was to provide an additional avenue for students to engage in the material, while maintaining flexibility. the decision to offer the longitudinal project as an optional component of the series was based on student feedback shared in focus groups. the rational was that: 1) this was an extracurricular program for students with significant academic responsibilities, and 2) a successful first iteration of the series would require reducing barriers to participations in order to encourage more students to engage in the program. journal of regional medical campuses, vol. 4, issue 1 original report table 2. the entrepreneurship in healthcare seminar series syllabus, outlining sessions 1-6, corresponding topic, and learning objectives, from november 2019 to may 2020. results stakeholder consultations the major emerging messages of the stakeholder consultations are summarized below. program structure reducing barriers to participation for both students and speakers was deemed important for ensuring the operation of the program. furthermore, providing a broad overview of entrepreneurship in healthcare was considered more appropriate than covering advanced topics less practical for medical students. the ideal number of sessions was determined to be 6-8. finally, recommendations were made to encourage speakers to address learning objectives within the context of their own entrepreneurial journey. program content emphasis was placed on using a well-established entrepreneurial framework to inform the development of the series’ learning objectives. consultants recommended providing opportunities for students to engage in entrepreneurial activities by developing healthcare solution ideas in the context of a longitudinal project. student engagement generating student interest was considered to be crucial to the ultimate success of the program, therefore, developing an effective promotional strategy was central to ensuring student engagement. additionally, incorporating the student doi: https://doi.org/10.24926/jrmc.v4i1.3564 perspective in the development of the series was noted as key to ensuring that the program catered to the needs of medical students. entrepreneurial community emphasis was placed on creating a multidisciplinary entrepreneurial community at the regional medical campus of mississauga by forging mutually beneficial relationships with local start-ups and providing students with invaluable opportunities to network with physician entrepreneurs. initiative offerings the program was deemed valuable in broadening the perspectives of medical learners by promoting critical analysis of current healthcare problems and considering ways to tackle issues with innovative solutions. the program was recognized as a vehicle for allowing students to explore novel career avenues in healthcare entrepreneurship. future directions recommended future directions included creating strategic partnerships with local champions in healthcare innovation and entrepreneurship. furthermore, evaluating the program and making iterative improvements were deemed central to the success and longevity of the initiative. program outcomes the series captured a total of 57 attendances by 37 unique attendees as shown in figure 1. the demographic of attendees comprised mostly of pre-clerkship medical students from the distributed medical education campus of mississauga (figure 1). the virtual session was the second most highly attended of the series. it was also the only session that featured attendees from the st. george campus, located in central toronto, as well as clerkship students. this data seems to suggest that holding sessions virtually would increase student participation in the program, likely by minimizing barriers to participation, such as commuting. given that this was the pilot year of the program, there was a limited number of program evaluations completed by student participants. a post-session survey, consisting of 6 questions graded on a 5-point likert scale, was used to measure student satisfaction. table 3 outlines percentage of respondents who answered agree to strongly agree on the 5point likert scale with regards to each of the 6 survey questions. the survey showed that greater than 85% of attendees deemed the sessions excellent to very good. the feedback survey also captured free text comments which were overwhelmingly positive. additionally, a significant majority of students indicated that they gained knowledge from the sessions which would be valuable in a real-world setting (table 3). although this feedback does not tell us exactly how participants plan to use the knowledge and skills learned in the program, it does help illustrate the perceived doi: https://doi.org/10.24926/jrmc.v4i1.3564 journal of regional medical campuses, vol. 4, issue 1 original report value and utility of the material, as there is a general consensus that enough useful information was extracted from the series to apply these principles to a practical scenario. the timing of sessions 5 and 6 did align with examination period, which may explain their drop-in attendance. furthermore, session 5 covered the financial aspect of startups, with a focus on financial metrics and funding models. while an important topic for entrepreneurship, we anticipate that the technical nature of this talk was less appealing to medical students, which was also supported by student feedback. following iterations of the program should consider ways to cater this material to medical students in an engaging and tangible manner. finally, sessions 5 and 6 had a drop in promotional efforts, which likely also contributed to the decline of participants. this finding points to the importance of effective promotion for student engagement. the following program iterations should develop and execute a comprehensive and multimodal promotional strategy to capture student interest and participation. additionally, student uptake of the longitudinal project was found to be low, likely given the time commitment required to engage with the material. the next iteration of the program should seek student feedback to modify the project in order to increase its appeal and utility for users. figure 1. number of attendees per session at the entrepreneurship in healthcare seminar series, university of toronto, 2019-2020. the number of students from the distributed medical education campus of mississauga and from the central toronto st. george campus are indicated. table 3. summary of post-session surveys of the entrepreneurship in healthcare seminar series, including session number, number of respondents, survey question, and percent respondents who rated agree to strongly agree on the given 5-point likert scale, from november 2019 to may 2020. 1note that n refers to the number of survey respondents per session. 2the percentage shown is an amalgamation of percent respondents who marked agree or strongly agree according to the 5-point likert scale for each respective survey question. discussion the entrepreneurship in healthcare seminar series was developed to promote entrepreneurship amongst the next generation of physicians by training medical students to generate problem solving designs, services, and products that respond to healthcare challenges. the program aimed to teach a systematic approach to creating a start-up company as a means to launch innovative solutions to healthcare challenges. developing an appreciation for healthcare innovation and entrepreneurship is central to training a new generation of physicians who are not limited by the status quo; instead, they are attuned to recognizing gaps in the system and seeking novel solutions to address them. delivering this important message early on in the training of future physicians is crucial for shifting perceptions around medical innovation and entrepreneurship. the program achieved a number of short-term outcomes. first, the series generated interest in the field of entrepreneurship among students who participated. second, the series trained participants in the entrepreneurial approach to problem solving and scaling an innovation. while the degree of competency gained is difficult to quantify at journal of regional medical campuses, vol. 4, issue 1 original report this time, we can infer that participants developed a basic understanding of the entrepreneurial framework as outlined in the learning objectives. third, the series served as an avenue for fostering mentee-mentor relationships between medical students and physician entrepreneurs. the long-term outcomes of the initiative were twofold. first, the program provided an opportunity to consider how best to position entrepreneurship and innovation within a medical school curriculum, whether as an elective opportunity, a core curricular requirement, or a more advanced learning opportunity in the form of a joint degree program in medicine and masters of innovation and entrepreneurship. second, we anticipate that with greater development of the initiative and multiple iterations of the program, we can see an increased number of successful physician-led medical start-ups which contribute to solving major healthcare challenges in canada. short-term next steps will include, first, rigorous evaluation of the program by obtaining student and presenter feedback and iterating the program accordingly. second, there is a need for developing virtual streaming of future iterations of the program to allow for greater accessibility. given the current pandemic and the university’s plans to move large classes online, we have chosen to deliver the next iteration of seminar series in the 2020-2021 academic year virtually. given our positive experience with the single online session, we anticipate that the next virtual iteration of the program will have greater student engagement, while maintaining meaningful discussion and connectivity. long-term next steps could include the development of practicums in healthcare start-ups, where students can gain hands-on experience and receive one-on-one mentorship, the program can be adapted and delivered to postgraduate medical residents who would also benefit from developing skills in entrepreneurship. there is also potential for the initiative to evolve into a joint degree program in medicine and masters of innovation and entrepreneurship; an intriguing opportunity that would provide both the depth of learning and the experiential scholarship necessary to prepare those with a firm interest to develop as future physician entrepreneurs. a dual degree program in medicine and entrepreneurship would reflect institutional accountability for training physician leaders who will pursue critical transformations in the healthcare system over the coming decades. finally, there is significant opportunity for the program to expand beyond the university of toronto to medical schools worldwide. one anticipated challenge may be the scarcity of physician-entrepreneurs who are often concentrated in innovation hubs such as toronto. this issue can be mitigated by using virtual programs broadcasted from the university of toronto to faculties of medicine across canada and aboard. doi: https://doi.org/10.24926/jrmc.v4i1.3564 conclusion the entrepreneurship in healthcare seminar series was a first of its kind program among canadian medical schools, designed to promote entrepreneurship within healthcare to early stage medical learners. the project is a model for other distributed medical campuses to leverage their unique strengths in order to create innovative opportunities for their medical student community. references 1. safi s, thiessen t, schmailzl kj. acceptance and resistance of new digital technologies in medicine: qualitative study. jmir research protocols. 2018;7(12). doi:10.2196/11072 2. niccum ba, sarker a, wolf sj, trowbridge mj. innovation and entrepreneurship programs in us medical education: a landscape review and thematic analysis. medical education online. 2017;22(1). doi:10.1080/10872981.2017.1360722 3. smith sw, sfekas a. how much do physicianentrepreneurs contribute to new medical devices? med care. 2013;51(5):461-7 4. deng d, zaric g. physician entrepreneurship: why it matters to all of us. university of western ontario medical journal. 2018;86(s1):12-13. doi:10.5206/uwomj.v86is1.2114 5. collier r. canadian health care lacks culture of innovation. canadian medical association journal. 2018;190(36):e1089-e1090. doi:10.1503/cmaj.1095655 6. al-musawi s, houbby n. addressing the void of entrepreneurship development amongst medical students in the uk. advances in medical education and practice. 2019;10:677-678. doi:10.2147/amep.s207533 7. fomd health entrepreneurship program. university of alberta faculty of medicine and dentistry. https://www.ualberta.ca/medicine/innovation/entre preneurship-program. accessed may 4, 2020. 8. healthcare delivery science, management and policy distinction. university of iowa health center carver college of medicine. https://medicine.uiowa.edu/md/curriculum/distincti on-tracks/healthcare-delivery-science-managementand-policy-distinction. accessed november 26, 2020. 9. building health entrepreneurs. health innovation, commercialization and entrepreneurship. https://healthinnovation.mcmaster.ca/. accessed may 1, 2020. 10. entrepreneurship 101. mars discovery district. https://www.marsdd.com/wpcontent/uploads/2014/03/entrepreneurship-101course-syllabus_final1.pdf. accessed may 4, 2020. doi: https://doi.org/10.24926/jrmc.v4i1.3564 journal of regional medical campuses, vol. 4, issue 1 original report 11. scholarly concentrations program. indiana university school of medicine. https://medicine.iu.edu/md/curriculum/scholarlyconcentrations. accessed november 23, 2020. microsoft word vulnerable patient outreach program article.docx published by university of minnesota libraries publishing vulnerable patient outreach program (vpop): meaningful roles and reinforcement of empathy for medical students during covid-19 thomas kellner, bs, brittainy hereford, bs, mark stephens, md doi: https://doi.org/10.24926/jrmc.v4i3.3627 journal of regional medical campuses, vol. 4, issue 3 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc thomas kellner, bs; pennsylvania state college of medicine, hershey, pa, usa. brittainy hereford, bs; pennsylvania state college of medicine, hershey, pa, usa. mark stephens, md; pennsylvania state college of medicine, hershey, pa, usa. department of family and community medicine, pennsylvania state health medical group – park avenue, state college, pa, usa. corresponding author: thomas kellner, bs pennsylvania state college of medicine, university park 1850 e. park avenue, suite 304 state college, pa 16803 phone: (804) 501-8884 fax: (814) 689-0015 email: tkellner@pennstatehealth.psu.edu all work in jrmc is licensed under cc by-nc volume 4, issue 3 (2021) journal of regional medical campuses original reports vulnerable patient outreach program (vpop): meaningful roles and reinforcement of empathy for medical students during covid-19 thomas kellner, bs, brittainy hereford, bs, mark stephens, md abstract introduction: the covid-19 pandemic significantly disrupted many traditional models of patient care delivery. to help meet patient needs, the pennsylvania state university department of family and community medicine initiated a medical student-run vulnerable patient outreach program (vpop) to address healthcare needs for highrisk patients during the early stages of the pandemic. methods: two senior medical student officers (smros) were identified as team leaders. the srmo invited student colleagues (n=36) and local primary care physicians (n=11) to participate. physicians were asked to identify patients on their panel at risk of morbidity/mortality due to sars-2 cov infection. patients were most frequently identified as vulnerable when they were over the age of 65 and/or had multiple medical comorbidities. medical student volunteers interviewed patients by phone from april to june 2020 to connect patients with community resources and necessary medical care. participating patients were later contacted to ask their impressions of the program and to offer suggestions for improvement. medical students were given a medical student empathy survey (mses) and medical student feedback survey (msfs) to better understand characteristics of participating students and to solicit opportunities for improvement. results: after the initial invitation to participate, a total of 16 medical students (44%) and 64 of 125 patients (51%) who were identified as being at high-risk enrolled in the vpop. thirty-four patients (38%) completed the vpop patient satisfaction exit surveys. eleven of the 16 medical students (69%) completed the msfs and 14 medical students (88%) completed the mses. overall, 94% of patients stated that they were satisfied with the program, 74% said they would be interested in participating again, 92% of participating students exhibited strong empathy scores on the mses, and 82% provided positive feedback about their participation in the program. conclusions: both medical students and patients had positive experiences with the vpop. these reactions suggest that outreach programs like this one are an effective way to not only connect vulnerable patients with needed care, but to connect medical students with patients in a value-added role. these findings also suggest that, as a longitudinal experience beyond covid-19, medical students may benefit from ongoing participation in vulnerable patient outreach programs. introduction: covid-19 and vulnerable patients the coronavirus-19 (covid-19) pandemic has had a devastating impact across the globe. to date there have been more than 600 000 covid-19 related deaths in the united states alone.1 to mitigate the community spread of covid-19, guidelines of mask use in public and physical distancing between people2 help limit the spread of covid-19.3 early in the pandemic, physician offices scrambled to alter clinical operations to mitigate the spread of the doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports virus while maintaining appropriate access to inperson care. as a result there was a 60% reduction in outpatient visits to ambulatory care centers in april 2020.4 patients also appear to have delayed or avoided medical care altogether.5,6 this reduction in visits may have contributed to an increase in all-cause mortality observed around the world during the pandemic.7 covid-19, empathy, and medical student clerkship year education unlike previous national emergencies, covid-19 significantly decreased medical student interactions with patients. this had a particular impact on medical students completing their clerkship year. on march 17, 2020, the association of american medical colleges provided guidelines suggesting that schools pause clinical rotations for medical students.8 with this pause in clinical rotations, students transitioned to online learning and remote participation in clinical activities.8 in a normal year, medical students report high levels of stress, burnout, and poor mental health.9 however, during covid-19 there was a marked increase in medical student stress and feelings of detachment from their communities. a total of 73% of medical students reported higher levels of stress during the pandemic.10 students also decreased the amount of time they spent studying.11 the transition to remote learning and additional stressors caused by covid-19 unquestionably impacted (most likely adversely) students’ educational experiences. previous studies show that medical student empathy significantly decreases during medical school, particularly in the clinical years.12 medical student empathy is inversely correlated with burnout and mental health.13 the correlation between high stress and decreased empathy in medical student and the increase in medical student reported stress during the covid-19 pandemic represents yet another reason for concern. with this background in mind, we sought to actively engage students in value-added roles that would help keep them engaged clinically while providing meaningful care to patients in need. as such, student run clinics (srcs) are protective in helping medical students to stay connected to their sense of purpose and overall wellbeing.14 in an effort to support medical student empathy and provide a sense of purpose and community, the vulnerable patient outreach program (vpop) was created as a remote src. the vpop sought to build 2 bridges: one between patients and medical services and another between medical students and their communities. the vulnerable patient outreach program (vpop) the vpop uses an enlightened self-interest in altruism (esia) approach to connecting patients and medical students. esia is a framework for re-aligning medicine’s dedication to altruism by reframing altruism as an act of self-interest.15 for medical students feeling stressed and disconnected from their communities, patient outreach can be an act of selfinterest that helps reconnect students with their community. as an act of altruism, vpop was a volunteer program with no cost to patients. the penn state vpop took inspiration from other srcs in being student-led, operating at no cost to patients, and seeking to connect patients with medical services and community support. like an src, vpop also helped educate patients regarding self-care and when to seek higher echelons of care. the vpop was created to honor recommended parameters of social distancing, the needs of patients, and the needs of medical students for authentic patient experiences and purposeful community interactions. methods: patient recruitment and follow up following approval from the institutional review board, physicians from the pennsylvania state college of medicine department of family and community medicine (fcm) and 2 medical students in their clerkship year collaborated to design and implement the vpop program. these senior student medical officers (ssmo) were central to the design and execution of the program. the fcm clinic chief contacted providers to assess interest in participating in the program. eleven of 15 primary care physicians in the fcm practice agreed to participate. each participating provider reviewed their patient panels and identified 10-15 of the most vulnerable patients. a total of 125 patients were identified as high-risk. providers identified patients as vulnerable doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports based on their knowledge of their patients’ medical and social history. all identified patients were at an increased risk of a negative covid-19 related health outcome based on either age or medical comorbidity. the decision of which patient was high-risk was based on the provider’s clinical judgment.16 thirty-six students at the university park regional campus were invited to participate in the program via email. twelve students initially volunteered with 4 more later joining the program. the ssmo assigned each medical student 6 to 10 patients to contact by phone. the caseload for each medical student was based on student availability and their experience with prior patient care. for each phone call, students used a standard script developed by senior physicians within the practice [table 1]. table 1: vpop student script this script screened for adherence to covid-19 precaution guidelines, behavioral and physical health needs, and food security challenges. students alerted patients to emerging telehealth options for care. students were encouraged to follow a standardized approach for each call using 6 detailed steps: 1) identify self and connection to the patient’s primary care provider (pcp); 2) express empathy regarding the challenges of the pandemic; 3) listen actively and affirm the patient’s perspective; 4) determine acute patient needs; 5) document the interaction in the electronic medical record (emr)—expedite patients with acute care needs by contacting the attending physician and nursing staff; 6) educate patients about expanding telemedicine options for care delivery. another core vpop objective was to assess patient food security status, behavioral health needs, and ability to social distance. students also checked in with patients to ensure there were no other urgent issues. when students identified urgent issues, they immediately contacted the patient’s provider through secure emr messaging. if a social issue such as a lack of food was identified, students helped direct patients to local resources such as a food pantry or food delivery service. in emergency situations, students directed patients to seek care immediately by calling 911. all patient/medical student encounters were documented using a templated medical student note in the emr. the patient’s primary care physician reviewed and co-signed each medical student note. medical student volunteers also logged de-identified patient interactions in a document file. each patient received a numerical identifier affiliated with their attending provider. database parameters matched those of the approved script, allowing the student to type “yes” or “no” to ensure adherence to protocol and ease of data entry. there was also a free text field for students to add associated notes or explanations. the vpop initially ran from april to july 2020. overall, 64 patients participated. in august 2020, the ssmo conducted an exit survey with all program participants. a total of 34 patients responded to the exit survey. these patients expressed continued interest in receiving phone calls from medical students at the end of the vpop. an 8 question exit survey was administered to assess the impact of the vpop. this survey was completed by telephone. the results of the patient exit surveys were recorded in a de-identified spreadsheet. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports additional comments made by program participants were also logged within the same spreadsheet. basic descriptive statistics were used for the analysis. medical student follow up at the conclusion of vpop, medical student participants received an 11 question exit survey based on the jefferson scale of empathy to assess the impact of the vpop on the students.17 fourteen of the 16 medical student participants responded. basic descriptive statistics were used for the analysis. alongside this, all 16 medical students received the medical student feedback exit survey via email. a total of 11 students responded to this survey. results: patient impact sixty-four of the 125 patients identified as candidates for the outreach program responded. we were not able to contact the other 61 patients, despite 3 calls from medical students. of the 64 patients who responded to the follow up request, 34 completed the vpop patient satisfaction exit survey. the average age of the survey participants was 75.6 + 11.5 years. table 4 highlights the patient satisfaction results of our exit survey and table 5 shows the impact statistics of the outreach program. patients were largely satisfied with the program [table 4]. patients responded most positively to the questions: “listening and communication skills of the medical student were professional and efficient”, “while speaking with the medical student, i feel like my medical concerns were being taken seriously”, and “overall, i am satisfied with the medical student organized covid-19 outreach program”. the lowest average satisfaction rating was “i would be interested in receiving phone calls from medical students in the future”. most patients indicated they were interested in participating in future outreach programs with medical students. table 4: patient satisfaction score averages (1 = strongly disagree; 3 = neutral; 5 = strongly agree) medical student impact of the 36 students invited to participate in vpop, 16 students (44%) chose to participate. of these, 14 completed the medical student empathy survey at the end of the program. among the students that participated in the survey, 10 were in their clerkship year, one was in their fourth year and 3 were in their first year of medical school. table 6 shows student empathy scores. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports table 6: medical student empathy scale scores discussion: patient impact the results from our vpop suggests that the program was effective in terms of patient contact, patient value, and ease of execution. most patients who participated had a positive experience. interestingly, 2 elements that did not rank as highly were telehealth interest and future participation in outreach programs. a potential reason for the apparent lack of interest in telehealth might relate to the average age of our participants (average: 75.6 + 11.5 years). this is consistent with previous studies suggesting that patients over 65 are less likely to utilize telehealth.17 lack of access to computer, telephone, or internet connection did not, however, appear factor in lack of interest in telehealth. all vpop participants reporting having access to telehealth. many, but not all, patients (75%), were interested in future participation in a medical student led outreach program. there are several important limitations to this pilot program. one was irregular medical student followup. while students were generally consistent in reaching out to all their patients initially, there was often a lack of follow-through in subsequent months. this made it difficult for some patients to remember previous interactions with students, and, as a result, some did not feel comfortable completing the survey. we attribute this drop-off to an increase in academic load, most notably fourth-year students, as they re-integrated into the hospital for clinical activities. midway through the program, 3 fourth-year students and one second-year student ended their participation citing difficulty balancing responsibilities in this program with their other clinical duties in medical school. another limitation of this study was the inability of medical students to contact patients identified by their physicians as high-risk or vulnerable via phone. there were several reasons why this may have occurred. patients may have been unavailable during the times they were called, patients may not have answered because they were unaware of this program’s existence, or patients did not recognize the incoming phone number. it is also possible that some of the patient phone numbers were not accurately reported in the emr. an additional limitation to consider is the lag time of 6 to 8 weeks between the end of the outreach program and the exit survey phone calls. this may also have contributed to patients not remembering details of their conversations in months prior. medical student impact a total of 16 medical students (excluding the 2 ssmos) participated in vpop. five were first-year students, 7 were second-year students, and 4 were fourth-year students. ssmos obtained feedback from the medical student volunteers through the medical student satisfaction interview. the questions asked in these interviews were: “what would you sustain in this program?” and “what would you change in this program?”. common positives voiced by the medical students include the level of personal autonomy, the helpful script, and the range of topics discussed with patients. students also mentioned that the most challenging aspect of this program was finding an optimal calling time to speak with patients. initiating first contact was especially difficult, as all patients had not been notified by their pcp about this program. despite this challenge, the medical students were able to contact a considerable number of patients doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports and identify many healthcare needs. areas for improvement included the need for greater studentprovider communication, initial provider-patient communication about the program, and identifying additional community resources for patients. the medical student empathy exit survey results were generally positive. the results may have been different if all 36 medical students participated in this study, since it is possible that more empathic students self-selected to participate. it is important to note, however, that most student participants were in their clerkship year, the year in which the steepest drop in patient empathy scores occurs for many students. it is possible that these medical students felt the deepest need to reconnect with their communities. it is also possible that, because the ssmos running this study and doing the recruitment came from their clerkship year, more medical students chose to participate in this study while in their clerkships. conclusion: this study describes patient and student experiences with vulnerable patient outreach program during covid-19. the goal of this program was to connect with patients, serve the community, and build and maintain empathy among medical students. we believe that this goal was achieved based on results from the patient satisfaction and medical student empathy surveys. patients were genuinely interested in connecting with medical students on a regular basis and were comfortable relaying their health concerns to medical students via phone. this program provides an opportunity for students to serve the community and improve communication skills with patients and providers. as such, telehealthbased patient outreach activities such as the vpop have potential to benefit patients and medical students alike. references 1. world health 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(2020). coronavirus disease (covid-19): situation report – 107. retrived 7 may, 2020 fromhttps://www.who.int/docs/defaultsource/coronaviruse/situationreports/20200506covid-19-sitrep107.pdf?sfvrsn=159c3dc_2. 2. coronavirus (covid 19): how to protect yourself and others. centers for disease control, 2020b. (https://www.cdc.gov/coronavirus/2019-ncov/ prevent-getting-sick/prevention.html.). 3. matrajt l, leung t. evaluating the effectiveness of social distancing interventions to delay or flatten the epidemic curve of coronavirus disease. emerg infect dis. 2020;26(8):1740-1748. doi:10.3201/eid2608.201093 4. mehrotra a, chernew m, linetsky d, hatch h, cutler d. what impact has covid-19 had on outpatient visits? published online 2020. doi:10.26099/ds9e-jm36 5. czeisler mé, marynak k, clarke ken, et al. delay or avoidance of medical care because of covid-19–related concerns — united states, june 2020. mmwr morb mortal wkly rep. 2020;69(36):1250-1257. doi:10.15585/mmwr.mm6936a4 6. garcia s, albaghdadi ms, meraj pm, et al. reduction in st-segment elevation cardiac catheterization laboratory activations in the united states during covid-19 pandemic. j am coll cardiol. 2020;75(22):2871-2872. doi:10.1016/j.jacc.2020.04.011 7. knight a. letter to the editor about the article “excess mortality estimation during the covid-19 pandemic: preliminary data from portugal https://doi.org/10.20344/amp.13928.” acta médica port. 2020;33(6):446. doi:10.20344/amp.14032 8. rose s. medical student education in the time of covid-19. jama. 2020;323(21):2131. doi:10.1001/jama.2020.5227 9. kadhum m, farrell s, hussain r, molodynski a. mental wellbeing and burnout in surgical trainees: implications for the post-covid-19 era. br j surg. 2020;107(8):e264-e264. doi:10.1002/bjs.11726 10. abdulghani hm, sattar k, ahmad t, akram a. association of covid-19 pandemic with undergraduate medical students’ perceived stress and coping. psychol res behav manag. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 4, issue 3 original reports 2020;volume 13:871-881. doi:10.2147/prbm.s276938 11. meo sa, abukhalaf daa, alomar aa, sattar k, klonoff dc. covid-19 pandemic: impact of quarantine on medical students’ mental wellbeing and learning behaviors. pak j med sci. 2020;36(covid19-s4). doi:10.12669/pjms.36.covid19-s4.2809 12. hojat m, shannon sc, desantis j, speicher mr, bragan l, calabrese lh. does empathy decline in the clinical phase of medical education? a nationwide, multi-institutional, cross-sectional study of students at dogranting medical schools: acad med. 2020;95(6):911-918. doi:10.1097/acm.0000000000003175 13. thomas mr, dyrbye ln, huntington jl, et al. how do distress and well-being relate to medical student empathy? a multicenter study. j gen intern med. 2007;22(2):177-183. doi:10.1007/s11606-006-0039-6 14. smith sd, johnson ml, rodriguez n, moutier c, beck e. medical student perceptions of the educational value of a student-run free clinic. fam med. 2012;44(9):646-649. 15. vearrier l. enlightened self-interest in altruism (esia). hec forum. 2020;32(2):147161. doi:10.1007/s10730-020-09406-8 16. haime v, hong c, mandel l, et al. clinician considerations when selecting high-risk patients for care management. am j manag care. 2015;21(10):e576-582. 17. hojat m, desantis j, shannon sc, et al. the jefferson scale of empathy: a nationwide study of measurement properties, underlying components, latent variable structure, and national norms in medical students. advances in health sciences education. 2018;23(5):899920. doi:10.1007/s10459-018-9839-9 18. mehrotra a, jena ab, busch ab, souza j, uscher-pines l, landon be. utilization of telemedicine among rural medicare beneficiaries. jama. 2016;315(18):2015. doi:10.1001/jama.2016.2186. microsoft word useofamockweekarticle.docx published by university of minnesota libraries publishing use of a mock week as a novel tool for evaluating and implementing reformed medical curriculum at a nascent branch campus nicole c. kelp phd, brittni burgess bs, arun chandnani bs, gregory c. amberg pharmd phd, christie m. reimer md, mary ann degroote md, suzanne brandenburg md doi: https://doi.org/10.24926/jrmc.v4i1.3457 journal of regional medical campuses, vol. 4, issue 1 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc nicole c. kelp phd; university of colorado school of medicine at colorado state university, department of microbiology, immunology, & pathology, college of veterinary medicine and biomedical sciences, colorado state university brittni burgess bs; university of colorado school of medicine, anschutz medical campus, these authors contributed equally arun chandnani bs; university of colorado school of medicine, anschutz medical campus, these authors contributed equally gregory c. amberg pharmd phd; university of colorado school of medicine at colorado state university, department of biomedical sciences, college of veterinary medicine and biomedical sciences, colorado state university christie m. reimer md; university of colorado school of medicine at colorado state university mary ann degroote md; university of colorado school of medicine at colorado state university, university of colorado school of medicine, anschutz medical campus suzanne brandenburg md; university of colorado school of medicine at colorado state university corresponding author: nicole c. kelp phd; nicole.kelp@colostate.edu all work in jrmc is licensed under cc by-nc volume 4, issue 1 (2021) journal of regional medical campuses original reports use of a mock week as a novel tool for evaluating and implementing reformed medical curriculum at a nascent branch campus nicole c. kelp phd, brittni burgess bs, arun chandnani bs, gregory c. amberg pharmd phd, christie m. reimer md, mary ann degroote md, suzanne brandenburg md abstract the university of colorado school of medicine is implementing comprehensive curricular reform designed to produce physicians with a lifelong dedication to leadership, curiosity, and commitment. the new longitudinally integrated and case-based curriculum interweaves content on basic/medical sciences, clinical skills, and health systems content such as bioethics, interprofessional skills, and social determinants of health. simultaneously, the school is forming a branch campus in partnership with nearby colorado state university. the newly formed branch campus faculty team wanted to test delivery of the novel curriculum, practice working together as a team, and examine the practical logistics of human and physical resources at the branch campus. herein, we describe our approach for running a mock week of first year of the new curriculum. this innovative methodology involved teaching a week’s worth of the new content and garnering feedback from clinician educators, medical science faculty, and students. our observations highlight practical insights for implementing an integrated curriculum at an inaugural branch campus. finally, we provide recommendations for using a mock week as a feasible and robust tool for improving and enhancing various facets of medical education. introduction medical education continues to advance and evolve to meet the ever-changing healthcare needs in the united states. programmatic changes at medical schools across the country include comprehensive curricular reforms designed to provide earlier clinical experiences, longitudinal integration of the basic and clinical sciences, and expanded use of casebased learning techniques.1 in addition to curriculum reform, medical schools are embracing the development and expansion of regional medical campuses.2,3 motivations underlying increased interest in branch campuses are varied but often involve increased student enrollment and acquisition of additional resources, expertise, and opportunities. individually, extensive curriculum reform and the launching of a new branch campus are daunting endeavors. when combined, implementing a reformed curriculum at a new branch campus not only brings additional challenges but also provides novel opportunities. in this era of rapidly evolving health care which impacts educational methods, we share an innovative approach and some practical tips for piloting a reformed and highly integrated case-based curriculum at a nascent 4-year branch campus. the university of colorado school of medicine (cu som) is a state university with ~180 students per class and is the only allopathic medical school in colorado. the school is currently engaged in curriculum redesign in order to promote the development of physician leaders who are committed to transforming the health of diverse communities and who are curious, lifelong learners. the new longitudinally integrated curriculum will incorporate more clinical skills into the basic science curriculum with additional focus on population health, bioethics, health care policy, interprofessional skills, and health system improvement, collectively termed “health & society.” rather than following a traditional block sequencing with 2 years of basic sciences followed by 2 years of clinical skills, the reformed curriculum focuses on fundamental science content in year one and core clinical content in year 2, with more integration of all content including health and society throughout the 4-year curriculum. the third and fourth years build on and refine basic and clinical concepts, respectively, while maintaining journal of regional medical campuses, vol. 4, issue 1 original reports the integrated nature of the first 2 years. in order to prepare students for clerkships in the second year, the first-year basic science curriculum is built on 3 pillars: medical sciences, clinical skills, and health and society. the curriculum is also case based, with a “chief concern” scheduled for the beginning of each week during the first year. independent of the curriculum reform, cu som has partnered with colorado state university (csu), another top ranked state university, to establish de novo a 4-year branch campus: cu som at csu. csu is in fort collins, approximately an hour north of the main cu som anschutz medical campus in the greater denver area. this branch campus will mirror the new curriculum as designed and delivered on the main campus; the branch campus will utilize the same learning objectives and assessments as the main campus in order to meet accreditation standards. the cu som at csu has recently assembled a small fort collins-based medical science faculty to deliver, in parallel with the main campus, the nonclinical portions of the 4-year curriculum. additionally, a robust group of clinicians throughout fort collins have been recruited as part time and volunteer faculty to support the clinical learning experiences across the 4-year curriculum. of note, the branch campus will start with only 12 students per class and thus will have numerous opportunities for active learning and innovative instructional strategies. additionally, csu is also home to a top ranked veterinary medicine program and a department focused on environmental health, thus providing unique opportunities for students to explore interests in one health (health of people, animals, and the planet)4,5 and other concepts integral to a broader vision of health. the newly formed medical science faculty team at the branch campus wanted to test their ability to work as a team, make use of a newly built classroom space, coordinate and teach the new curriculum, and include evidenced-based active learning practices in their instruction. two students who had recently completed their first year in the legacy curriculum at the main campus were selected to serve as student ambassadors to help the branch campus team with this pilot project. the team chose to run a what we termed a “mock week” of the first year of the new curriculum, which is an innovative technique in medical education development. in short, during the mock week process the team prepared and taught a week of content in the new curriculum, including basic/medical sciences, clinical skills, and health & society content. medical students completed pre-work, attended the sessions, and took an end-of-week assessment. extensive debrief sessions provided feedback to shape the development of curriculum deployment at the branch campus. in this paper, we outline how we developed and conducted a first year mock week, critique and discuss our experiences, doi: https://doi.org/10.24926/jrmc.v4i1.3457 and provide recommendations to medical schools interested in using this approach. in sum, we found that tangibly going through the process of planning, executing, and debriefing a full week of curricular content provided an abundance of insightful information that exceeded expectations. we also conclude that the mock week exercise is an accessible, versatile, and useful tool for gathering insight and improving medical education. methods and process timeline the mock week occurred approximately one year before the cu som at csu branch campus is scheduled to matriculate the inaugural 4-year class of students. the main cu som campus was still finalizing the reformed curriculum, which would debut the same year as the branch campus. thus, the mock week served as a pilot test of both the new branch campus and the new curriculum. core faculty team at the time of the mock week exercise, the faculty team working on the first-year curriculum at the branch campus consisted of 4 md-trained clinician educators and 5 phdtrained medical science faculty. the clinician educators included the associate dean of the branch campus, the assistant dean of the branch campus, a liaison between the 2 campuses who has worked at both institutions, and the health and society content director. the associate dean has been involved in the main campus medical education for years, the assistant dean has previous experience and professional development in medical education, and the liaison also has experience in medical education. the 5 medical science faculty, ranging in academic rank from assistant professor to professor, included the director of basic sciences, who also has a pharmd degree; a faculty member with a primary appointment to teach at the branch campus; and 3 faculty members who had smaller appointments in the branch campus while teaching in other programs at csu. the medical science faculty had departmental homes in various units within the csu college of veterinary medicine and biomedical sciences, including the department of microbiology, immunology, and pathology, and the department biomedical sciences. at the time of the mock week, additional faculty were still being recruited from departments including environmental and radiological health sciences. additionally, a few guest speakers were invited to lead sessions on particular topics in their expertise, including a local clinician who is a former neurology program director at a medical school. recruitment of student ambassadors an application for the curriculum ambassador position was sent to all students finishing their first year in the legacy curriculum at the main campus. the position was particularly advertised to students already involved in a curriculum journal of regional medical campuses, vol. 4, issue 1 original reports reform group. the application asked all interested students to write about why they wanted to become a curriculum ambassador and what skills or relevant experiences they had that would help in the position. the applications were reviewed by the students of curriculum reform committee and the senior associate dean for education. together they matched applicants with opportunities based on that review. the students live in denver, only an hour from fort collins, and thus drove to fort collins daily during the mock week. a couple of sessions were held virtually to limit the number of days that students had to drive. planning of the mock week the cu som at csu core science faculty planned the mock week for a month preceding the on-site exercise. a week within the neurology unit was chosen, since that content had not yet been taught to the student ambassadors in the legacy curriculum; this would provide a more authentic experience with students experiencing the content for the first time. most of the week was basic sciences content. there were also blocks of time for clinical skills, such as performing a neurological exam, and health and society content related to neurological pathology. the medical sciences faculty divided the content based on expertise and the amount of effort dedicated to teaching in the branch campus; the clinical faculty developed case studies and physical exam sessions; and the health and society director organized extramural guest speakers to speak about the concepts planned for that week. overall, the faculty utilized 47 learning objectives for the week from the reformed curriculum; these learning objectives were developed by the curriculum build team at the main campus and will be used by both main and branch campuses when the reformed curriculum is deployed. the student ambassadors actively participated in the planning process and provided a perceived pre-ranking of their knowledge and understanding of learning objectives related to the mock week content. execution of the mock week for the most part, the team followed the schedule that will be used in the new first year curriculum. the medical sciences, clinical skills, and health and society faculty taught sessions on different topics, using a variety of teaching methods. innovative, evidenced-based teaching methods included problem-based learning and the use of mini cases to teach basic science information.6,7 after each learning session, the students and faculty provided verbal feedback on the strengths and weaknesses of the teaching methods in a round table discussion. some faculty were present for the entirety of the exercise, including sessions where they were not actively teaching, to develop a comprehensive view of the week and provide continuity and insight regarding the curricular elements as a whole. we found this to be critical for effective feedback on teaching methods as well as for doi: https://doi.org/10.24926/jrmc.v4i1.3457 team building. finally, to provide feedback on the strengths and weaknesses of the instructional methods used, the faculty composed an assessment of a similar form to that used on the cu som main campus. (however, when the curriculum is deployed for actual students in a non-mock setting, both main and branch campuses will use the same assessments.) debrief of the mock week to complement and unify the feedback gathered over the previous days, the faculty held a final debriefing session at the end of the week. the post-exercise feedback and brainstorming session yielded several important lines of information. included was a critique of learning objectives and other curricular components, ideas for improving instructional techniques, and approaches for integrating and creating synergy between the basic and clinical science faculty to provide an optimal first-year medical school experience. the students re-ranked their knowledge of the learning objectives following the mock week, providing a subjective assessment of the quality of instruction. finally, key takeaways were consolidated and presented to the curriculum reform leadership at the main campus so that both main and branch campuses could benefit from the mock week. the students and main campus teams were instrumental in providing an objective, unbiased assessment of the branch campus development. results and discussion there were 47 learning objectives for the mock week. the students ranked their knowledge of these learning objectives from 1 (little or no prior knowledge) to 3 (detailed knowledge). before the mock week, the students quantified their perceived knowledge of the learning objectives with a score of 1.21 ± 0.07. after the mock week, the students reassessed their knowledge of the learning objectives using the same scale as before. following the mock week, the student rankings of their perceived knowledge of the learning objectives increased dramatically to 2.42 ± 0.12, with a robust effect size (r) of 0.98 (pearson’s r, ranging from -1.0 to 1.0, with 0 indicating no effect; p < 0.01; however, this was calculated with an n of 2 students). these encouraging pilot data suggest positive instructional efficacy at an early stage by the cu som at csu branch campus faculty. those participating in the mock week deemed the exercise insightful and impactful. faculty appreciated the opportunity to practice functioning as a as a cohesive academic unit, and it was helpful for the students to see a different format of instruction than what they were used to in the legacy curriculum and provide feedback on the reformed curriculum in contrast to the legacy curriculum. overall, the mock week was critical for practicing implementation of an integrated doi: https://doi.org/10.24926/jrmc.v4i1.3457 journal of regional medical campuses, vol. 4, issue 1 original reports central curriculum designed by the main campus into the branch campus environment. key takeaway observations and conclusions fell into 3 general categories: 1) faculty development, 2) curriculum innovation, and 3) branch campus development. 1. faculty development: a. medical education: while some of the medical science faculty at the branch campus had experience in medical education, others were new to medical student education; the mock sessions provided an opportunity to teach medical students, receive feedback, and identify instructional strengths and weaknesses. b. teamwork: the branch campus faculty found the opportunity to work together for the first time energizing and informative. the sessions highlighted the unique skills and strengths brought to the group by different individuals and uncovered areas in need of improvement for the evolving planning and execution processes. 2. curricular innovation: a. curricular design: the new curriculum organizes content by body system instead of by subject area. challenges regarding longitudinal integration of pervasive subject areas, such as anatomy, pharmacology, and microbiology were discussed (as were potential remedies). there will be pros and cons to using any curriculum. the mock week identified potential challenges and enabled the development of potential solutions within the unique context of the branch campus faculty. b. curricular integration: the mock week demonstrated in real-time the advantages and challenges of integrating the basic/medical sciences, clinical skills, and health and society content. throughout the week, and especially during the debrief, the faculty and students considered different approaches for maximizing integration and minimizing compartmentalization. ideas included complementing the weekly chief concern/case study with multiple mini case studies and having a co-representation of basic science and clinical faculty during as many learning sessions as feasible. importantly, our mock week exercise produced results and outcomes similar to other previous attempts at implementing an integrated curriculum; namely, that interdisciplinary teaching and a high degree of communication between faculty is critical for success.8 3. branch campus development: a. community networking: the mock week prompted the faculty to connect with clinical faculty and others in the community that may be appropriate guest speakers for a variety of topics in the future. building this network is critical for a branch campus with a small faculty team. importantly, establishing community connections well in advance of student matriculation, one year in our case, has allowed the process to develop gradually and organically, as opposed to being rushed and forced. the result has been an enthusiastic community response in support of the cu som at csu branch campus. b. physical resources: a new building houses the branch campus and offers a state-ofthe-art, future-forward designed learning environment. being located on the csu campus provides other advantages and resources, such as a renowned human anatomy laboratory and the csu translational medicine institute. the mock week helped the faculty identify not only the physical resources available but also provided insight towards practical considerations such as physically traveling to different campus locations. c. human resources: the mock week highlighted areas in the curriculum that lacked faculty with expertise in the partially built branch campus team, pinpointing areas for future hires. once again, recognizing these issues a year in advance provides opportunities to recruit existing csu faculty or to run new faculty searches. d. student resources: the mock week led to important discussions about how students in the branch campus will connect with each other, with students in other programs at csu, and with medical students at the main campus. during the debrief process, the faculty team decided that the mock week process was so beneficial that we will do this again. the team plans to run another mock week approximately 3 months before the first students matriculate. this will allow the team to have more practice working together with additional members and a finalized curricular map. as medical student ambassadors will not be available during the second mock week time period, we will recruit journal of regional medical campuses, vol. 4, issue 1 original reports current csu students planning on submitting medical school applications to participate and provide student-level input. as mentioned, the key takeaways from the mock week were shared with the curriculum reform leadership on the main campus. in particular, the assistant dean leading the curriculum reform team at the main campus was positive about the findings from the branch campus’ mock week and led the curriculum reform team to implement central changes to the new curricular design based on these findings. in sum, the mock week shed light on several challenges and potential risks to the success of the fledging branch campus and allowed the team to begin to brainstorm solutions to these issues. in contrast, the mock week also highlighted several opportunities that are unique to the new branch campus, such as connections with faculty and resources at csu and in fort collins. finally, this approach executed in one area of a larger program was useful to the overall reform team’s work. recommendations for medical education we highly recommend the use of a mock week as a method for testing innovations in medical education. specific scenarios where a mock week strategy could prove useful include: • evaluating or implementing a centrally mandated curriculum at a branch campus, and providing feedback on that curriculum to the main campus • providing faculty new to medical student education or new to a branch campus an opportunity to practice before teaching their actual courses • fostering integration and team building within a faculty group • practicing implementation of new teaching methods and active learning strategies, such as converting a traditional lecture into team-based learning, even by seasoned faculty • examining logistical considerations related to the learning space and the local community • piloting new or revised curricula or new pedagogy on a small scale before comprehensive implementation while we outlined a process for the mock week based on our experience, the number of mock/pilot strategies and variations are limited only by the creativity of the participating faculty. for example, an entire week is not necessarily the optimal length for every mock exercise. premedical students or other medical-related students (e.g., veterinary) could fill the role of student ambassadors if necessary. when feasible, we highly recommend that all participating faculty attend as much of the mock week as possible. overlapping faculty participation facilitates exposure to other doi: https://doi.org/10.24926/jrmc.v4i1.3457 teaching styles, enhances feedback, and builds a culture of integrated teaching and learning. constructive discussions during and after the mock week are essential within and beyond the core team involved. in the end, the success or failure of a mock academic week exercise depends on commitment and effort by the faculty to learning and receiving constructive feedback.9 acknowledgments: the authors thank the curriculum build teams at the university of colorado school of medicine, anschutz medical campus, who have been working to develop the reformed curriculum. the authors thank the clinical and instructional faculty who provided expertise during guest speaker sessions for both the medical sciences and health & society content during the mock week. references 1. aamc. how medical education is changing. in: policy priorities to improve the nation’s health. ; 2016. accessed august 20, 2020. https://www.aamc.org/advocacypolicy/priorities 2. akins r, flanagan m, carter l, mcowen k. the new regional medical campus: a practical guide. j reg med campuses. 2019;2(4). doi:10.24926/jrmc.v2i4.1769 3. bates j, grand’maison p, banner sr, lovato cy, eva kw. exploring the contributions of combined model regional medical education campuses to the physician workforce. acad med. 2020;publish ahead of print. doi:10.1097/acm.0000000000003560 4. destoumieux-garzón d, mavingui p, boetsch g, et al. the one health concept: 10 years old and a long road ahead. front vet sci. 2018;5. doi:10.3389/fvets.2018.00014 5. mackenzie js, jeggo m. the one health approach—why is it so important? trop med infect dis. 2019;4(2). doi:10.3390/tropicalmed4020088 6. kasim rm. what can studies of problem-based learning tell us? synthesizing and modeling pbl effects on national board of medical examination performance: hierarchical linear modeling meta-analytic approach. adv health sci educ. 1999;4(3):209-221. doi:10.1023/a:1009871001258 7. clough rw, shea sl, hamilton wr, et al. weaving basic and social sciences into a casebased, clinically oriented medical curriculum: one school’s approach. acad med. 2004;79(11). doi:10.1097/00001888-200411000-00013 8. muller jh, jain s, loeser h, irby dm. lessons learned about integrating a medical school doi: https://doi.org/10.24926/jrmc.v4i1.3457 journal of regional medical campuses, vol. 4, issue 1 original reports curriculum: perceptions of students, faculty and curriculum leaders. med educ. 2008;42(8):778785. doi:10.1111/j.1365-2923.2008.03110.x 9. fetterman dm, deitz j, gesundheit n. empowerment evaluation: a collaborative approach to evaluating and transforming a medical school curriculum. acad med j assoc am med coll. 2010;85(5):813-820. doi:10.1097/acm.0b013e3181d74269 microsoft word astudentdirectedarticle.docx published by university of minnesota libraries publishing a student-directed community cardiovascular screening project at a regional campus emma c. doyle, bs; william r. southall, bs; blake s. edmonson, bs; william j. crump, m.d. associate dean doi: https://doi.org/10.24926/jrmc.v4i4x.4299 journal of regional medical campuses, vol. 4, issue 4 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc emma c. doyle, bs, trover rural track student, university of louisville school of medicine trover campus at baptist health madisonville, madisonville, kentucky william r. southall, bs, trover rural track student, university of louisville school of medicine trover campus at baptist health madisonville, madisonville, kentucky blake s. edmonson, bs, trover rural track student, university of louisville school of medicine trover campus at baptist health madisonville, madisonville, kentucky william j. crump, m.d. associate dean, university of louisville school of medicine trover campus at baptist health madisonville, madisonville, kentucky corresponding author: william j. crump, m.d. associate dean university of louisville school of medicine trover campus at baptist health madisonville 200 clinic drive, third north madisonville, ky 42431 p. 270.824.3515 f. 270.824.3590 e. bill.crump@bhsi.com all work in jrmc is licensed under cc by-nc volume 4, issue 4 (2021) journal of regional medical campuses original reports a student-directed community cardiovascular screening project at a regional campus emma c. doyle, bs; william r. southall, bs; blake s. edmonson, bs; william j. crump, m.d. associate dean abstract introduction cardiovascular disease (cvd) is an important threat to public health, especially in rural communities. clinical medical students at a rural regional campus can be a valuable resource to plan and implement cvd risk factor case finding project in the host community. methods directed by a representative county advisory council and supervised by a regional dean, clinical medical students designed and implemented cvd screenings at several public locations, recording health history and measurements of blood glucose, total blood cholesterol, and blood pressure. those screened with abnormal readings were directed to definitive care including the local student-directed free clinic. students were surveyed using a likert scale before and after participation to assess their confidence in executing a community health project. the host health system irb approved the protocol as exempt, and the authors have no conflicts of interest. result over a period of almost 2 years in 2017 and 2019, a total of 572 participants were screened. the demographics reflected those of the entire county, except screening was focused on adults. high blood pressure was found in 43%, high glucose in 28%, and high cholesterol in 48%. these values were similar to published countywide prevalence proportions. the student preto postincrease in confidence was remarkable (p< 0.001). conclusions our results show that regional campus medical students directed by a representative county advisory council and supervised by a regional dean can successfully implement a community cvd screening effort. the students also expressed a dramatic increase in their confidence in designing and implementing such a project. lessons learned are shared for consideration by those at other regional health campuses. introduction cardiovascular disease (cvd) remains one of the greatest threats to public health in both urban and rural communities in the united states. the burden of cardiovascular disease is heavier in rural communities, due to higher prevalence of diabetes, obesity, hypertension, lack of physical activity, and tobacco usage.1,2 many interventions have targeted individual cvd risk factors, aiming to reduce one risk factor at a time, while failing to include in the intervention the local health care facilities that provide definitive care.3-7 medical students at a regional medical school campus can be valuable contributors in rural communities’ cvd prevention programs.8 teaching future physicians to design a community-based project also gives them valuable journal of regional medical campuses, vol. 4, issue 4 original reports skills for designing and implementing future screening efforts after graduation.9 the most comprehensive rural community project reported in the united states was implemented and sustained in franklin county, maine from 1970 to 2010.10 the prevention program included educating residents on healthy lifestyle habits such as smoking cessation as well as screening for hypertension and hyperlipidemia in an effort to decrease cvd, hospitalization, and mortality. participants who were found to have uncontrolled risk factors for cvd were referred to local clinicians for treatment. this 40-year effort started with just screening and included active involvement of the community driven by an advisory council made up of local physicians and community leaders including local business owners, teachers, and nurses. early on, this group found that there were not enough easy access, low-cost options for primary care in their community, so they established a nonprofit medical practice dedicated to providing this care.10 later, they also partnered with the local hospital and regional campus of the state university.11-12 the program resulted in hypertension control rates increasing from 18.3% to 43.0% and elevated cholesterol control rates increasing from 0.4% to 28.9%, leading to 1.7% fewer hospitalizations per capita and a lower age adjusted mortality rate of 60 fewer deaths per 100 000 residents.10 these results suggest that cvd screening and intervention programs implemented in rural, low income, and predominantly white communities can have significant positive outcomes. from 1972 to 2012, a community cvd screening and education program in north karelia, finland used community-based interventions and national level policy changes to reduce the levels of smoking, hyperlipidemia, and hypertension in the population.13 the program utilized legislation, local media outlets, community meetings, and pamphlets to educate the population on cvd behavioral risk factors. the aim was to reduce smoking rates and reduce intake of saturated fat and salt. the program resulted in 20% lower cholesterol levels and a reduction of mean systolic blood pressure measures from 149 to 134 mm hg in men and 153 to 127 mm hg in women. smoking rates decreased from 51% to 36%. the reduction of these 3 cvd risk factors resulted in a decrease of cardiovascular mortality from 690 deaths per 100 000 to 100 deaths per 100 000.13 another cvd screening and intervention program implemented in rural västerbotten county, sweden resulted in a 12.1% reduction in all-cause mortality for women and a 7.8% reduction in all-cause mortality for men.14 the program was overseen by a scientific advisory board from umeä university, consisting of cardiologists, family medicine physicians, and epidemiologists as advisory board members. from 1990 to 2006, all citizens aged 30, 40, and 60 years in the county were invited to a health screening where participants would undergo an oral glucose tolerance test, along with screenings for blood lipids, body mass index, and blood pressure. participants also completed a comprehensive questionnaire to assess their socioeconomic status, psychosocial conditions, self-reported health, family history of cvd and diabetes, quality of life, and lifestyle habits including level of physical activity, alcohol and tobacco usage, and diet. following the questionnaire and screening, results and responses were discussed with the patient by a nurse employed by the program using motivational interviewing.15 the nurse would present each participant with a visual representation of their risk factors for cvd to encourage lifestyle modification. all the screening measures took place at a participating primary healthcare facility in the county. follow-up visits were scheduled with the nurse at the same healthcare facility when warranted, along with referrals to the participant’s family physician for further assessment and therapy as needed. another rural community program was completed in 2009 in rural new ulm, mn, population of 13 522. heart health screenings, a local weight loss competition, nutrition education sessions, and a phone coaching program for those with high cvd risk factors were implemented to engage the community.16 the program resulted in increased physical activity from 62.8% to 70.5% and improved nutrition as defined by eating 5+ fruits/vegetables per day from 16.9% to 28.1%. limited changes were seen for smoking, alcohol consumption, and stress.17 in 2010, johns hopkins university began an interdisciplinary cvd disparities training and career journal of regional medical campuses, vol. 4, issue 4 original reports development fellowship program.18 the curriculum included monthly cvd disparities didactic lectures along with participation in mentor-guided research of cvd health disparities among african american women. a student-directed program at the university of miami miller school of medicine provides free blood glucose, blood lipids, and blood pressure screenings and other examinations at free health clinics throughout the rural florida keys.19 when abnormal results were found, students referred participants to seek care at reduced cost clinics. students that participated in the rural health fairs tended to practice in low-density populated areas after graduation. one systematic review of student-run cvd community health interventions found that the projects demonstrated a short-term decrease in hba1c ranging between 0.9 and 1.7%, a decrease in ldl ranging between 12 and 34.5 mg/dl, and a decrease in blood pressure ranging between 5.2 mm and 9.5 mm systolic pressure and 5.7 mm and 6.8 mm diastolic pressure.20 the studies included in this review ranged from 6 to 12 months of intervention. we report here the initial results of a communitybased cvd screening effort led by medical students at a regional medical school campus, directed by a county advisory council, and supervised by the regional dean. the host community for the campus is remarkably similar in demographics, population, and socioeconomic descriptors to franklin county, maine. this screening effort was considered the first step to a long-term plan to replicate the interventions that were part of the later years of the franklin county maine project. methods the regional campus is located in a town of 20 000 in the upper southeast.8 clinical medical students are active in the community and have managed a local free clinic since 2004. the purpose of the campus is to produce physicians for the region’s small towns by training students with rural upbringing in a rural community setting. as a part of the longitudinal community medicine training of these regional campus medical students, community screenings were performed beginning in 2017. a student free clinic director scheduled m-3 volunteers for each screening, working around the most demanding rotations. every m-3 student volunteered for at least one session, and most did several. during the summer pathways programs, rising m-1 and m-2s joined the m-3s, with all volunteering at least once. screenings at typical “health fair” events resulted in reaching those who had the resources to get to the typical mall or civic-club sponsored events, which was not the low resource target population. to solve this problem, a steering committee was formed that, over the next 2 years, became an advisory council. council members were chosen from those who were in touch with underserved populations and knew when the target population would be gathered for some other purpose (see table 1). this resulted in a dramatic shift for screening to be scheduled where and when requested by informal and formal leaders of the target groups, even if this was inconvenient for the medical students, such as a saturday morning food bank. table 1: advisory council positions president, city-county economic development director, housing authority co-director, saturday session food bank pastor, prominent black congregation director, weekday food bank president, local community college business liaison, regional jobs program. a screening station was set up where people were waiting in line to receive free goods or services unrelated to the screening with a large sign and a community volunteer who walked along the line explaining the screening. the first step was a simple risk assessment written at the sixth grade reading level and, if necessary, administered verbally to the screened individual (see table 2). the health risk assessment recorded the participant’s past medical history of cvd-related illnesses and events, level of physical activity, quality of diet, tobacco product usage, form or lack of health insurance coverage, and journal of regional medical campuses, vol. 4, issue 4 original reports use of a primary care provider. next, the client moved one chair over where a single finger-stick was performed resulting in a total cholesterol and blood glucose. the medical-quality machine took about 3 minutes to produce a result, and the medical student used this time to review the health history on the form and address the client’s questions. the client then moved one chair over again to a medical student who measured the blood pressure with an automatic, validated machine, then the student reviewed all the results with the client. the students were careful not to provide any medical advice, but each participant was provided with individualized lifestyle advice. if the client had a primary care provider (pcp), the student did advise how soon the client might seek an appointment based on the results. the client was provided a card showing all the results to be taken to the pcp. if the client did not have a pcp, the student explained how the student -directed free clinic works and added the date and time of the client’s appointment at the clinic to the results card. the back of the card included information about available lowcost transportation options. all free clinic appointments were scheduled within 6 days from the screening date. table 2: cardiovascular screening health risk assessment results: table 3 describes sites where cvd screenings were conducted. the greatest participation was at food banks, where a large number of would-beparticipants were available while waiting in line. some other successful venues included street fairs and job fairs. table 3: sites of cvd screenings food banks 320 community fairs 125 job fairs 58 civic club meetings 32 churches 16 immunization clinics 14 hospital housekeeping 7 total 572 journal of regional medical campuses, vol. 4, issue 4 original reports table 4 displays the demographics of screened participants. most of the participants were white, which is representative of the county as a whole. the age of participants ranged from 19 to 59 years, and more males were screened. table 4: demographics of population screened an excludes missing information not provided by participants. bcounty values obtained from u.s. census bureau (21). table 5 shows the percentage of abnormal blood pressure, blood glucose, and blood cholesterol readings we collected, using two threshold values defining “abnormal” for each element. table 5: cvd screening results aexcludes missing information when participants declined this portion of the screening. table 6 displays the prevalence of diagnosed hypertension, diabetes, and hyperlipidemia in the county, as compared to the percent of abnormal readings for blood pressure, blood glucose, and total cholesterol we found in our screenings. table 6: prevalence of cvd risk factors in county acounty data retrieved from centers of disease control and prevention, brfss prevalence and trends data22 before and after the regional campus programs that included the screenings, we surveyed the students involved concerning their confidence in their ability to design and implement a community project (see table 7). participants reported a large increase in confidence. (p = 0.001). sixty-two percent (42/68) of our students were female and 84% (56/68) were from small towns, which we defined as a population fewer than 30 000 and non-metro rural urban continuum code.23 journal of regional medical campuses, vol. 4, issue 4 original reports table 7: student opinions ai am comfortable planning and implementing a community health project or i have a good understanding of what it takes to design an effective community activity. bmann-whitney u = 1503.0, n1 = 69 n2 = 71, p < 0.001 two-tailed. ctwo students did not complete their pre-test discussion overall, we accomplished our goal of demonstrating that a group of students based at a regional medical school campus could plan and implement a successful cvd screening program. we learned that students’ confidence in their ability to design and implement a community health project was increased dramatically. it is our hope that the training in a community health project was successful in preparing our students to implement other projects in the future in the communities they will serve as physicians. our sample yielded a percentage of participants whose abnormal readings were like those of the entire county, suggesting that they are representative of the larger population. these initial results provide a good basis for designing the implementation phase of our project. limitations: although the primary data focus of the study was to estimate overall cvd risk, without an hdl value we were not able to calculate a numerical risk using calculators based on national evidence. test strips that measured total blood cholesterol cost approximately $1, while the test strips used to measure hdl along with total cholesterol cost approximately $8. our funding for this study was not sufficient to use the more expensive strips, so only total serum cholesterol could be measured. future screenings could benefit from increased funding to measure hdl levels. additionally, a formal diagnosis of hypertension requires 3 separate high blood pressure readings on three different occasions. because we only measured blood pressure several times at one sitting, no definitive diagnosis of hypertension could be made. participants with elevated blood pressure readings were directed to a definitive source of care so that a diagnosis of hypertension could be made if appropriate. our blood glucose readings should be considered random measures, as we were unable to know precisely when the patient last ate. although we attempted to choose representative screening venues, we went only where we were invited, directed by our advisory council’s community contacts. our initial results may be subject to selection bias. our original plan was to gather regular data over several years. however, the covid-19 pandemic forced us to suspend operations at our screening locations, limiting our results to a 2-year period. we expect to return to regular screenings soon and will track how many participants subsequently become established with our free clinic. the future due to loss of funding and logistical obstacles, the renowned franklin county cvd prevention program reduced its leadership, staff, and programs beginning in 2001. from 2006 to 2015, the county saw a gradual increase in smoking and mortality rates. by 2015, franklin county’s mortality rate had risen to be no better than the expected mortality rate of maine based on income.24 this shows that a cvd screening program built over almost 25 years may lose its benefits within 10 years if continuity is broken. with sustained funding and support from the community, we hope we can avoid this problem as we continue to plan the implementation phase of our effort. conclusions our results show that regional campus medical students directed by a representative county advisory council and supervised by a regional dean can successfully implement a community cvd screening journal of regional medical campuses, vol. 4, issue 4 original reports effort. the students also expressed a dramatic increase in their confidence in designing and implementing such a project. lessons learned are shown in table 8, which we offer for consideration by those at other regional campuses. table 8: suggested strategies for a successful community project references 1. o'connor a, wellenius g. rural-urban disparities in the prevalence of diabetes and coronary heart disease. public health. 2012;126(10):813-820. epub 2012 aug 24. doi: 10.1016/j.puhe.2012.05.029. 2. samanic cm, barbour ke, liu y, et al. prevalence of self-reported hypertension and antihypertensive medication use by county and rural-urban classification united states, 2017. mmwr morb mortal wkly rep. 2020;69(18):533-539. doi: 10.15585/mmwr.mm6918a1. 3. jennings ca, berry tr, carson v, et al.. uwalk: the development of a multi-strategy, community-wide physical activity program. transl behav med. 2017;7(1):16-27. doi: 10.1007/s13142-016-0417-5. 4. kamada m, kitayuguchi j, abe t, taguri m, et al. community-wide intervention and population-level physical activity: a 5-year cluster randomized trial. int j epidemiol. 2018;47(2):642-653. doi: 10.1093/ije/dyx248. 5. mahon s, krishnamurthi r, vandal a, et al. primary prevention of stroke and cardiovascular disease in the community (prevents): methodology of a health wellness coaching intervention to reduce stroke and cardiovascular disease risk, a randomized clinical trial. int j stroke. 2018;13(2):223-232. epub 2017 sep 13. doi: 10.1177/1747493017730759. epub 2017 sep 13. 6. bahramnezhad f, asgari p, zolfaghari m, farokhnezhad afshar p. family-centered education and its clinical outcomes in patients undergoing hemodialysis short running. iran red crescent med j. 2015;17(6):e20705. doi: 10.5812/ircmj.17(5)2015.20705. 7. lingfors h, persson lg. all-cause mortality among young men 24-26 years after a lifestyle health dialogue in a swedish primary care setting: a longitudinal follow-up register study. bmj open. 2019;9(1):e022474. doi: 10.1136/bmjopen-2018-022474. 8. crump wj, fricker rs, ziegler ch, wiegman dl. increasing the rural physician workforce: a potential role for small rural medical school campuses. j rural health. 2016;32(3):254-259. epub 2015 oct 30.doi: 10.1111/jrh.12156. 9. crump wj, fisher sm, fricker rs. community service as learning laboratory: a report of six years of a rural community-academic partnership. j kentucky med assoc. 2014;112:131–136. 10. record nb, onion dk, prior re, et al. community-wide cardiovascular disease prevention programs and health outcomes in a rural county, 1970-2010. jama. 2015;313(2):147-55. erratum in: jama. 2015;313(21):2185. doi: 10.1001/jama.2014.16969. 11. ezzati m, friedman ab, kulkarni sc, murray cj. the reversal of fortunes: trends in county mortality and cross-county mortality disparities in the united states. plos med. 2008;5(4):e66. doi: 10.1371/journal.pmed.0050066. erratum in: plos med. 2008;27;5(5). doi: 10.1371/journal.pmed.0050119. 12. dixon dc. franklin county up to date. j maine med assoc. 1971 nov;62(11):278-9. 13. puska p, jaini p. the north karelia project: prevention of cardiovascular disease in finland through population-based lifestyle interventions. am j lifestyle med. 2020;14(5):495-499. doi: 10.1177/1559827620910981. 14. blomstedt y, norberg m, stenlund h, et al. impact of a combined community and journal of regional medical campuses, vol. 4, issue 4 original reports primary care prevention strategy on all-cause and cardiovascular mortality: a cohort analysis based on 1 million person-years of follow-up in västerbotten county, sweden, during 1990–2006 bmj open 2015;5:e009651. doi: 10.1136/bmjopen-2015-009651. 15. hettema j., steele, j., miller wr. (2005). motivational interviewing. annu rev clin psychol. 2005;1:91-111. doi: 10.1146/annurev.clinpsy.1.102803.143833. 16. sidebottom ac, sillah a, miedema md, et al.. changes in cardiovascular risk factors after 5 years of implementation of a populationbased program to reduce cardiovascular disease: the heart of new ulm project. am heart j. 2016;175:66-76. epub 2016 feb 17. doi: 10.1016/j.ahj.2016.02.006. 17. benson g, sidebottom ac, sillah a, et al. population-level changes in lifestyle risk factors for cardiovascular disease in the heart of new ulm project. prev med rep. 2019;31;13:332-340. doi: 10.1016/j.pmedr.2019.01.018. 18. golden sh, purnell t, halbert jp, et al. a community-engaged cardiovascular health disparities research training curriculum: implementation and preliminary outcomes. acad med. 2014;89(10):1348-1356. doi: 10.1097/acm.0000000000000426. 19. landy dc, gorin ma, o'connell mt. studentled rural health fairs: attempting to improve medical education and access to health care. south med j. 2011;104(8):598-603. doi: 10.1097/smj.0b013e31822580a9. 20. suen j, attrill s, thomas jm, smale m, delaney cl, miller md. effect of student-led health interventions on patient outcomes for those with cardiovascular disease or cardiovascular disease risk factors: a systematic review. bmc cardiovasc disord. 2020;20(1):332. doi: 10.1186/s12872-020-01602-1. 21. u.s. census bureau quickfacts: hopkins county, kentucky. united states census bureau. (n.d.). https://www.census.gov/quickfacts/fact/table/ hopkinscountykentucky/pst045219. 22. centers for disease control and prevention. 2017. brfss prevalence & trends data: home. centers for disease control and prevention. https://www.cdc.gov/brfss/brfssprevalence/in dex.html last accessed august 2, 2021. 23. united states department of agriculture, economic research service. 2003. rural urban continuum codes. http://www.ers.usda.gov/data-products/ruralurban-continuum-codes.aspx last accessed july 19, 2021. 24. onion dk, prior re, record nb, et al. assessment of mortality and smoking rates before and after reduction in community-wide prevention programs in rural maine. jama netw open. 2019;2(6):e195877. doi: 10.1001/jamanetworkopen.2019.5877. erratum in: jama netw open. 2019;2(7):e199340. microsoft word feasibilityofpeer-ledarticle.docx published by university of minnesota libraries publishing feasibility of peer-led didactics in the core clinical year on a regional medical campus christine waasdorp hurtado, md, faap; erik wallace, md, facp; chad stickrath, md, facp doi: https://doi.org/10.24926/jrmc.v2i5.2138 journal of regional medical campuses, vol. 2, issue 5 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc christine waasdorp hurtado, md, faap erik wallace, md, facp chad stickrath, md, facp all work in jrmc is licensed under cc by-nc volume 2, issue 5 (2019) journal of regional medical campuses original reports feasibility of peer-led didactics in the core clinical year on a regional medical campus christine waasdorp hurtado, md, faap; erik wallace, md, facp; chad stickrath, md, facp abstract purpose the best methods for learning outside of the clinical setting in the core clinical year, especially at regional medical campuses with limited full-time academic faculty, are unknown. methods we developed and implemented a peer-led didactic program to complement our longitudinal integrated clerkship (lic) for students at our new regional medical campus (rmc) to achieve the same goals, objectives, and competencies as students at our main campus. these didactic sessions were developed and led by students for their peers with the assistance of community faculty members. student scores on usmle step exams and national board of medical examiner (nbme) subject exams for the core specialties were compared among the intervention group at the regional medical campus, the main campus, and the national average. finally, a student focus group and survey provided qualitative data about student perceptions of these sessions. results among participating students who completed the survey, 19 (95%) reported that the student-led didactics were relevant to their clinical work and 16 (80%) reported that these sessions enhanced their knowledge and the content was provided at the right pace and level. students ranked preparing to teach student-led didactics as one of the most valuable learning experiences and “worth the time it took to prepare.” students scored comparably to their main campus peers on all 7 nbme subject exams and the step 2 ck exam. conclusion utilizing peer-led didactics as a part of a longitudinal integrated clerkship is feasible and effective in helping students achieve the goals, objectives, and competencies of the core clinical year. this educational method should be considered at other regional medical campuses and lic-based programs. the authors do not have any conflicts of interest to disclose. this project received no funding. as all data were completely anonymized and no patients were involved, this was not reviewed by an ethics board. introduction in 2016, the university of colorado school of medicine, a large university-affiliated public medical school, launched its first regional medical campus (rmc) in a large urban setting in colorado springs, co. students at the rmc, which educates up to 24 students (n=21 for the inaugural class) during the core clinical year, were expected to achieve the same goals, learning objectives, and competencies as the students at the main campus, which utilizes a traditional block model with faculty provided didactics. faculty utilize several different teaching modalities including powerpoint lectures, team based learning, and small groups discussions. to fulfill these expectations, students completed a longitudinal integrated clerkship (lic) with comparable clinical experiences and a complementary didactic component. since the rmc relied primarily on community-based, volunteer clinical faculty compared with full-time academic faculty on the main campus, we utilized alternative teaching methods, in particular, peer-teaching for delivering core didactic content. benefits of peer teaching have been described in the medical education literature; however, these benefits have not been specifically reported in the core clinical year. peer based learning is a well-established educational strategy in which peers teach peers with demonstrated educational advantages for peer teachers, and to a lesser degree, for peer learners.1-3 one study showed that medical student peer teachers in an advanced cardiac life support (acls) course demonstrated improved understanding of the course concepts compared with peers who prepared to teach, but did not teach, both immediately following their teaching and in follow-up testing 60 days later.4 another study showed improved confidence among medical student peer teachers in material they taught.5 educators postulate that the time spent in teaching preparation allows for a deeper journal of regional medical campuses, vol. 2, issue 5 original reports understanding of the material.1,4,6 re-accessing the material to teach to their peers allows for development of scaffolding to previous knowledge which improves retention. one study demonstrated improved testing outcomes for 29 of 36 courses taught by peers compared to faculty.7 others have shown that these benefits occur without sacrificing the performance of peer learners.8,9 in addition to the favorable peer learner performance found in peer teaching studies, previous studies found peer learners frequently preferred peer-led lectures to faculty-led sessions.9-12 other studies reported that students found peerled sessions to be more interactive and taught at a more appropriate level.6 finally, the literature suggests peer learning may lead to more frequent utilization of high-yield and interactive teaching modalities, which may improve learning and satisfaction.13 an additional benefit for medical student peer teachers is the development of teaching skills that are required in residency. the liaison committee on medical education (lcme) specifies that residents must be prepared to teach and evaluate medical students.14 medical student peer teaching develops the knowledge, skills, and attitudes to be effective educators during residency. moreover, evidence suggests that students who teach their peers in medical school go on to be better teachers in clinical practice, which may directly improve patient care.1,6 resources available at a rmc that utilize primarily community-based, volunteer clinical faculty are different than those at a traditional academic medical center. effective methods, outside of the clinical setting, to help medical students learn the important concepts from the core clinical year are not well defined. we aimed to implement and evaluate a primarily student-led, faculty-assisted longitudinal 10-month didactic curriculum as a part of the lic at our new rmc to help students achieve the goals, objectives, and competencies of the core clinical year. program description rmc students were selected prior to starting their first year of medical school. upon acceptance to our institution they were asked their preference between several programs, including the rmc. in order to be considered they were required to complete an essay indicating their interest in our campus. a committee comprised of members of the admissions committee and the local rmc community selected 24 students from the incoming medical school class. all students complete the first t2 years and take the usmle step 1 at the main campus and rmc students then complete their core clinical year at the rmc. at the start of their fourth year all students complete a sub-internship at the main campus. they complete their fourth-year rotations at the rmc, main campus or away, similar to their peers. for the core clinical year, students at the rmc completed 8 weeks of inpatient clinical immersion experiences, followed by a 10-month lic. in addition to working with preceptors in the clinical environment, students engaged in a year-long didactic curriculum. the didactic curriculum at the rmc was developed to cover learning objectives and content comparable to the traditional block clerkship model on the main campus. however, the rmc curriculum utilized an integrated, developmentally appropriate curriculum that was mostly student-led and faculty supported. to minimize clinical interruptions, 4-hour didactic sessions were held on friday afternoons. every student was assigned to provide one 4-hour didactic session. students were assigned a topic with associated learning objectives and provided a community faculty advisor who was a subject matter expert. each student/faculty team was given the liberty of presenting the material with powerpoint, case-based learning, problembased learning, algorithm development, games (i.e. game show formats) or other techniques. sessions were developed over a 4-6-week time frame. students led the sessions with faculty providing assistance through insights, personal examples, answering questions, and ensuring the accuracy of the materials and discussion. over the course of the year, there were approximately 140 hours of scheduled didactic time. faculty-led sessions were utilized in the first 2 months while the students were on clinical immersions. topics were interspersed over the course of the year with a focus on each specialty prior to the required national board of medical examiners (nbme) subject exam. each week at the start of the didactic session, students were given a short quiz based on pre-reading to help prepare for the in-class material. the open-book quiz was completed in groups of 4 to 5 students over 20-30 minutes. following the didactic session, students were given an individual 10question quiz that covered all didactic sessions completed to date with 2 to 3 questions on the material covered that day. methods to assess the feasibility and efficacy of the educational program, required nbme subject exams were used to assist in knowledge assessment in 7 of the institution’s core clinical specialties in addition to 2 pass/fail in-house exams for musculoskeletal care and emergency medicine. these exams occurred every 2 to 4 weeks in the second half of the academic year. students took united states medical licensing exam (usmle) step 1 prior to starting the lic and step 2 one to 3 months after completing the lic with a 30-day study journal of regional medical campuses, vol. 2, issue 5 original reports period to prepare. the main campus students had the same timing and study periods. students completed online evaluations after each didactic session to assess perceived efficacy of the session. to evaluate new rmc and the impact of the didactic curriculum, all students (n=21) participated in a focus group and were provided a survey at the end of the year, which included 5 questions about the overall didactic curriculum and a ranking of the efficacy of the various types of non-clinical learning methods they experienced. statistical analysis utilized appropriate t-tests for comparison. results the survey was completed by 20 of our 21 students (95.1% completion), with a few questions completed by only 19 students. our rmc students did not differ significantly on entrance into medical school with mcat scores and gpas not statistically different by t-test. on entrance into our rmc, their step 1 scores were slightly higher, although not significantly, than the main campus. at completion of their clinical year at our rmc their step 2 scores were slightly higher than their main campus peers, although again not significantly. of the 140 hours of didactics, 85 hours (61%) were studentled and 55 hours (39%) were faculty-led. among participating students, student survey data demonstrated 16 (80%) felt that student-led didactics were provided at the right level for their knowledge and skill base. nineteen of students completing the survey (95%) reported the student-led sessions were relevant to their clinical work. most students, 15 out of 19 responding to question, (79%) felt more engaged in student-led didactics compared to faculty led lectures (table 1). eighty percent of the students felt that student led sessions enhanced their knowledge. students self-reported spending an average of 9.45 hours (2-23, median 8) preparing to lead each session; however, 17 (85%) of the students thought the time required in preparation to lead the session was “worth it” with only 3 students disagreeing. a portion, 4 of the 19, (21%) reported they did not find the peer-led sessions more engaging and 4 (20%) did not feel the sessions enhances their medical knowledge. table 1. student rating of student-led didactic sessions student agreement with the following statements about friday didactic sessions. (n=19 or 20) in comparing the relative efficacy of various learning methods, students ranked independent study and leading a didactic session as the 2 most effective methods, followed by participating in student led-didactics, participating in facultyled didactics, and preparing for required quizzes (figure 2). students commented that “(some) faculty-led sessions were too basic or superficial (and some) were overly detailed beyond relevance to us. overall, i feel that the student-led sessions were at a better ability level and more practical.” another student commented, “preparing a didactic lecture was one of the most educational experiences of the year. i still remember the subject matter from my talk near the beginning of the year.” figure 2. student ranking of preference of learning methods utilized outside the clinical setting at our rmc (n=18) evaluations were completed by students after each session (table 3) and showed no significant difference between the faculty and peer-led session evaluations with the exception of faculty wrapping up sessions with clear take home points more consistently than peer educators. there was no journal of regional medical campuses, vol. 2, issue 5 original reports significant difference in audience-engagement or overall assessment. table 3. summary of post-session didactic student evaluations key data for the academic year finally, among the 7 required nbme subject exams, rmc students performed comparably to their main campus peers who participated in the traditional block curriculum with faculty lectures (table 4). rmc students also performed comparably to main campus peers on their usmle step 2 clinical knowledge exam. table 4. student performance on all 7 nbme subject exams for the 2016-2017 academic year discussion students preferred peer-led didactics. surveys indicated that students perceived peer-led didactics to be valuable as both a teacher and learner, worth the time required to prepare to lead a session, and typically presented at a more appropriate level and in a more engaging way than faculty-led sessions. the process of teaching peers ideally provides them with the knowledge, skills, and attitudes to be a better teacher as they transition to fourth year and residency. most importantly, students at the rmc performed comparably on standardized tests compared with students on the main campus, supporting the feasibility of utilizing peer-led didactics in the core clinical year. our finding that students participating in peer-led sessions as a teacher perceived the experience to be a valuable learning experiences is consistent with the peer teaching literature in other settings. one study showed that peer teachers felt more confident than non-teacher peers in material they prepared and that teachers may have out-performed nonteachers on exams.15 peer teachers in an acls and electro cardio gram (ecg) interpretation courses demonstrated the greatest exam score gains on material they prepared for and taught. these results were durable in delayed post-tests.4 we were encouraged to find that in our setting where students are intensely busy with their clinical obligations, they found time to prepare to teach sessions and found this time was worth it. however, because the students interacted with the material in such a deep manner, they may have experienced improved retention and therefore a reduction in the amount of studying required on that topic at exam time. the utilization of a longitudinal integrated clerkship model, with its attendant increase in student scheduling flexibility, may have also made preparing to teach a session more feasible.16,17 students also felt that participating in a peer-led session as a learner was beneficial and generally preferable to participating in a faculty-led session. other medical education teaching methodologies that utilize a high amount of peer teaching, such as problem-based learning (pbl) and teambased learning (tbl), have been shown to be highly beneficial for peer learners. one study demonstrated improved clinical reasoning following tbl sessions, when directly compared to interactive seminars, without differences in multiple choice exam performance.18 another study showed long-term improvements in team dynamics, problem solving, communications skills and perceived self-learning in addition to development of professionalism associated with tbl.19 also, pbl techniques resulted in improved knowledge outcomes and perhaps more importantly, increases in selfdirected learning.20 the benefits of pbl include improved integration of basic science and clinical knowledge, improved team working skills and professionalism all in a model that students find more enjoyable and stimulating. many of our peer-led sessions employed pbl and tbl approaches to learning and it may be that these relatively newer methodologies were more readily considered and more easily implemented in our peer-led sessions. in addition, the benefits of peer teaching may be related to feeling an increased sense of responsibility to their peers. this has previously been reported in one study which evaluated gross anatomy learning using reciprocal peer teaching (rpt) and found that 83% of students agreed or strongly agreed that they were more likely to read prior to rpt compared to 35% with traditional methods (i.e. – faculty led sessions).13 although we did not explicitly measure the development of teaching skills by our students who were peer teachers, studies have shown that peer teachers develop teaching skills and are more likely to express an interest in continued involvement in teaching.21 since medical students are expected to teach as residents and as practicing physicians, it is important to find mechanisms such as medical student peer journal of regional medical campuses, vol. 2, issue 5 original reports teaching to help them develop teaching skills in a mentored environment. we must also consider the benefit of reducing the teaching burden on our volunteer clinical faculty. they spent an average of 2.5 hours in reviewing the material and preparation with the students. the majority of our faculty (82%) reported the process to be enjoyable a plan to continue supporting our peer led didactic program. many factors likely contributed to the success of our students during their core clinical year and it is difficult to attribute their performance on medical knowledge assessments, such as nbme subject exams and step 2 clinical knowledge exam, entirely to the peer-led didactic component of their year. it is likely the lic and other factors played a significant role in their testing outcomes. regardless of these confounders, our experience and outcomes demonstrate peer-led didactics can be utilized as an effective methodology to accompany an lic curriculum in the core clinical year. limitations of our study include a small sample size of selected students, the lack of higher level, downstream outcomes such as information on how our students transition to residency and how our curriculum affects their future teaching and learning. conclusions it is feasible to utilize a student-led, faculty supported didactic curriculum as a part of a longitudinal integrated clerkship at a regional medical campus to help students achieve the goals, objectives, and competencies of the core clinical year. peer-led didactics should be considered as a part of longitudinal integrated clerkships at other institutions. further evaluation of peer-led didactics can help us understand if they are more effective than traditional didactics. longer term follow-up can allow us to employ more sensitive assessments to pick up other differences in this modality (the development of teaching skills, testing differences, and any benefit of having teaching presentations on residency applications). references 1. bene kl, bergus g. when learners become teachers: a review of peer teaching in medical student education. fam med. 2014;46(10):783-787. 2. bennett sr, morris sr, mirza s. medical students teaching medical students surgical skills: the benefits of peer-assisted learning. j surg educ. 2018. 3. tai jh, canny bj, haines tp, molloy ek. implementing peer learning in clinical education: a framework to address challenges in the "real world". teach learn med. 2017;29(2):162-172. 4. gregory a, walker i, mclaughlin k, peets ad. both preparing to teach and teaching positively impact learning outcomes for peer teachers. med teach. 2011;33(8):e417-422. 5. nestel d, kidd j. peer assisted learning in patientcentred interviewing: the impact on student tutors. med teach. 2005;27(5):439-444. 6. ten cate o, durning s. peer teaching in medical education: twelve reasons to move from theory to practice. med teach. 2007;29(6):591-599. 7. ten cate o, van de vorst i, van den broek s. academic achievement of students tutored by nearpeers. international journal of medical education. 2012;3:6-13. 8. rudland j, rennie s. medical faculty opinions of peer tutoring. education for health. 2014;27(1):4-9. 9. house jb, choe ch, wourman hl, berg km, fischer jp, santen sa. efficient and effective use of peer teaching for medical student simulation. west j emerg med. 2017;18(1):137-141. 10. escovitz es. using senior students as clinical skills teaching assistants. acad med. 1990;65(12):733-734. 11. jayakumar n, srirathan d, shah r, et al. which peer teaching methods do medical students prefer? education for health (abingdon, england). 2016;29(2):142-147. 12. mills jk, dalleywater wj, tischler v. an assessment of student satisfaction with peer teaching of clinical communication skills. bmc med educ. 2014;14:217. 13. manyama m, stafford r, mazyala e, et al. improving gross anatomy learning using reciprocal peer teaching. bmc med educ. 2016;16:95. 14. aamc. functions and structure of a medical school 2018. 15. iwata k, furmedge ds, sturrock a, gill d. do peertutors perform better in examinations? an analysis of medical school final examination results. med educ. 2014;48(7):698-704. 16. hirsh d, gaufberg e, ogur b, et al. educational outcomes of the harvard medical school-cambridge integrated clerkship: a way forward for medical education. acad med. 2012;87(5):643-650. 17. latessa r, beaty n, royal k, colvin g, pathman de, heck j. academic outcomes of a community-based longitudinal integrated clerkships program. med teach. 2015;37(9):862-867. 18. brich j, jost m, brustle p, giesler m, rijntjes m. teaching neurology to medical students with a simplified version of team-based learning. neurology. 2017;89(6):616-622. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 5 original reports 19. zgheib n, dimassi z, bou akl i, badr k, sabra r. the long-term impact of team-based learning on medical students’ team performance scores and on their peer evaluation scores. med teach. 2016;38(10):1017-1024. microsoft word development of nely recruited.docx published by university of minnesota libraries publishing the development of newly recruited clinical teachers at a regional medical school campus michelle a. nuss, m.d.; janette r. hill, ph.d.; ronald m. cervero, ph.d.; julie k. gaines, mlis; bruce middendorf, m.d. doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 1, issue 4 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc michelle a. nuss, m.d.; au/uga medical partnership, athens, ga, usa janette r. hill, ph.d.; college of education, university of georgia, athens, ga, usa ronald m. cervero, ph.d.;university of georgia, athens, ga, usa julie k. gaines, mlis; au/uga medical partnership, athens, ga, usa bruce middendorf, m.d.; st mary’s hospital, athens, ga, usa corresponding author: michelle a. nuss, au/uga medical partnership, uga health sciences campus, 108 spear road, winnie davis rm. 203, athens, ga 30602, usa, email: snuss@uga.edu all work in jrmc is licensed under cc by-nc volume 1, issue 4 (2018) journal of regional medical campuses original reports the development of newly recruited clinical teachers at a regional medical school campus michelle a. nuss; janette r. hill; ronald m. cervero; julie k. gaines; bruce middendorf abstract background physicians who become clinical educators need specific forms of knowledge to become effective teachers. the purpose of this yearlong qualitative study was to use the teaching and learning experiences of newly-recruited preceptors and students to understand what knowledge community physicians need as they develop into effective clinical teachers at a regional medical school campus. methods semi-structured interviews with the 9 newly-recruited community hospital physicians and 37 medical students occurred at the beginning, weekly, and at the end of the year. weekly rounding observations were also completed. interview recordings and observation notes were transcribed confidentially and analyzed using inductive thematic analysis. results irby’s forms of knowledge were selected as the underlying structure for presenting the results. for preceptors, the strongest areas were knowledge of medicine, patients, and context. for students, knowledge of medicine was strongest. knowledge of pedagogy and learners was an area of weakness for preceptors and more work is needed to continue their developmental growth. conclusion this study provides evidence that new teacher-physicians use and/or develop knowledge about medicine and patients, the healthcare context, and pedagogy and learning to effectively enable 3rd year students learn the clinical practice of medicine. new community physician preceptors require robust, ongoing faculty development to enable more effective interactions for teaching and learning. keywords: clinical teaching, community physicians, forms of knowledge, qualitative research introduction due to a growing physician shortage, the association of american medical colleges (aamc) called for a 30% increase in medical school enrollment in 2007.1 the us is on track to meet this expansion soon by creating new medical schools and by increasing enrollments at existing medical schools on their main or regional campuses. just as most medical schools expanded their enrollment since 2007, so did the medical college of georgia (mcg). in partnership with the university of georgia, the state’s land-grant research university, the combined years 1, 2, 3, and 4 model regional campus (rc)2 was established in 2009 as the mcg/uga medical partnership. forty mcg students matriculated on the new campus in 2010, which was the site for this research project. the rise in medical student enrollment, while a necessity, also increased the need for new clinical teaching faculty across the us. many regional campus expansions (2 or 4-year campuses) have occurred in communities where no prior medical students or residents have been educated. thus, the new regional medical school campuses rely on community physician preceptors who are inexperienced in teaching medical students.3 for example, at rc approximately 650 new clinical preceptors have been recruited in northeast georgia with 100 community preceptors actively teaching the third and fourth-year medical students at any one time. currently, doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original reports faculty development sessions are held with as many as possible to provide introductory skills needed for effective teaching of medical students. the benefits of front-line physicians are many and are of high value for students.4 however, one of the major challenges facing new regional medical campuses is preparing the new community physicians to teach in an office or hospital setting.5-9 in that regard, irby has provided a framework for the kinds of knowledge that supervising physicians need for teaching in clinical practice, including 1) medicine and patients: contextualized and integrated knowledge of medical science and clinical practice, 2) context: understanding the context (e.g., outpatient, emergency rooms) and how it impacts your treatment options, 3) pedagogy and learners: often learned through observation and apprenticeship, understanding what learners know and are able to do in clinical practice, and 4) teaching scripts: integration of all forms of knowledge into clinical cases, adjusting as needed for the context and circumstances, and “…contain 3-5 commonly used teaching points, which vary by case, circumstance and teaching method.”10(p 780) identifying ways to use the framework to inform ongoing research and practice can extend professional development for preceptors. in an ongoing research initiative,11 we sought to explore the opportunities and challenges associated with this new collaboration between a regional medical school campus and community hospital as a site for clinical education. although there have been previous studies of the knowledge that new clinical teachers need,5,10,12 two characteristics of our regional campus make this study unique. the first is that the study was conducted during the first year that the clerkships were conducted at the hospital. secondly, residencies had not been developed at the time we conducted the study, so the attendings taught the medical students directly. the purpose of this study was to use the teaching and learning experiences of preceptors and students in order to understand what knowledge community physicians need as they develop into effective clinical teachers. methods we used a qualitative design to conduct basic field research in this exploratory study.13 data was collected using interviews and observations of preceptors and students to inform the results. context and participants. the study took place during six, 8-week internal medicine clerkship rotations at a local community hospital after human subjects approval was granted (irb #cr00000343). the community hospital where the data was collected has approximately 10 000 hospital discharges and 158 beds. the overall study period was one year, july to june. participants were working in the local community hospital and were either preceptors who were rounding with medical students for the first time or students who were rounding in internal medicine for the first time. we invited all 10 hospitalist preceptors to participate; 9 agreed through written consent. we also invited all 40, third-year medical students from the rc who rotated to the hospital; 37 agreed to participate through written consent. in a typical rotation, a group of 2-3 medical students would work with 3-4 different preceptors over an 8-week period. prior to starting the clerkships, the preceptors received a 3-hour faculty development session on the “1-minute preceptor” at the community hospital. there were additional sporadic faculty development sessions conducted throughout the year. research design, procedures, and analysis. this year-long qualitative study involved data collection by the team of 5 experienced researchers. the research team conducted beginning and end of year interviews with the 9 preceptors and 37 students (oneon-one, face-to-face or by phone) as well as conducting weekly interviews with preceptors and students after they rounded during the internal medicine clerkship. each interview took between 30-60 minutes, totaling more than 150 hours of interviews. questions asked of the preceptors included best and most challenging doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original reports teaching moments. questions asked of the students included best and most challenging interactions with preceptors. similar to graffam et al.’s study,5 the research team spent more than 100 hours during the year as a team in weekly observations (a minimum of 2 hours each week), recording interactions between the first-time preceptors and third-year medical students. observations ranged from one-on-one teaching to bedside rounding to didactic small group teaching. observations were completed in pairs so that the notes could be compared to generate final observation notes for each week. following confidential transcription of the interview recordings and observation notes, inductive analysis was used to code the open-ended responses from a representative sample of the large data set. the sample was selected based on the thoroughness of the responses (e.g., rich, thick descriptions of the preceptors’ and students’ experiences).14 using an interpretivist frame, initial data analysis was open-ended and conducted individually by members of the research team to identify preliminary patterns and themes. the research team met to compare codes and to generate the next level of patterns and themes. updates to the list of themes were made based on negotiation and re-examination of the data. a subset of the data was coded by independent researchers to corroborate the themes identified by core researchers and establish inter-rater reliability. the final level of analysis by the research team was guided by irby’s framework of forms of knowledge.10 interpretative rigor was established through inter-rater reliability and triangulation of data to ensure trustworthiness.12,15 three forms of data triangulation were used in the study: data sources, investigator, and methodologic.16 results irby’s 4 forms of knowledge10 needed to transform and master clinical teaching serve as a framework for presenting the results of this study: 1) medicine and patients, 2) context, and 3) pedagogy and learners (see table 1 for an overview). irby’s fourth form of knowledge, teaching scripts, were not found in the data. as this is a relevant finding, it is discussed in the closing section. knowledge of medicine and patients: preceptors. “the foundational knowledge of medical science and clinical practice forms the bedrock of clinical teaching.”10 the preceptors participating in this study showed evidence of a great depth of foundational knowledge. one important finding is how the preceptors viewed their work with the third-year students as a way to keep up-to-date with current knowledge. one preceptor noted what he was looking forward to as the year began: “just to be kept on my toes and to sort of see where they are in their learning in compared to where i am with my experience.” preceptors continued to talk about their knowledge of medicine and patients during the year in terms of their teaching and learning with the students. being able to interact and learn from and with the students over time was mentioned as a benefit by many preceptors. one preceptor shared a story relating to a particularly meaningful interaction with a longterm patient: …we had a patient who had a devastating code, cardiopulmonary arrest and sort of talk and teach about the complexities of being managed by a lot of specialists. then that left us with the family to really kind of be that connection between the specialist and the family and still being a part of that patient’s care. to me, that was the most important thing i did this week because we lost a patient, we talked about how the whole cascade happened. we got to see some pretty fancy interventions by specialty doctors and then we also kept that family really connected through, i thought, a really difficult time, but they did great. preceptors indicated another meaningful student interaction was “talking through a case,” which enabled a thorough review of the issues leading to a diagnosis. it is important to note that the preceptors also expressed concerns related to knowledge of medicine and patients. this was particularly evident at the beginning of the doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original reports year. several preceptors expressed being nervous about their knowledge base as exemplified in this quote: “i’m a little bit nervous about how far behind i may be and so a little bit of trepidation there.” knowledge of medicine and patients: students. foundational knowledge for the third-year medical students was clearly not as rich as that of their preceptors; that said, the students expressed their eagerness to be in a real-world context and to learn from the preceptors. specifically, the students mentioned that they were looking forward to applying their knowledge from classes taken during their first two years and to working with the preceptors to learn. one student conveyed his excitement as follows: “…the idea that we’re going to be having 3 or 4 patients a day…that’s actually really exciting because we’re just going to be actually practicing what we’ve been doing for the past two years … every single day in a functional environment.” students also expressed some concerns related to their knowledge base as the year started. students shared concerns if their knowledge of medicine and patients was “good enough” for the task ahead, particularly working with the preceptors. as one student stated: “i’ve never been under the gun at all times and i know our experience is going to be different because we don’t have that buffer between us and the attending physician [or patient]. so, i guess being on the spot and ‘on’ all the time.” as the year progressed, students continued to share insights related to knowledge of medicine and patients. for example, the majority of the students mentioned “clinical pearls” given by the preceptors as one of their best learning moments. several mentioned that getting first-hand knowledge and basic concepts from the preceptor enabled valuable learning. following patients through an entire process and learning about the care management team was also a valuable learning moment. as one student indicated: “the meaningful interactions for me were learning moments where we were talking, discussing our patients, and they [the preceptors] were helping me make connections, helping me walk through their processes and how they were treating the patients.” many students stated that the larger view enabled them to see multiple perspectives from different preceptors as well as others on the care management team. another meaningful interaction frequently mentioned by the students was the preceptor modeling a doctorpatient interaction. as stated by most of the students, this enabled them to gain valuable experience for their own interactions with patients. one student shared an example of how her preceptor modeled knowledge of medicine and patients for her: he's so comfortable talking with the patients. not that he makes light of their situation but he knows how he can approach them. he lets them know what's going on and what we're doing about it and is very upbeat about it without making light of it… i think that makes a big difference to the patient. the students also mentioned several challenges with knowledge of medicine and patients in comparison to their preceptors. the volume of information needed was mentioned by many as an enormous challenge, although the students also recognized that sometimes you can only know/do so much. managing a difficult patient/family situation was also mentioned as a challenge. some students also indicated they did not always feel like they had the complete story, with some wondering if their position as a medical student had an influence. one student shared the following story related to knowledge of medicine and patients: “i met him for the first time; he had a long history of alcohol abuse and liver failure. he was telling me how bad he hurt and i automatically questioned him because he had never complained to anyone else. you don’t know if they’re telling the truth.” knowledge of context: preceptors. the preceptors working with the third-year medical students had a great deal of knowledge about context, particularly inpatient services and the emergency room. most preceptors had worked in the hospital for many years, thus had considerable understanding of “...types of patients seen, [typical] diseases treated and treatment options available.”10(p 779) as the year started, all preceptors made note of the unique opportunity of having the third-year medical students in the context, indicating learning together as a team as a positive aspect. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original reports as the year progressed, most of the preceptors continued to indicate that having the third-year medical students working as an inter-disciplinary team was positive, noting the value of multiple perspectives. preceptors and students had ipads that further enabled ready access to information at the point-of-care for patients.11 a preceptor described the value of these additions: “i was trying to look up something i didn’t know the answer to; none of us could find the answer. it was about a different kind of bacterial infection, whether or not it was a true pathogen. each of us found it on our own later on and shared.” the preceptors mentioned several contextual challenges. at the beginning of the year, the preceptors expressed concerns about balancing time with daily tasks, and finding good spaces for effective teaching. time continued to be mentioned by the preceptors as a challenge to interactions throughout the year, specifically noting: flow of the day, time management, time for students to present, and simply having too much to do. several preceptors mentioned having too many patients or the topic being discussed is too big (i.e., patient presentation is too complex) given limited time. knowledge of context: students. students had varying clinical experiences coming into the hospital for the internal medicine rotation. some may have had experience in inpatient services, others in outpatient settings. all of the students indicated that they were looking forward to working in the hospital independently and on a team with their peers and the preceptor. as the year progressed, the students continued to express the value of learning in the hospital context. many students stated that the larger view enabled them to see multiple perspectives from different physicians and others on the care management team. students also mentioned that participating in catastrophic medical events under the guidance of their preceptors as a “best” and “invaluable” learning moment because those were immersive experiences with high emotional content. while the benefits of the real-world context of the hospital were clear, the students also expressed concerns about meeting the expectations of preceptors and patients, particularly at the beginning of the year. some students also expressed concern that this was the first time medical students would be rounding with preceptors at the hospital, expressing concern about logistics management and the limited teaching experience of the preceptors. one student articulated the concerns relating to knowledge of context as follows: “the fact that they have not had students at all or maybe just not recently. we’re kind of the first ones through here, so i am sure there will be bumps in the road.” concerns raised by the thirdyear medical students throughout the year included the demands and time pressures of inpatient services. like the preceptors, the lack of time to discuss patients was one of the biggest challenges expressed by the third-year medical students. closely related, students mentioned the caseload as a challenge and indicated they had too many patients assigned to fully engage in meaningful interactions with the patients and preceptors. knowledge of pedagogy and learners: preceptors. naturally, all of the preceptors had experienced being a student and resident in a clinical setting, learning “...by observing positive and negative examples of teaching.”10(p 780) however, none of the preceptors had any recent experience teaching students or residents. despite this interval, there was evidence throughout the year of preceptors asking questions, engaging in case discussions, observing and giving feedback, and other clinical teaching methods (e.g., one-minute preceptor).17 one of the most positive aspects noted by the preceptors was the ability to teach in the moment. as many preceptors indicated, seeing the patient over a series of days enabled them to teach at the point of care, thus facilitating real world learning and problem solving. it is important to note that preceptors expressed concerns at the beginning of the year about their lack of formal training to teach medical students; these concerns continued throughout the year. preceptors described how unexpected patient complications were a challenge to teaching. knowing how and what to teach was also mentioned as a concern. one preceptor shared a larger perspective on his concerns related to doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original reports knowledge of pedagogy and learners: “i am trying to develop some flow through the week and not really knowing how to make sure they are getting their monies worth… we want to be the best, we want to compete against every other program around.” lastly, preceptors mentioned concerns related to their perception of themselves as teachers and their teaching abilities: “am i teaching them what they need to know?” and “am i growing as a teacher?”. knowledge of pedagogy and learners: students. the students indicated the immersive learning experience in the hospital as invaluable. students noted some specific pedagogical techniques used by the preceptors that were useful, including when the preceptor questioned the student to commit to what is going on with the patient, enabling students to share their knowledge and demonstrate their thinking process. the majority of students also indicated that a detailed discussion of a patient after examination was meaningful. the students mentioned several challenges with their preceptor interactions related to pedagogy. for example, students raised concerns that the preceptors rarely observed their history and physical examinations in the hospital, and, as indicated earlier, students were concerned about the teaching experience of the preceptors. as one student stated: “the challenge was just that they haven’t had students before. i guess gauging my level of where i was, it seemed like there was both under and overestimation.” discussion this year-long, in-depth qualitative study provided a rare opportunity to study the addition of teaching responsibilities to a cohort of busy hospitalists at a community hospital while a new medical school campus was using these hospitalists for the internal medicine clerkship for the first time. numerous studies have been conducted of barriers and motivations for clinicians becoming preceptors and the process of learning to become a clinical teacher. 5-8 however, this study was able to explore these issues and processes with preceptors with no prior history of teaching in a new internal medicine clerkship. one major conclusion of this natural educational experiment was that as physicians undertake the role of teachers, they experience learning processes similar to that of third-year students learning the clinical practice of medicine: it evolves and deepens over time. preceptors and medical students were both concerned about how they would manage multiple responsibilities as they were, respectively, learning new skills as educators and aspiring physicians, and whether they were prepared to succeed in learning these new roles. preceptors and medical students found that “learning by doing” (see, for example, kolb, 1984)18 during the clerkship was essential to becoming teachers and physicians deepening their understanding of multiple forms of knowledge.10 it was important for the preceptors and students to accept the complexity of clinical situations as they found these were both the best, and most challenging teaching moments. graffam, et al.5 developed an approach to clinical instruction for medical education, explaining that the “model would introduce a method of guided reflection for clinicians who, generally lacking pedagogical training, teach as they were taught.”19,20 the preceptors in our study had little pedagogical training, and we confirmed that many of their teaching processes were based on their experiences as residents. throughout the year, preceptors questioned if they were teaching what the students needed to learn, but also if their clinical teaching methods were effective. central to the graffam, et al. model5 is the role of reflection, which is as important for learning the practice of precepting as it is for learning the practice of doctoring.21-23 our data indicated many missed opportunities for effective teaching throughout the year, which may have been lessened if a model of reflection had been used to coach the preceptors to develop effective teaching strategies. helping the preceptors to think about how they can improve their pedagogical practice is an important barrier to remove so they can explore what they do not know. time was one of the most significant challenges for the preceptors and students. finding ways to increase time so the preceptors can work on skills to become effective clinical teachers is important. preceptors need doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original reports time and training to develop: 1) knowledge of pedagogy and learners and 2) the ability to get that knowledge effectively across to the medical students. enabling preceptors to teach in other contexts (e.g., the medical school campus) can also assist with deepening pedagogical strategies and techniques. in doing so, preceptors will be able to create integrated teaching scripts,10 which were not evident in this study. we hypothesize that irby’s fourth form of knowledge was not found because these new clinical teachers had not yet developed teaching scripts. additionally, partnering master clinical teachers from the medical school campus with the community physicians may help to alleviate some of the concerns voiced in our study. the use of mentoring, role-modeling, and frequent feedback will help to accelerate the development of the community physicians. this “academic infusion” of clinical teachers to the learning process will not only help the development of the new preceptors, but also improve the teaching and learning processes for the medical students. we found that the single most valuable pedagogical strategy was to focus on improving students’ clinical reasoning processes. students reported their most meaningful interactions were when the preceptor pressed them to make a commitment about the patients’ histories and findings with supporting evidence and reasoning. although the preceptors were exposed briefly in a workshop to the “one-minute clinical preceptor”24,25 as well as other models of clinical teaching,24 these approaches were not always evidenced in the learning experiences of the students. modeling of the clinical reasoning process is critically important for faculty development efforts, because there is substantial evidence for its effectiveness.26,27 this study has several limitations, two of which were part of the study context: 1) there was only sporadic, unplanned faculty development to enhance teaching effectiveness, 2) there were no residents in the hospital that would have typically been a part of the medical team, and 3) there was an existing relationship with participants by three of the five members of the research team (i.e., in supervisory roles for the students). while the first two contextual characteristics may have limited what might have been possible with the preceptors and medical students, they also provided a unique opportunity for more first-hand interactions between the preceptors and medical students. this not only provided the medical students with a rare experience, it also enabled the preceptors to extend and enhance their practices as educators in ways that might not otherwise have been possible. although some of the challenges did continue throughout the year (time, balancing teaching and patient care), the preceptors also indicated that the “flow” of the interactions in terms of logistics and student interactions did improve over the year. conclusion we had a unique opportunity to study a context that is rare: a new regional medical school offering rotations in the third year for the first time in a setting with no residents to act as mediators between the third-year students and the preceptors. we found that learning how to teach in a busy clinical setting has similarities to learning the practice of medicine: both take time. lessons for practice include: • finding ways to increase preceptors’ time and training to work on skills to become effective clinical teachers is important. • a valuable pedagogical strategy is to focus on improving students’ clinical reasoning processes. • modeling of the clinical reasoning process is critically important for faculty development efforts. • the use of mentoring, role-modeling, and frequent feedback will help to accelerate the development of the community physicians. • helping the preceptors to think about how they can improve their pedagogical practice is an important barrier to remove so they can explore what they do not know. several recommendations result from the study and include: 1) new regional campuses partnering with community hospitals must take seriously the importance of preparing preceptors to teach medical students, particularly if they are new to this role, 2) faculty development should use existing evidence-based models, doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original reports such as the one-minute preceptor or snapps,24,25 to provide effective learning for medical students, 3) time is always going to be limited so focusing on key aspects of educating the students (e.g., clinical reasoning, modeling patient interaction, observation of unique cases) is critical for continued development of the medical students, 4) preceptor caseloads should be managed so that time for teaching is more robust and effective for the preceptor and medical students, and 5) hiring academic physicians to assist with teaching in clinical settings may assist with balancing the work load for the community physicians. future research could replicate this study with the initiation of new residency programs, as the issues and learning processes for new teaching new residents is likely to mirror the processes of the preceptors learning to teach new medical students. references 1. association of american medical colleges. aamc statement on the physician workforce. https://www.aamc.org/download/55458/data. published june 2006. accessed august 4, 2017. 2. cheifetz ce, mcowen ks, gagne p, wong jl. regional medical campuses: a new classification system. acad med. 2014;89(8):1140-1143. 3. farnsworth tj, frantz ac, mccune rw. community-based distributive medical education: advantaging society. med educ online. 2012;17:8432. 4. ferenchick gs, chamberlain j, alguire p. community-based teaching: defining the added value for students and preceptors. am j med. 2002;112(6):512-517. 5. graffam b, bowers l, keene kn. using observations of clinicians' teaching practices to build a model of clinical instruction. acad med. 2008;83(8):768-774. 6. latessa r, colvin g, beaty n, steiner bd, pathman de. satisfaction, motivation, and future of community preceptors: what are the current trends? acad med. 2013;88(8):1164-1170. 7. peyser b, daily ka, hudak nm, railey k, bosworth hb. enlisting new teachers in clinical environments (entice); novel ways to engage clinicians. adv med educ pract. 2014;5:359-367. 8. scott i, sazegar p. why community physicians teach students (or not): barriers and opportunities for preceptor recruitment. med teach. 2006;28(6):563-565. 9. christner jg, dallaghan gb, briscoe g, et al. the community preceptor crisis: recruiting and retaining community-based faculty to teach medical students-a shared perspective from the alliance for clinical education. teach learn med. 2016;28(3):329336. 10. irby dm. excellence in clinical teaching: knowledge transformation and development required. med educ. 2014;48(8):776784. 11. nuss ma, hill jr, cervero rm, gaines jk, middendorf bf. real-time use of the ipad by third-year medical students for clinical decision support and learning: a mixed methods study. j community hosp intern med perspect. 2014;4(4). 12. o'brien b, cooke m, irby dm. perceptions and attributions of third-year student struggles in clerkships: do students and clerkship directors agree? acad med. 2007;82(10):970-978. 13. kitto sc, chesters j, grbich c. quality in qualitative research. med j aust. 2008;188(4):243-246. 14. miles mb, huberman am, saldaña j. qualitative data analysis: a methods sourcebook. 3rd ed. thousand oaks, ca: sage; 2014. 15. ruona w. analyzing qualitative data. in: swanson r, holton e, eds. research in organizations: foundations and methods of inquiry. san francisco, ca: berrett-koehler; 2005:223-263. 16. thurmond va. the point of triangulation. j nurs scholarsh. 2001;33(3):253-258. 17. aagaard e, teherani a, irby dm. effectiveness of the one-minute preceptor model for diagnosing the patient and the learner: proof of concept. acad med. 2004;79(1):42-49. 18. kolb da. experiential learning : experience as the source of learning and development. englewood cliffs, nj: prentice-hall; 1984. 19. hurst jw. the overlecturing and underteaching of clinical medicine. arch intern med. 2004;164(15):1605-1608. 20. hesketh ea, bagnall g, buckley eg, et al. a framework for developing excellence as a clinical educator. med educ. 2001;35(6):555-564. 21. cervero rm. place matters in physician practice and learning. j contin educ health prof. 2003;23 suppl 1:s10-18. 22. schön da. the reflective practitioner : how professionals think in action. new york, ny: basic books; 1983. 23. brookfield s. becoming a critically reflective teacher. 1st ed. san francisco: jossey-bass; 1995. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original reports 24. neher jo, gordon kc, meyer b, stevens n. a five-step "microskills" model of clinical teaching. j am board fam pract. 1992;5(4):419-424. 25. parrot s, dobbie a, chumley h, tysinger jw. evidence-based office teaching--the five-step microskills model of clinical teaching. fam med. 2006;38(3):164-167. 26. cayley we, jr. effective clinical education: strategies for teaching medical students and residents in the office. wmj. 2011;110(4):178-181; quiz 203. table 1. forms of knowledge for teaching and learning: perceived strengths and concerns about preceptor and student knowledge bases. preceptors students knowledge of medicine and patients strengths • keeping up to date • interacting with and learning from students overtime • thoroughly reviewing and talking thru diagnosis concerns • concerns with being behind with knowledge base strengths • applying knowledge • valuing clinical pearls • teaching in the moment; real-life situations; seeing a longitudinal perspective • modeling doctor-patient interaction concerns • questioning knowledge base (i.e., is it enough) • volume of information need to know • managing a difficult patient situation knowledge of context strengths • unique opportunities • learning together as an interdisciplinary team with multiple perspectives • teaching/treating at point of care with technology concerns • time: balancing tasks, managing time/tasks, time for teaching, too many cases • not having a good space for discussions • unexpected patient presentations: lots of patients all at once, not so straight forward strengths • working independently and in a team • experiencing real-world experiences with multiple perspectives • learning from “catastrophic” medical events concerns • preceptor and patient expectations • first time happening (mp/stmh) • demands and time pressures • case loads knowledge of pedagogy and learners strengths • teaching in the moment • learning together/interactions over a series of days concerns • teaching experience and/or training limited or no prior experience • questioning own teaching abilities and struggling with new identity as a teacher strengths • valuing immersive learning • seeking preceptor probing student to commit to what is going on with patient • having detailed discussion of patients concerns • preceptors not observing • need to recognize that sometimes can only know/do so much microsoft word the development of a wellness article.docx published by university of minnesota libraries publishing the development of a wellness curriculum at a new regional campus: a pilot study katelyn edel, mph, michael flanagan, md, juan qiu, md, jacqueline gardner doi: https://doi.org/10.24926/jrmc.v4i2.3620 journal of regional medical campuses, vol. 4, issue 2 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc katelyn edel, mph michael flanagan, md juan qiu, md jacqueline gardner all work in jrmc is licensed under cc by-nc volume 4, issue 2 (2021) journal of regional medical campuses original report the development of a wellness curriculum at a new regional campus: a pilot study katelyn edel, mph, michael flanagan, md, juan qiu, md, jacqueline gardner introduction with burnout on the rise for healthcare professionals in both practice and training alike, there has recently been an increased focus on student wellbeing and resilience in medical education. burnout is characterized by several symptoms, including emotional exhaustion, decreased empathy, and cynicism.1 burnout can also be accompanied by other mental health conditions, such as depression and anxiety. it is well documented that the demands associated with medical school challenge the personal wellness of students, leading to significant distress.2,3,4 in one study, a survey of fourth-year students from 6 medical schools revealed that 50% of the students expressed signs of burnout at graduation.5 this is especially remarkable given that matriculating medical students, when compared to age-matched controls, have lower rates of burnout and depression symptoms,6 suggesting that issues with burnout and mental health manifest over the course of a student’s medical education. a number of factors related to medical education are thought to contribute to the deterioration of personal wellbeing among medical students, including academic pressure, cognitive and physical workload, poor support systems, and sleep deprivation.3 in an effort to combat the decline in personal wellness, medical schools started to examine ways in which they could better support their students. as early as 2004, governing bodies such as the american association of medical colleges (aamc) and the liaison committee on medical education (lcme) called for “schools to rise to the challenge of the new understanding of the risks of medical training for trainees”.2,7,8 a statement from the aamc suggested that the medical education system prioritize the “health and well-being of students” in an effort to “improve the overall experience of medical education in the united states”.7 many of the early initiatives to address student burnout and distress have been described as “reactive” and took the form of increasing access to mental health services on campus.9 additionally, school-wide campaigns focused on reducing the stigma related to seeking mental health counseling.9 more recent efforts have taken a proactive approach to medical student wellness, including a wide variety of initiatives such as comprehensive wellness programs administered through the office of student affairs, curricular changes, faculty development sessions about student wellness, and the incorporation of mindfulness-based stress reduction.9,10 two schools, vanderbilt school of medicine and saint louis university school of medicine, have described their initiatives in depth. at vanderbilt school of medicine, a 3-tier program consisting of intensive advising, a school-wide “wellness cup” activity competition, and a longitudinal curriculum designed to emphasize personal and professional development for physicians-in-training was developed.10 the program is primarily administered through the office of student affairs but has significant student involvement in the form of leadership and committee development. fully incorporated in 2005, the program is based on the national wellness institute’s six dimensions of wellness.10,11 these 6 domains include social, physical, spiritual, occupational, emotional, and intellectual. the program has been well-received by students and continues to grow and evolve with student input. saint louis university school of medicine has developed a similarly comprehensive program. over the course of 3 years, a “wellness curriculum” was incorporated into the pre-existing medical education structure. these changes include transitioning from a hierarchical grading structure to pass/fail grading, faculty development sessions about the importance of prioritizing student wellness, learning communities to increase levels of student engagement and strengthening relationships with faculty and peers, and a resilience program for students with sessions about stress reduction, imposter syndrome, optimistic explanatory styles, and energy management.9 the curriculum is administered over the 4 years of medical school. by starting to introduce concepts of resilience and wellness in the first year of journal of regional medical campuses, vol. 4, issue 2 original report training, it is believed that “good habits can be part of a daily schedule” and may help to slow or prevent the decline of mental health often observed in medical students between matriculation and graduation.10 given that many medical schools are developing wellness programs such as those described above, it is important to capture the students’ experience of wellness. the graduation questionnaire (gq), administered to all graduating medical students through the aamc, now includes a section about “wellness” and seeks to ascertain how well a medical school addresses student concerns related to personal wellbeing and resilience.10 saint louis school of medicine used the results of the gq to assess the success of their program. student satisfaction with the school’s wellness program increased on the graduation questionnaire from 3.6 to 4.4, with 5.0 being “completely satisfied” after implementation of the curricular changes.9 the integration of wellness and resilience into medical school curricula draws heavily on previous research about burnout and poor mental health outcomes in both health professionals and physicians-in-training.1 it also reflects the understanding of what constitutes a comprehensive medical education and acknowledges the changing attitudes in regard to a medical school’s responsibilities for supporting and protecting student mental health. by focusing on how wellness programs are implemented and how successful they are at positively impacting students, more schools can develop curricula to meet the needs of their student bodies. specific aims/objectives while the graduation questionnaire can be used to determine the impact of completely integrated wellness programs, and medical schools such as vanderbilt school of medicine and saint louis university school of medicine have written about the shortand long-term effects of their curricular changes, there is little research describing the implementation and refinement of a wellness curriculum at a regional campus of an academic medical center. the relatively new penn state college of medicine university park campus (established as a 4year campus in 2017) represents a unique opportunity to develop a comprehensive wellness program because of the flexibility of our curriculum and the small number of students. we sought to pilot a longitudinal wellness curriculum, run primarily through the office of student affairs, for the 36 first, second, and fourth year students at the campus (at the time of the project, there were no third-year students). the project was modelled on the six dimensions of wellness from the national wellness institute (social, physical, spiritual, occupational, emotional, and intellectual), as was done by vanderbilt school of medicine.10,11 there was also a resilience and mindfulness focus that started in the first year of medical school, as was done by saint louis university school of medicine.9 the specific objectives for our project included the following: 1) develop a dedicated wellness program specific to first-year (ms1) students in their second semester, which did not previously exist, and 2) create a companion program of inter-professional wellness exercises open to all teaching faculty (both academic and community-based), and all learners (residents, medical, physician assistant (pa), and nurse practitioner (np) students) at the penn state college of medicine university park campus. using the results from this pilot program, we plan to develop a more formal curriculum that is accessible, helpful, and convenient for all members of the university park regional campus community. methods in order to develop a wellness program for all students, resident physicians, faculty and staff at the penn state college of medicine university park campus, a number of different “project arms” were implemented. those developing the pilot curriculum felt that the current wellness program was incomplete. prior to the implementation of the pilot curriculum, second-year and fourth-year medical students attended kienle groups (named after drs. lawrence f. and jane witmer kienle). these interactive sessions provide a dedicated time each week for self-reflection, group dialogue about humanism in medicine, and professional development for students actively involved in patient care and are believed to contribute to overall student wellness; the groups are typically well-received. before the pilot program, there were also sporadic activities advertised as “wellness workshops” offered to all members of the university park regional campus community. while certainly providing some benefit, the kienle sessions and various wellness activities did not constitute a comprehensive wellness program and overall there lacked a formalized, consistent curriculum. we felt it was especially important to have a wellness curriculum in place for first-year medical students to create a culture of vitality upon matriculation and to fully maximize the possibility for a longitudinal wellness curriculum offered throughout all 4 years of medical training. journal of regional medical campuses, vol. 4, issue 2 original report an institutional grant created to specifically advance wellness and vitality among healthcare professionals within the penn state college of medicine was secured for the development and implementation of this pilot program. this competitive grant was funded by the college of medicine’s office of faculty development. it was entitled the office of faculty and professional development wellness mini-grant program. the first part of the project included a series of required formal sessions for first-year medical students during regularly scheduled class time. there were 4 sessions in total, led by a community-based professional health and wellness coach. a portion of the grant was used to pay for the coach’s services. each session focused on a different domain from the national wellness institute’s six dimensions of wellness.11 session one was “professional;” session two was “intellectual,” session three was “spiritual,” and session four was “emotional.” each session was co-created by the wellness curriculum designers, the medical education team, and the professional health and wellness coach. these mandatory sessions were offered during a regularly scheduled course in the ms1 curriculum, 4 times throughout the second semester. students completed an anonymous paper pre-survey for each session, containing questions addressing the topic for that session. after the completion of the 4 sessions, students completed an anonymous post-survey. paper surveys were used for convenience. students could complete the survey at the beginning of class, thus ensuring that all responses were collected in a timely fashion. a presurvey was given before each of the 4 sessions and one post-survey was given at the completion of the last session. each pre-survey had general wellness questions as well as questions specific to the professional, intellectual, spiritual, and emotional domains of wellness. the second part of the project focused on the “physical” wellness domain and included students, faculty, and staff. a 10-session traditional tai chi course was offered in the evenings from 6:00pm to 7:30pm at the main university park educational facility. the courses were taught by a tai chi practitioner experienced in teaching tai chi to beginner-level students. a portion of the grant was used to pay for the instructor’s time. the tai chi classes were advertised to all members of the university park community, including all learners, residents, attending physicians, teaching faculty, and staff. the sessions were optional and individuals could attend as many or as few times as their schedules allowed, at no charge. it was a flexible initiative offered at a convenient time in the evenings. before their first session, participants completed a paper pre-survey with questions about wellness and physical activity and their prior experience with tai chi. after their class, participants were asked to complete a post-survey. paper surveys were used because participants often did not have a computer with them during class and the researchers wanted to ensure that all participants completed a survey promptly. hot tea and flavored water were offered at all sessions. lastly, the third part of the project was designed to address the “social” wellness domain. several watercolor sessions were advertised to all members of the university park campus community. the watercolor sessions were offered in the evening from 6:00pm to 7:30pm at the main university park campus facility. sessions were facilitated by a wellness curriculum designer and faculty member who has experience with teaching painting and creative arts to students of all levels. the sessions were advertised as an informal space for people to “relax, paint, and talk”. all of the supplies for the sessions were provided at no cost to the participants. at the start of the session, participants were asked to complete an anonymous paper pre-survey. at the completion of the session, participants completed a post-survey. if a participant attended more than one session, they completed the corresponding preand post-survey. some of the later sessions focused on a specific medical topic, including ophthalmology, infectious diseases, and pathology, where students painted images associated with each specialty, such as retinal hemorrhages, staph aureus and melanoma. collectively, each arm of the project contributed to one of the six dimensions of wellness in an effort to create a well-rounded curriculum for all students. the preand post-surveys from the formal ms1 educational sessions, the tai chi sessions, and the painting sessions were reviewed on redcap to assess the reach and impact of each project component. results all preand post-surveys from the watercolor sessions, tai chi sessions, and mandatory ms1 sessions were reviewed on redcap, a secure web application for building and managing online surveys and databases. information from the surveys was collected to better understand the student, faculty, and staff response to the variety of new wellness programs at the university park regional campus. there were 34 unique participants across the 3 study arms. for the mandatory wellness classes, all 13 first-year students attended because it was journal of regional medical campuses, vol. 4, issue 2 original report a curriculum requirement. a total of 20 individuals participated in the watercolor sessions. there were 15 participants for the tai chi sessions (table 1). table 1. participants in ms1 sessions, tai chi sessions, and watercolor sessions. session type number of participants percent medical student ms1 lecture session 13 100% (13/13) tai chi session 15 27% (4/15) water color session 20 60% (12/20) a. mandatory wellness didactic sessions (professional, intellectual, spiritual, and emotional domains of wellness) of the 13 student participants, 10 students stated that they had a consistent wellness practice (graph 1). of the students with a wellness practice, there were a wide variety of activities in which the students participated, including physical exercise, meditation and/or prayer, socializing with friends, and watching television. for students with a wellness practice, the amount of time devoted to the practice ranged from 2 times per week to 7 times per week. eight students indicated that their wellness practice was moderately or somewhat effective at helping them maintain their wellbeing. for students without a wellness practice (n=3), the limiting factors included lack of available time and lack of interest in developing a wellness practice. a majority of students (58%) stated they were “extremely open” to making a regular wellness practice part of their lifestyle. in the post-survey, the first-year students were again asked about general wellness (graph 2). interestingly, a fewer number of students stated they had a consistent wellness practice (n=5, compared to the 10 students who had a consistent wellness practice at the time of the pre-survey). graph 1. pre-survey results of students with a consistent wellness practice. graph 2. posts-survey results of students with a consistent wellness practice. when asked what types of wellness activities they would like to see offered at the university park campus, most students indicated they would enjoy arts-based activities and physical activity. there was also a request from 2 students to have “less forced wellness” and more “time alone”. six students did not feel the mandatory 4 sessions on wellness were a valuable part of their medical education. however, more than half (55%) of the students strongly agreed or agreed somewhat that a dedicated first-year wellness curriculum would be a critical component of the penn state college of medicine university park campus curriculum. similarly, 89% of students indicated that it was the responsibility of the medical school to provide wellness activities as part of the curriculum. 77% 23% percent of students with consistent wellness practice yes no 38% 62% percent of students with consistent wellness practice yes no journal of regional medical campuses, vol. 4, issue 2 original report b. tai chi sessions (physical domain of wellness) there were 15 total participants in the tai chi sessions. four of the participants were students and the remaining 11 were clinical faculty or staff. for the tai chi presurvey, the majority of participants indicated they had a wellness practice (n=9). the wellness practices listed were overwhelmingly fitness and exercise-based. all respondents stated that their wellness practices were only somewhat or moderately effective at achieving or maintaining wellness. the biggest limitations to a consistent effective wellness practice were time, motivation/sustained commitment, and knowledge about effective wellness activities and resources. participants attended the tai chi classes for a number of different reasons, most commonly stress relief (table 2). table 2. reasons for participating in tai chi sessions (percent total is less than 100 as some respondents did not select a reason). reason for attending percent (n) exercise/fitness 13% (2) stress relief 34% (5) maintaining balance 20% (3) promoting wellness at school and/or my workplace 13% (2) social connection 8% (1) at the time of the tai chi post-survey, 6 participants indicated that they had a regular wellness practice, which was a decline from the number of people in the presurvey. five people stated that tai chi was moderately or somewhat effective at stress relief and/or as an exercise class, and 2 people said they would be extremely likely to attend tai chi classes if they were regularly offered at the university park campus, although none of these respondents were students. c. watercolor painting sessions (social domain of wellness) twenty participants were involved with the watercolor sessions. twelve were students. of the 12 students who participated, 9 were first year students. eleven people stated that their current wellness practice was only somewhat or moderately effective at maintaining wellness. student participants indicated that the biggest limiting factor that they have in maintaining their own wellness is time. fourteen participants indicated that they attended the watercolor session primarily for stress relief (table 3). table 3. reasons for participating in watercolor sessions (percent total is greater than 100 as respondents could select more than one reason for attending). reason for attending percent (n) stress relief 70% (14) maintaining balance 40% (8) promoting wellness at school and/or my workplace 40% (8) social connections with colleagues 45% (9) fifty percent of participants felt that the watercolor workshop was an effective wellness-based activity. when asked about additional wellness activities that could be offered at the university park campus, the overwhelming response was for creative activities, such as arts and crafts nights, sculpture, or photography. nineteen of 20 (95%) of these respondents felt that a health system, such as those associated with an academic medical center, are moderately or extremely responsible for providing wellness-based activities to students, faculty, and staff. of the 34 study participants, 20 (58.8%) indicated they would be extremely or moderately likely to attend future wellness activities offered at the university park regional campus. discussion the pilot program spanned a period of 6 months, from january 2019 to june 2019. overall, attendance at the events was low; this was especially true for the tai chi sessions. a very small number of students attended the tai chi sessions. faculty and staff participated in the tai chi sessions more than students, suggesting that certain wellness-related activities might be of interest to different groups at the regional campus. there are a number of ways that could improve the implementation of a formal wellness curriculum in order to maximize attendance. many students indicated that one of the reasons they didn’t have a formal wellness practice was due to lack of time. the time constraint component may be the reason attendance at the optional events was limited. when thinking about a wellness program for medical students, it is certainly journal of regional medical campuses, vol. 4, issue 2 original report difficult to reconcile the challenge of available time. medical school itself is a demanding, time-intensive endeavor and the traditional curricular components of classwork and clinical experiences leave little room for additional activities. as such, students may choose to spend what limited time they do have pursuing their own personal interests rather than engaging in schoolbased wellness events. this was captured in the survey responses of students requesting less “forced” wellness and more time to pursue their own interests. a student’s wish for more personal time and fewer school-sanctioned wellness activities must be balanced with the responsibility of medical schools and medical educators to support students in ways that extend beyond academics. it is unclear how medical schools can devote an appropriate amount of time to wellness activities while not overwhelming a student’s already full schedule. the fact that some survey responses indicated that it was a health system’s responsibility to provide wellness activities, as well as the responses from some students stating they didn’t have the knowledge or tools to develop their own wellness activities, suggests there is some expectation and responsibility for a medical school to provide these resources to students regardless of the challenges related to time constraints or other barriers to wellness. similarly, a major challenge of implementing a formal wellness curriculum is that the effect of the program is limited by the number of students who choose to engage. this is well-described by other individuals who have attempted to design such programs.9 it is possible that the students who selectively choose to attend wellness-focused programs are those who already have an interest in wellness, while those who do not attend are the ones who may be struggling with balancing the competing demands on their time. the very fact that students aren’t attending a wellness event might suggest that they feel they don’t have room for wellness activities in their daily life, given the other numerous personal and academic demands facing a medical student. in the pre and post-surveys completed by ms1s, there was a 50% decrease in the number of students consistently prioritizing wellness over the course of a semester which may represent growing time pressures and other obligations. similarly, more people attending the tai chi sessions indicated they had a consistent wellness practice at the time of the pre-survey compared to the post-survey. this suggests a possible decline in wellnessrelated activities over a several month period. the challenge, therefore, is how to reach the people who need the most help without adding additional stressors and further monopolizing their time. it may require an overall change in the culture of medical education and academic medicine in order to give students and faculty peace of mind when they choose to devote time to their own wellbeing rather than continue to strive to meet the exceptionally high educational demands of medical school. this 6-month long pilot program was designed to inform the development of a more robust, long-term wellness curriculum. after the project was underway, it became clear that it would have been helpful to first conduct a formal needs assessment of the student body. this could have made it easier to develop more impactful programming that was specifically suited to students’ needs. it would have likely been more focused on creativity and the arts, as these types of activities were predominantly favored by students. other limitations associated with this pilot program included the low attendance, which makes it difficult to generalize these findings to larger medical schools. additionally, this pilot program was completed at a regional medical campus; students who are interested in a unique medical education program self-select to interview and attend school at the regional campus. as such, as a whole the students surveyed in this study may differ fundamentally from students who choose to attend a more traditional curricular program. despite these challenges and limitations this pilot program served an important purpose. it provided insight into the understanding of student wellness and the academic medical center’s role in promoting student wellness. with this knowledge, the appropriate next steps can be taken to more effectively address the wellness needs of medical students. certainly, the first step for any school interested in designing a wellness curriculum should be to conduct a needs assessment of the students to better understand preferences related to activity type, frequency of activity, and time of activity. our post-survey data indicated that the watercolor painting sessions were extremely popular, so a decision was made to optimize students’ exposure to the creative arts. consequently, a focus on the arts will be the foundation for the next iteration of a formal, longitudinal wellness curriculum at our regional campus. while the institutional grant funding used for the original pilot program described here ceased in june of 2019, other avenues of funding are being explored for future curricula. additionally, the limited student response to this program suggests the need for increased student journal of regional medical campuses, vol. 4, issue 2 original report involvement in the planning and implementation of wellness programs. as such, a goal of the university park campus is to establish a student-led wellness committee, charged with organizing wellness-oriented events and maintaining a sense of morale among the student body. it is imperative to continue to think intentionally about developing helpful and sustainable wellness curricula in medical schools. in order to effectively address the challenges of burnout, and the high rates of depression and anxiety among medical students, the status quo must change. it is not acceptable for medical school curricula to place such high demands on medical students without providing concurrent instruction for balancing those demands with personal wellbeing and resilience. providing support for work-life balance and overall wellness is likely to create physicians in both training and practice who are more effective and resilient. references 1. maslach c, jackson s. the measurement of experienced burnout. j occup behav. 1981; 2:99113. 2. ludwig ab, burton w, weingarten j, milan f, myers dc, kligler b. depression and stress amongst undergraduate medical students. bmc medical education, 15. 2015. retrieved from http://ezaccess.libraries.psu.edu/login?url=https: //search-proquestcom.ezaccess.libraries.psu.edu/docview/1780257 365?accountid=13158. 3. dyrbye ln, thomas mr, shanafelt td. systematic review of depression, anxiety, and other indicators of psychological distress among u.s. and canadian medical students. academic medicine. 2006; 81(4):354-373. 4. brazeau c, schroeder r, rovi s, boyd l, harrell h, yudkowsky r. relationships between medical student burnout, empathy, and professionalism climate. academic medicine. 2010; 85(10):s33s36. doi: 10.1097/acm.0b013e3181ed4c47. 5. dyrbye ln, thomas mr, massie fs et al. burnout and suicidal ideation among u.s. medical students. ann intern med. 2008; 149:334-341. 6. brazeau cm, shanafelt t, durning sj, massie fs, eacker a, moutier c, satele dv, sloan ja, dyrbye ln. distress among matriculating medical students relative to the general population. academic medicine. 2014; 89(11):1520–1525. doi: 10.1097/acm.0000000000000482. 7. educating doctors to provide high quality medical care: a vision for medical education in the united states. report of the ad hoc committee of deans. washington, dc. association of american medical colleges. https://med.fsu.edu/sites/default/files/userfiles/f ile/facultydevelopment_aamc_report_educatin g_doctors.pdf. updated 2004. accessed july 27, 2020. 8. lcme. accreditation standards. http://www.lcme.org/publications.htm. updated 2012. accessed july 27, 2020. 9. slavin sj, schindler dl, chibnall jt. medical student mental health 3.0. academic medicine. 2014; 89(4):573–577. doi: 10.1097/acm.0000000000000166. 10. drolet bc, rodgers s. a comprehensive medical student wellness program—design and implementation at vanderbilt school of medicine. academic medicine. 2010; 85(1):103110. doi: 10.1097/acm.0b013e3181c46963. 11. hettler b. six dimensional model of wellness. https://nationalwellness.org/resources/sixdimensions-of-wellness]. accessed june 22, 2020. microsoft word evaluation of a research internship article.docx published by university of minnesota libraries publishing evaluation of a research internship in a rural healthcare system: the essentia health summer research intern program catherine benziger, md, mph; ryan thiel, ma; nicole groth, bs; vicki pink, rn; joseph doerer, md; kate dean, mba doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 3, issue 2 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc catherine benziger, md, mph cardiologist in the division of heart and vascular, essentia health, duluth. joseph doerer, md, cardiologist in the division of heart and vascular, essentia health, duluth. ryan thiel, ma, is a research & evaluation specialist at the essentia institute of rural health. nicole groth, bs, is a research associate at the essentia institute of rural health. vicki pink, now retired, was a nurse at the minneapolis heart institute abbott northwestern hospital. kate dean, mba, is executive director of the essentia institute of rural health. corresponding author: catherine benziger 407 east third street duluth, mn 55805 email: catherine.benziger@essentiahealth.org twitter: @drbengizerheart all work in jrmc is licensed under cc by-nc volume 3, issue 2 (2020) journal of regional medical campuses original reports evaluation of a research internship in a rural healthcare system: the essentia health summer research intern program catherine benziger, md, mph; ryan thiel, ma; nicole groth, bs; vicki pink, rn; joseph doerer, md; kate dean, mba abstract background: training medical and premedical students in clinical research is challenging with the demands of medical education. students pursue research opportunities in specialty practice to acquire knowledge and gain experience in the clinical setting. pairing clinical observation with mentored research informs the value of evidence-based medicine and prepares students for a career in medicine and science. however, programs that offer both research training and clinical observership are rare, particularly in rural areas. hypothesis: early exposure to sub-specialty practice in rural areas is important to recruit and train the next generation of physicians to serve this population. the aim of this program was to provide undergraduate and medical students in a largely rural community the opportunity to participate in clinical cardiovascular disease research and active clinical observership. methods: this report provides a description of the essentia health summer research internship program, a pilot program with the university of minnesota medical school aimed to provide mentored clinical research training and clinical observership for medical and premedical students. the program provided an experiential model of clinical patient interaction, problem solving, and access to research that is integrated into clinical experiences as students learn the value of evidence-based medicine. results: six medical and 4 premedical students have participated in the internship within the program’s first 2 years. studentcompleted weekly journals and surveys reveal enthusiasm for various research and clinical components of the program. program highlights include the acquisition of research and clinical knowledge through mentorship and research lectures, and observerships throughout the heart and vascular center. conclusion: the program aims to provide underrepresented rural students training in research methodology through mentorship and observership within specialty practice. background preparing medical students to be doctors trained in clinical research is challenging with the current demands of medical education. preclinical medical students desire the introduction to research and are eager for experience in the hospital setting. understanding the nature of medical knowledge requires experience with scientific methodology through participation in research. evidence-based medicine (ebm), the foundation of medical education, has emerged as the accepted philosophy of practice wherein health care practitioners provide therapies based on empirical results instead of tradition or opinion.1 today, ebm has wide support among medical providers and is considered a requisite foundation for optimal medical care. the question becomes how to train the underlying constructs of ebm. shadowing in clinical medicine is often passive and observational and may not be the best way to facilitate learning.2 furthermore, hands-on research experience must have relevance to clinical practice. until recently, medical schools have taken a standard approach to educating students, following a conventional curriculum, without emphasizing external scholarship or independent research.3,4 by creating an academic environment in which the students and faculty share the scholarly activities, this promotes both curiosity and knowledge of the research.5 programs that integrate research and active clinical observations are rare but important to help students understand the value of evidencebased practice. the model for this research program was inspired by the minneapolis heart institute foundation (mhif) summer research intern (sri) program at abbott northwestern hospital in minneapolis, mn, which started in 2001.6 two mentors of the essentia health summer research intern program (ehsri) were former students in the mhif program, which is why this model was chosen for our program. the ehsri program is similar to the mhif program and gives doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports undergraduate premedical and preclinical medical students exposure to mentored clinical research.6 the mhif program trained a diverse group of undergraduate and medical students and 52 of 65 alumni (80%) went on to study medicine.6 there is a lack of diversity in cardiovascular specialists, specifically underrepresented minorities and women.7,8 furthermore, native americans and students from rural areas remain underrepresented in medical schools.9-12 there are a growing number of institutions, predominantly in urban areas, that have either active clinical observership programs for premedical students or research-focused programs.6,13-20 however, opportunities for undergraduate and medical students to engage in both clinical research and active clinical observerships remains limited, particularly for students not located in large metropolitan areas.6,13,18-21 studies suggest that research experience offers students the opportunity to enhance analytical skills, self-directed learning, improved oral and written communication skills, and a better understanding about how to apply knowledge to patient care.3 other studies have shown that advantages of a research and quality improvement of health services experience, like mentor connection and networking at conferences, can increase the likelihood of a student matching with a future residency program of choice and plays a major role in the student’s professional growth and development during medical school.22 the aim of this program was to provide undergraduate and medical students in a largely rural community the opportunity to participate in clinical cardiovascular disease research and active clinical observership. methods essentia health research program description the essentia health summer research intern program (ehsri) operates within the essentia institute of rural health (eirh) and essentia health-heart and vascular center. located in duluth, mn, usa, the essentia health-heart and vascular center is a tertiary care center which services a large rural area. in the summer of 2018, we completed our first year piloting the 6-week ehsri with 2 medical students. the program expanded to eight (4 pre-medical and 4 medical) students in the summer of 2019. students in the program came from 4-year undergraduate programs or an accredited medical school. a prerequisite was having a “pre-medical” focus so most students had recently completed or were currently enrolled in bachelor’s degree majoring in the sciences, applying to medical school, or were current firstyear medical students. there were 2 students who applied for the internship in 2018, 19 students in 2019 and 14 students in 2020. students completed a 4-12-week internship based on availability. selection criteria for the program included students in excellent academic standing with a strong letter of recommendation and personal statement indicating interest and experience in research. students received a stipend in alignment to similar summer research programs. the program was run by volunteer faculty including 4 cardiologists and a clinical pharmacist, who guided and mentored students on projects related to their specialty. the ehsri program is unique in that it recruits students from rural areas, particularly minnesota and the upper midwest, and gives them early exposure to specialty practice (cardiology) and clinical research. due to geographical limitations and lack of academic medical centers in the region, this program was unique in that it provided mentored clinical research at a community hospital that focused on disparities in cardiovascular disease care in rural areas. early exposure to specialty practice in rural areas is important to recruit and train the next generation of physicians. furthermore, this patient population is largely rural and has a higher percentage of native americans and recruiting students that reflect the population we serve is important.7,8,12,23 introductory training a timeline of the summer research experience is outlined in table 1. a critical aspect of the summer research program was orientation. students were supervised in a step-by-step process to satisfy requirements for patient contact and research (table 2). prior to orientation, students were expected to complete citi training, which included approximately 8 hours of online modules that are required by the essentia health institutional review board for all research personnel. during orientation, staff provided necessary forms, reference websites (uptodate, pubmed) and introduction to various cardiology, clinical trials, and essentia institute of rural health (eirh) personnel involved in the program. without supervision, navigating the various components and understanding the roles of various key personnel would be challenging and time consuming. each student received a 3-ring binder that included a campus map, program orientation guide, face sheets of key personnel, extensive list of abbreviations used in clinical research and cardiology, description of common cardiovascular procedures, powerpoint slides of cardiac anatomy, common cardiovascular procedures, and a journal for the students to complete weekly about their experience. the orientation guide included guidelines on appropriate dress-code, guidelines for interactions with physicians and staff, daily schedules, research project assignments, and information about protected health information and confidentiality, as well as helpful hints for their final presentation and poster. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports table 1. timeline for 6-week student summer research program table 2. summer intern program orientation training components clinical experience the clinical observation was a significant part of the overall experience and involved rounding with a physician and cardiovascular department staff on 6 half-days. the students had a checklist of required clinical experiences to complete with the aim of understanding how research can inform clinical practice. the number of patient cases that students experienced are organized by department in table 3. a schedule was created that included dedicated time for observation of at least 3 st-elevation myocardial infarction patients in the cardiac catheterization laboratory, implantation of a cardiac device in the electrophysiology laboratory, observation of an echocardiogram, and an exercise nuclear stress test. students also had the opportunity to interview cardiology patients and round on an inpatient critical care cardiology consult patients. table 3. clinical experience research experience all research projects were investigator-initiated projects in cardiovascular disease that were approved by the institutional review board. the pilot program provided students the unique opportunity to learn about cardiovascular research while seeing patients in the hospital and clinical setting with various cardiovascular conditions. the research experience required students to read the study protocol and complete a thorough literature search including downloading and becoming familiar with a reference manager, endnote, prior to data analysis or manuscript preparation. during orientation, the students were given 2 half-day research lectures on study design and basic statistical analysis. the students were provided a dataset with instructional materials on how to conduct simple data analysis to find means, standard deviations, t-tests and anova, and asked to conduct simple analysis. three members of the research staff at the eirh volunteered to help guide students in data analysis and interpretation. students were required to meet with the eirh informatics team to learn how clinical electronic medical record (emr) data is stored in large databases (epic clarity) and how to communicate effectively with non-clinical informaticists on merging datasets, as well as how to best extract data from the emr. an overview of redcap, a secure web application for building and managing online databases, was also provided. the irb protocols, datasets, and draft manuscripts were stored in a private group using microsoft sharepoint and only those with irb approval were allowed access to the group. one cardiologist was responsible for ensuring ongoing project development, meeting biweekly with students, reading the weekly intern journals, and providing general medicine and cardiology-specific career expertise, information, and advise. presentation at program conclusion, the students were required to submit a powerpoint presentation to the program director and give a 15-minute presentation about their experience to the division at the weekly journal club. the first component of the presentation was the project background, methods, and preliminary results. next, students shared highlights of their clinical experiences, including lessons learned. the presentation concluded with discussion amongst heart and vascular, clinical trials, and research staff regarding questions and additional information. the presentation afforded students formal experience presenting and interacting with clinical and research staff, as is often expected in clinical doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports medicine and demonstrates how research informs clinical practice. additional educational opportunities weekly attendance at journal club, multidisciplinary heart team meetings, and valve conferences were encouraged. mandatory attendance at a summer intern-specific lecture on various topics, such as research study design, epidemiology, biostatistics, cardiac anatomy, electrocardiograms, coronary artery disease, heart failure, cardiac imaging, and “surviving the wards.” students also participated in a simulation catheterization lab experience where they experienced the hands-on deployment of cardiac stents, toured the manufacturing facilities where stents and other devices, such as the watchman are assembled, and participated in an indepth learning experience reviewing imaging of the heart at boston scientific in maple grove, mn. supplemental program metrics students in 2019 completed 2 identical knowledge tests (the first and last week of the program) that evaluated their knowledge of general cardiology principles (8 questions), such as definitions of common cardiology acronyms and identification of common structures on echocardiogram and angiogram, and research methods and analyses (12 questions), including type of study design and regulatory requirements. all students completed weekly reflection journals regarding their confidence, comfort level, knowledge, and understanding of their research project. the journal was submitted to the program director and additional research support staff to gauge progress and triage questions or concerns. following the conclusion of the program, students completed an online survey detailing their experiences in the program. all survey responses were transcribed in a microsoft excel database. an iterative analysis was used in coding the data to achieve rich description and identify emergent themes within the text. results a total of 10 students completed the internship. knowledge evaluation results from the 2019 pre-and post-test are displayed in figure 1. the mean pre-test score was 51% (sd = 3.9), while the mean post-test score was 75% (sd = 1.7). separate cardiology tested scores versus research method scores. overall, students showed an approximate mean increase of 24% in their knowledge and understanding of the components of heart and vascular research, and individual increases in score ranging from 10% to 45%. figure 1. student knowledge of general cardiology principles and research methods program evaluation ten students completed an exit survey that found 40% identified as female, 80% ever-lived in rural areas, and 10% were underrepresented minorities. through the weekly journal, students self-reported weekly improvement regarding comfortableness of content with a plateau period of 6 weeks to become “very comfortable” with the content of their research project (figure 2). additionally, students selfreported a total of 23 manuscripts (m = 2.6, sd = 1.7) completed or in-production at the time of the final survey. wood w., et al (2018)24 found that about 25% of previous articles discussing similar programs had required students to achieve a specific outcome, for instance, submission of a manuscript or presentation at a regional or national conference. students in our program were required to give a research presentation locally and were encouraged to submit an abstract to a national conference. overall, 80% (n=8) had presented at a regional conference and 30% (n=3) at a national conference. over 50% submitted manuscripts to national peer-reviewed journals. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports figure 2. weekly student self-rated understanding of project content (*denotes medical students who completed only 6 weeks) qualitative assessment previous studies have noted the difficulty in evaluating outcomes of educational programs until several years after initiation,3 however, students did report (agree, strongly agree) that they were interested in pursuing a career in cardiology (n=9, 90%), research/academic medicine (n=6, 60%), or practicing medicine in a rural area (n=8, 80%). knowledge acquisition and staff interaction were 2 key themes that emerged from the survey. additionally, the students suggested earlier assignment of research projects and additional clinical experiences to improve the program. knowledge acquisition students described the knowledge they gained from their clinical observations and leading their research project. one student commented “i appreciate that we were able to see a project through from start to finish. it helped provide a better understanding of all the moving parts that go into a research project.” another student remarked that “i was very involved in choosing variables and setting up my research study. i feel like i have a better understanding of all the work that goes into research now.” a student elucidated their project dissemination experience, exclaiming “i learned about writing manuscripts, abstracts, posters, and even presenting in front of a room full of physicians.” students routinely commented on the integral knowledge they acquired and its importance throughout their upcoming career. staff interaction students emphasized the significance of interactions and mentorship from physician mentors and research support staff. a student indicated “the mentors were all so excited and passionate about their research, which rubbed off on me and made this experience a great one.” another student said “it was wonderful to work with such dedicated people who were always very welcoming and kind. they genuinely wanted me to grow from this experience, and i believe that i have.” this sentiment was echoed by another student who remarked “it genuinely seemed like the providers wanted me to learn and were more than willing to take time to explain things to me in greater detail.” for many students, the interaction between providers and research staff was the highlight of their experience and fostered team-building and personal growth. suggestions for program improvement the final question of the survey asked students “what would you change about the program?” several students suggested earlier assignment of their research project, saying “notify the students of what their project will be earlier during orientation week,” and “i would have liked to know my research topic earlier, or even in advance of arriving.” students also recommended additional clinical experiences, including “i would add more clinical experiences. it would be good to shadow providers in clinic and see their patient interactions,” and “have a shadowing experience with a clinical cardiologist and follow an interventionalist between procedures. i would love to see more of what their day to day operations look like.” students offered concrete suggestions to improve the program for future implementation. discussion we describe the initial experience with the ehsri program. a total of 10 undergraduate preclinical and medical students completed the program and were eager to engage in clinical and research activities. the ehsri was adopted from the mhif summer intern program based in minneapolis, mn and aimed to offer mentored training for preclinical and medical students from underserved and rural areas in northern minnesota the opportunity to gain clinical and research experience in the cardiology specialty. the program successfully recruited students who had lived in rural areas (80%) and female (40%). we aim to increase opportunities for undergraduate and medical students from rural areas to engage in both clinical research and active clinical observerships as most of these internship are located in large metropolitan areas.5,12,17-20 studies suggest that research experience offers students the opportunity to enhance analytical skills, self-directed learning, improved oral and written communication skills, and a better understanding about how to apply knowledge to patient care.3 furthermore, we believe students who are exposed to research early in doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports their training are more likely to understand and practice evidence-based medicine and continue in research in their career. sustaining an internship program required stakeholder engagement and a dedicated leadership team. continual evaluation and adaptation of the program with a focus on program outcomes with adequate financial resources to support the students are important. we found that students improved their cardiovascular disease and research knowledge from orientation to completion of internship. we found that it took approximately 6 weeks for students to self-report confidence and understanding of their research project. we would not recommend a summer internship shorter than 6 weeks given this data. program evaluation was positive. students valued the staff interaction highly and were eager to have more clinical exposure. all students were able to present their research at a local and most at a national meeting. adopting future program evaluation using a standardized tool, such as the “scholarly concentration program outcome model” (figure 2 in havnaer a., et al.)3 could be implemented. this tool could be used to describe in more detail the steps for other health care systems to aid with research program implementation and allow program planners and educators to more rigorously evaluate the scholarly characteristics and outcomes of the program. evaluation tools, including preand post-tests and weekly journals, helps increase the reproducibility of the program at different institutions. longterm tracking of students to determine if this program influenced their career decision or interest in research are needed; however, due to the long latency period between undergraduate students and completing residency and fellowship, this data will not be available for many years. limitations limited advertising and no program website initially limited the number of applicants to those who attended local institutions. moreover, due to contractual agreements the internship was not available for medical students at all institutions. the start dates for several students were staggered throughout the summer, which made orientation, education, and allocation of resources challenging. the authors recommend a standardized start date for all students. the short duration of the program for medical students limited observational opportunities. efforts to increase underrepresented minority students in pre-medical and medical school programs are needed to increase minority students in the internship. this program can be adopted for other healthcare systems and other specialties, but we feel it requires dedicated leadership and departmental support and formal mentors. general challenges to conducting research included difficulty merging various datasets, and lack of prerequisite knowledge of data analysis programs and software. students encountered errors and missing data, which delayed data analysis. conclusion undergraduate preclinical and medical students are eager to engage in clinical and research activities. however, students in rural areas face barriers in gaining research and clinical experience due to heavy academic workloads and paucity of academic medical centers. the ehsri offered mentored training for preclinical and medical students to gain clinical and research experience in the cardiology specialty. initial enthusiastic feedback demonstrates the program’s potential and success in propelling students to a career in medicine and research. reproduction of this program in other departments and other community hospitals would help improve access to scholarly activities and clinical exposure for students in rural areas. acknowledgements the authors wish to thank christine leone, kaitlyn rikkola, and brianna lemke for their assistance creating and implementing the program, and richard mullvain, dr. wilson ginete, dr. michael mollerus, dr. kalkidan bishu, and anne meyer for providing data and mentoring support. references 1. sackett dl, rosenberg wm, gray jm, haynes rb, richardson ws. evidence based medicine: what it is and what it isn't. in: british medical journal publishing group; 1996. 2.clark cd. doctoring undercover: updating the educational tradition of shadowing. medical education online. 2017;22(1):1-8. 3.havnaer ag, chen aj, greenberg pb. scholarly concentration programs and medical student research productivity: a systematic review. perspect med educ. 2017;6(4):216-226. 4.(cofm) coofom. scholarly activity within distributed medical education programs: reflections and reccomendations. 2019. 5.frank jr sl, sherbino j. canmeds 2015 physician competency framework. ottawa: royal college of physicians and surgeons of canada;2015. 6.willenbring bd, mckee kc, wilson bv, henry td. the minneapolis heart institute foundation summer research internship program: the benefits of preprofessional experience for prospective physicians. minnesota medicine. 2008;91(8):47-49. 7.warnes ca, fedson se, foster e, et al. working group 2: how to encourage more women to choose a career in cardiology. journal of the american college of cardiology. 2004;44(2):238-241. 8.francis ck, alpert js, clark lt, ofili eo, wong rc. working group 3: how to encourage more minorities to choose a doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports career in cardiology. journal of the american college of cardiology. 2004;44(2):241-245. 9.metz am. medical school outcomes, primary care specialty choice, and practice in medically underserved areas by physician alumni of medprep, a postbaccalaureate premedical program for underrepresented and disadvantaged students. teaching and learning in medicine. 2017;29(3):351-359. 10.nivet ma, taylor vs, butts gc, et al. diversity in academic medicine no. 1 case for minority faculty development today: diversity in academic medicine no. 1. mount sinai journal of medicine: a journal of translational and personalized medicine: a journal of translational and personalized medicine. 2008;75(6):491-498. 11.capers q, mcdougle l, clinchot dm. strategies for achieving diversity through medical school admissions. journal of health care for the poor and underserved. 2018;29(1):9-18. 12.acosta d, olsen p. meeting the needs of regional minority groups: the university of washington’s programs to increase the american indian and alaskan native physician workforce. academic medicine. 2006;81(10):863-870. 13.alexander sf, lyon lj, nevins ma, ycre lr, thayer hs. ten years of orienting college students to careers in medicine. jama. 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bmc med educ. 2018;18(1):318. microsoft word returningtoanewnormalarticle.docx published by university of minnesota libraries publishing returning to a ‘new normal’ in regional campus research laboratories during the covid-19 pandemic sara l. zimmer, jean f. regal, janet l. fitzakerley, ruifeng cao journal of regional medical campuses, vol. 3, issue 3 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc sara l. zimmer, phd; department of biomedical sciences, university of minnesota medical school, duluth campus jean f. regal, phd; department of biomedical sciences, university of minnesota medical school, duluth campus janet l. fitzakerley, phd; department of biomedical sciences, university of minnesota medical school, duluth campus ruifeng cao, phd, md; department of biomedical sciences, university of minnesota medical school, duluth campus corresponding author: sara zimmer, phd associate professor, biomedical sciences university of minnesota medical school, duluth campus duluth, mn. 55812 szimmer@d.umn.edu all work in jrmc is licensed under cc by-nc volume 3, issue 3 (2020) journal of regional medical campuses returning to a ‘new normal’ in regional campus research laboratories during the covid19 pandemic sara l. zimmer, phd; jean f. regal, phd; janet l. fitzakerley, phd; ruifeng cao, phd, md abstract in the spring of 2020, the worldwide biomedical sciences community anticipated a need to return to critical laboratory research prior to the end of the covid-19 pandemic. models for accomplishing recovery from a worldwide disaster are mostly found in the business realm. in the pandemic situation, literature focuses on how governments or clinical care settings can best respond. very few guidelines exist for accomplishing the resumption of academic biomedical research, particularly for basic science laboratories and programs. a u.s. regional medical campus can be in a unique situation if it must follow the return-to-work dictates of the larger institution, and yet have different challenges and potential advantages from its parent institution. we present a model used by one such regional medical campus in order to navigate the resumption of laboratory research activities after covid-19 driven operations shutdown. this model allowed us to accomplish our target of a rapid yet smooth return to the “new normal” way of executing laboratory research, although our success in mitigating sars-cov-2 transmission is an outcome that we cannot yet know. templates for materials used in the resumption of laboratory activities are provided. the lessons learned in our experience of laboratory restart go beyond the current pandemic. introduction disasters that affect human populations lie on an event continuum. most natural disasters such as earthquakes and hurricanes have somewhat distinct stages: a mitigation stage, a planning stage, and an action stage (such as shelter in place or move to safety), followed by a recovery stage.1 while the sars-cov-2 pandemic has a different disaster time course than what we typically think of for natural disasters, the same principles can apply.2 in this case, the ‘disaster’ will last for months to years, and the frontline workers are still working tirelessly to care for patients and make sure intensive care facilities are not overwhelmed, while other portions of the population are in a recovery phase. the recovery phase has begun, even when the disaster has not yet cleared. the united states finds itself in this situation during the summer of 2020. from family units to corporations to economies and international organizations, the process of returning to normal has begun in the midst of the ongoing sars-cov-2 pandemic. academic institutions are one of these units. academic institutions have endless variety in terms of mission, physical plant, student population, community size, and community norms. academic institutions can be highly networked, research-driven, teaching-focused, fiercely independent, private, public, or a combination of the above. they are also answerable to a wide range of stakeholders; students, faculty, staff, and community. a unique situation is the medical school regional campus, itself anything but monolithic. regional campuses have some structures in common with the parent campus but have varied independence in operation and mission. often, they serve some specialized mission, for example, a focus on rural medicine. in some models, primarily the basic sciences are taught at the remote location, in others, clinical components of training are included and regionally managed.3 many variations of these themes occur in practice. the university of minnesota medical school has a 2-campus system with both campuses having teaching and research missions. under one classification system, it would be considered a year 1 and 2 basic science model.3 part of the research mission on each campus involves “bench” or “wet laboratory” studies. this laboratory research focuses on questions essential to our understanding of human health and disease but does not have major interaction with the public. when laboratories are shut down, delays in research jeopardize productivity in terms of publications, and generation of new data for garnering research funding. in addition, the lab risks loss of reagents, cell lines, and unique research animal resources. laboratory research tasks cannot be completed from home, and thus technical staff and doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 3 students engaged in research are left waiting to do their jobs. in addition, progress on extramurally funded projects is delayed and careers of graduate student and postdoctoral trainees jeopardized. for all of these reasons, laboratory bench work of most academic institutions, including those of regional campuses, has been deemed potentially safe yet important work for resumption during the current pandemic. how to execute resumption of these operations is the challenge. there is a focus on pandemic management at a governmental level (e.g.4). offerings are sparser for academic institutions, although resources such as pandemic planning exercises that include recovery for academic institutions can be found.5 for a regional campus, the challenge of phased resumption of bench research activities involves navigation of central university and medical school directives, as well as being attentive to local campus policies on returning to work. for a large organization with extensive electronic communication, it is key that regional campus employees have help navigating the directives from the main campus and interpreting their importance for operation on a coordinate campus. the path forward can be informed by features of the practice of business continuity management. continuity management consists of steps taken so that the essential operations of an organization can be maintained/resumed upon or after disaster, and can be applied to research laboratories as well as businesses.6 a key feature of the recovery plan portion of continuity management is that it takes place quickly, prior to the resolution of the disaster itself.6 thus, rapid resumption became one of our main priorities. here, we report our methods for the planning and execution of resumption of research after covid-19 hibernation of bench laboratory activities at a regional medical campus. we stress the key actions that helped us to have a smooth return to a ‘new normal’ in laboratory activities, as we were measuring success partly as a rapid and organized resumption of activities. we also describe what we might have done differently and the measures of success that we are yet unable to ascertain. background and execution institutional organizational structure. one campus of the university of minnesota medical school is located in the minneapolis-st. paul metropolitan region (twin cities; tc) and is interconnected with the university of minnesota (u of m) east bank campuses and health care entities including m health fairview. the regional duluth medical campus is located a couple of hours north of the twin cities area on the campus of the university of minnesota duluth (umd), home to approximately 10 000 undergraduate students and a regional campus of the college of pharmacy of the university of minnesota. the university of minnesota medical school, duluth campus is responsible for basic and behavioral science research and delivery of medical school year 1 and year 2 curriculum. the duluth campus has 2 departments plus the administrative structure for admissions and delivery of the medical school curriculum. the department of family medicine and biobehavioral health houses clinical faculty as well as faculty engaged in community based participatory research. the department of biomedical sciences (bms) is a basic sciences department with 17 active research laboratories, most with small teams of 1-6 staff and trainees. the medium-sized bms department has a leadership structure that centers around a department head (dh). fig. 1a outlines the organizational relationships of the university of minnesota entities involved in the resumption of laboratory activities of the medical school, duluth campus. figure 1. a. relative relationships of university of minnesota entities discussed here. bms, biomedical sciences; ms medical school. b. structure and connections of the entities necessary for the safe execution of staged resumption of laboratory activities at the university of minnesota medical school, duluth campus (regional campus) during the sarscov-2 pandemic. bms, biomedical sciences department. normal black text indicates names of committees while blue text denotes individuals. only members of each committee/team most relevant to planning for staged resumption of laboratory activities are noted; committees/teams all have additional members. black dotted lines show individuals that are present on committees/teams at multiple levels. thick arrows represent informational flow between individuals (blue), or groups (white); arrowheads indicate main direction of information flow. entities in the grey box are not part of the medical school, they are part of u of m system president finance & operations senior vice president university health and safety assistant vice president duluth office of environmental health and safety duluth campus chancellor finance and operations vice chancellor facilities management director medical school dean regional campus regional campus dean bms department department head bms sunrise committee chair research vice dean ms sunrise committee chair bms department head regional campus dean medical school dean university of minnesota duluth • leadership • facilities management • environmental health and safety ms sunrise committee: approval of laboratory resumption plans bms sunrise committee cvbms sunrise committee chair bms cv regional campus regional campus leadership team bms department head bms sunrise committee chair cv bms department head entire medical school regional campus dean medical school leadership teams regional campus administrator a b journal of regional medical campuses, vol. 3, issue 3 the campus of the university of minnesota duluth, which is a campus of the university of minnesota system but distinct from the medical school. the university of minnesota duluth campus supports the building that contains the majority of the regional medical school campus. state and university pandemic response. the stay-at-home order of the governor of minnesota began on march 28 and was only replaced by a series of stay safe mn directives starting on may 18. by march 18, prior to the stay-at-home order, the university of minnesota had already required laboratories to reduce activities to operations essential for preservation of resources or approved covid-19 research (fig. 2). medical student instruction went virtual with all of its attendant challenges. the work from home directives still allowed the faculty to meet the teaching mission of the regional campus. however, the order meant that most bms laboratories entered a state of formal hibernation with relatively little advance notice. the stress associated with closing research laboratories was heightened by the fact that resumption dates were unknown. to ease the eventual transition back to activity, the university was planning for resumption of activity well before the expiration of the state stay-at-home order (may 17; fig. 2). a committee was charged with this planning by the u of m vice president of research on april 16. by april 28, the university of minnesota had devised a plan for staged resumption of select research operations such as basic science research of high priority. both the university of minnesota medical school and umd participated in the creation of that plan. following those guidelines, each u of m college developed a process to responsibly implement those guidelines. wet laboratory-based research was deemed a relatively safe priority for return, but all teaching, community-based research and clinical research were still to be performed remotely or else still on hold. figure 2. timeline of integration of university-wide and medical school-wide guidance into executing return of laboratory activities of the biomedical sciences department (bms) of a regional medical campus. u of mn, university of minnesota dh, department head. fm, facilities management department of the regional university that houses the regional medical campus. by may 4, the dean of the university of minnesota medical school (fig. 1a) charged a committee: the sunrise committee for the medical school and the office of academic clinical affairs. in alignment with the sunrise plan announced by the university of minnesota president gabel, the medical school sunrise committee was charged to review and either approve or deny individual employee requests to return to on-site work, in line with the guidelines established by the entire organization (fig. 1b). regional campus representation on this committee was essential to the smooth resumption of laboratory activities at the regional duluth campus for reasons detailed below. the family medicine and biobehavioral health department did not initially identify any laboratory-based work slated for immediate resumption. thus, the dh of the bms department was the logical regional campus representative in the medical school sunrise committee given the preponderance of regional campus wet laboratory research it performs (fig. 1b). the first product generated by the medical school sunrise committee was a template for each laboratory to populate to request resumption of activity (fig. 3, table 1). upon release of the medical school-wide guidelines of staged resumption of activities, bms determined to develop its own plan for the resumption of activity that would occur within the single on-campus building of the medical school, duluth campus. the bms dh established and charged a departmental committee to shepherd the department through the first stages of resumed laboratory activity (figs. 1b, 2), with author zimmer acting as chair. upon dr. zimmer’s agreement to act as chair, the dh requested volunteers for the committee at a departmental faculty meeting. these volunteers, an additional faculty member, a laboratory infrastructure manager and a senior laboratory technician with extensive experience working with many building research teams comprised the 6-person bms sunrise committee. bms sunrise committee goals and actions. the overall goal of this committee was to develop a plan for all bms laboratories to perform essential research given the working mandates of the medical school. the department needed to consider its own unique needs, plus consider that the plan it generated would be the de facto on-campus activity resumption plan for the entire regional medical school. its approach to synthesizing a discrete plan of action from broad dictates and guidelines from larger entities is a model that may serve as a framework for other units and institutions. in practice, this involved the chair and the dh daily meeting to identify the current most time-sensitive piece of the plan, which would change over time. the bms sunrise committee duluth sunrise time may 20. first laboratory staff return may 1. dh appoints and charges bms sunrise committee may 10. bms template for resumption of activities is completed may 5. first bms sunrise committee meeting may 11. first bms individual lab plans are evaluated by dh may 8. medical school committee procedure to apply to restart individual laboratory is established. may 18. training of first returning laboratory staff by dh may 17. agreement for start-up with fm may 12. first bms individual lab plans are evaluated by medical school committee march 18. university limitations to laboratory activities deadline for execution march 16. university limitations to laboratory activities announced may 18. replacement of state stay-at-home order with stay safe mn order (minnesota begins relaxing restrictions) march 28. governor’s stayat-home order enacted shutdown time april 16-28. u of mn resumption committee journal of regional medical campuses, vol. 3, issue 3 would then focus on this element of the plan in a subsequent zoom meeting or through comments of a google document. some larger, philosophical issues were addressed by email. to begin plan development, the u of mn and medical school dictates described in fig. 3 were reviewed by all members ahead of the initial meeting. these, plus other fig. 3 documents and entities comprise the larger directives that the committee followed in generation of a plan. committee to pivot to the most immediate challenge of generation of individual laboratories’ safety plans that would have to be submitted to the medical school sunrise committee for approval for resumption of activities. the bms sunrise committee used what it had already generated as smed building-wide resumption policies and procedures to pre-populate safety plan templates for each individual laboratory. this allowed for both consistency and a time savings for individual investigators. the dh sent the prepopulated template to all bms faculty for them to add their laboratory-specific details. such laboratory-specific details included which members of the laboratory would be allowed to return in what stages of resumption, and how use of the investigator space would be apportioned to ensure social distancing. all bms investigators were instructed by the dh to wait for the overall department plan on this template before adding their lab specific information and personnel for return. this minimized faculty and dh time and effort devoted to generating 17 lab specific plans for approval. the sunrise committee could then turn its attention back to other priorities important for resumption of research. at times it became necessary for one member of the committee to interface with umd facilities management team and environmental health & safety to keep them appraised of our progress. the bms sunrise committee also had one meeting with the regional campus’s information technology group to establish an electronic sign in and sign out interface that allowed storage of the collected data. a timeline of actions leading up to resumption of laboratory activities is shown fig. 2. throughout the process, bms department faculty were updated almost daily by the dh regarding the pathway for approval of resumption of their lab activities. the documents and other supports generated by the bms sunrise committee leading up to and allowing for laboratory activity resumption are described in table 1. a final key element in planning for laboratory activity resumption was communication with other entities whose research and facilities intertwined with the medical school, duluth campus. much of our shared equipment is also used by the regional college of pharmacy faculty and the umd swenson college of science and engineering faculty. shared physical plant services and oversight by umd environmental health and safety as well as shared facilities and equipment connect these units on the umd campus. in parallel with the medical school, these 2 entities were developing separate application procedures for resumption of laboratory work. thus, informal discussions with the leaders of these units was also key to success for a smooth resumption of activities. because of the continued output of central directives and the beginning of planning for laboratory activity resumption within umd departments, bms department faculty were instructed to ignore university of minnesota duluth and central directives, and focus on medical school directives, bms sunrise committee figure 3. inputs in blue are the documents and considerations of the larger institution or university of minnesota regional campus that the bms sunrise committee had to adhere to when formulating a departmental plan. in green are the resources from these same entities that the bms sunrise committee was able to use in the execution of its plan. u of mn, university of minnesota. umd, university of minnesota duluth. most of the equipment of the bms department is shared yet placed within the laboratories of individual investigators on 3 floors of a single building. under these circumstances, one laboratory’s agreed-upon procedures would profoundly affect the work and well-being of individuals in other laboratories. therefore, the initial committee meeting determined that most working policies and procedures would have to be consistent among laboratories. developing these according to larger institutional guides in fig. 3 was largely accomplished in the first meeting. further meetings were set up with the goals of developing a training mechanism to communicate new policies and procedures to initial returnees, and the concrete steps to execute resumption of laboratory activities using our plan. the department had to particularly consider how it would marry its extensive degree of shared space with medical school sunrise committee dictates. because of size and scope of research, the regional campus does not operate with equipment cores in contrast to the larger tc campus. communication occurred daily between the bms sunrise committee chair and the dh during this time. immediately after the bms sunrise committee’s first meeting, medical school sunrise committee released the template individual laboratories would use to apply for resumption of activities (fig. 3). the dh therefore could work with the bms sunrise broad resumption guidelines poster staged resumption of activities guidelines plan for return of staff who cannot work from home template for writing specific plans for individuals laboratories environmental health & safety: checklist for return from laboratory hibernation environmental health & safety: door sign depicting open laboratory at reduced capacity facilities management: time needed to arrange staff to execute return cleaning protocols and increased cleaning umdu of mn medical school regional campus inputs (blue) and resources (green) journal of regional medical campuses, vol. 3, issue 3 specifically those that had been transformed to discrete investigator action items by the bms sunrise committee and dh. table 1. tangible supports generated by departmental (bms) sunrise committee. versions of asterisked outputs are included as supplementary information. evaluating success. our major goals during planning for resumption of regional campus laboratory activities was for the transition to be rapid, smooth, and safe. on the day that stay-at-home orders were relaxed in minnesota, remote training was executed by the dh with presentation slides developed by the bms sunrise committee. the department head trained principal investigators and staff of 14 of the 17 departmental research programs. the approved portion of the laboratory workforce returned 2 days later to set up resumption of activities, which allowed time for facilities management to fulfill a building cleaning protocol prior to their arrival. the following day, laboratory research activity was resumed under the new policies and procedures that minimize transmission of sars-cov-2. since then, all 17 of the laboratories have had their resumption plans approved and at least one representative trained for return. the bms sunrise committee’s work is viewed as completed, with the possible exception of updating training resources for individuals that will resume activities at later times according to their individual laboratory’s plan for scheduling of returnees. we feel that we have met our temporal goals for laboratory activity resumption. a smooth transition suggests that individuals resuming their activities were at all times clear on what they needed to do, and from what entity the directives would come. for the most part, this was true, although there were some central directives issues prior to the start of bms sunrise committee that resulted in minor duplication of effort by a few of the most eager investigators to return. one thing we have not yet discussed is whether differing conditions between the 2 campuses and their respective cities might warrant progression to a forward step in the staged resumption process before it is warranted from the other campus. thus, there may be a need for less cohesive progress forward in the future. the measure of how safe our laboratory activity resumption was, and remains to be, will take longer to evaluate. there are still a number of unknowns. we do not yet know how many of covid-19 cases will occur within the regional campus laboratory staff, and whether or not our methods of transmission reduction will be sufficient to prevent spread of the infection within the medical school duluth campus. individual laboratory plans required description of activity resumption all the way to normal operation to occur in a series of 3 steps, and we are currently in the first of these. we do not know whether one of these stages will inadvertently introduce an unsafe practice. finally, with the discussion of resumption of clinical activities now occurring, it is unknown whether the resumption of non-bench research and teaching will find our policies useful and whether procedures set by the initial cohort of returning bench scientists and trainees at the regional campus level will remain intact. in both our methods and our unknowns, it is interesting that there are some parallels to the development of specific practices to maximize safety for the continuation and resumption of procedures for cancer surgery during covid19 pandemic times, termed a “covid-minimal pathway”7. obviously, this situation is far different than ours in that extremely vulnerable populations are being brought into institutions in which the presence of sars-cov-2 is known. in contrast, early stages of our return are voluntary, staff returnees are relatively healthy individuals, and the existence of the actual virus within our building is unknown. thus, it is all the more telling that we see similarities in their use of a leadership team (our sunrise committee), identification of stakeholders, consideration of use of the space and its physical preparation for safe usage, effective communication of the details of the new policies and the reasoning behind them to the end users, and use of screening for covid-19. like us, they stress that while their planning process may be of use to other institutions at this time, they can only suggest that their pursuit of best practices would logically lead to a reduction in the possibility of sars-cov-2 transmission to their vulnerable surgical population. in fact, they also must wait for any outcomes to understand fully the impact of their safety measures. lessons learned. it is important to evaluate our development and decisionmaking process for resumption of laboratory activities in this pandemic situation now that resumption is actively underway. it is certainly possible that another event could unfold in the future that requires resumption of research activities following cessation for an emergency. also, other journal of regional medical campuses, vol. 3, issue 3 institutions, particularly the parts that are in a remote or subsidiary situation, may only be in the resumption planning stages now. for the regional campus experience specifically, we have identified several factors in planning for this resumption that may be useful more broadly. • nimbleness of sunrise committee. under typical situations, anticipating the necessary next steps and future challenges and acting on them in a proactive fashion is an effective way to organize and govern. however, in this situation, the specific demands that would be placed on individual investigators in order for them to re-open their laboratories were not known. nor could it be anticipated exactly how transmission of the virus would continue, and on what time frame. the “rules” for staged resumption of activity varied somewhat depending on the institutional level that was issuing them. in these unique circumstances, we found it advantageous for the bms sunrise committee to function in a reactive rather than proactive capacity. despite pivoting from one focus to another and back as the dictated format for re-opening became clear, we as a committee were surprisingly efficient. the initial explicit acknowledgement of the committee members that the committee would have to be primarily responsive to institutional forces and leadership needs was helpful in that regard. • frequent check-ins at the departmental level. the bms sunrise committee focused primarily on how to get bms department faculty laboratories running again. the dh was ultimately responsible for the collective resumed activities of the department. therefore, daily communication of the chair of the bms sunrise committee with the dh was essential to the rapidity at which we progressed. • association with the entity in which the institution is physically placed. many research nonprofits and startups are physically placed in a building or buildings within a larger institution’s campus. research groups can have varying arrangements with the larger entities in which they are places. these arrangements must be included in considering resumption of activities. in our case, management of our facilities – our regional medical campus building – is in the hands of the facilities management department of umd. likewise, safety oversight of research activities is largely also at this local level. it was important for our committee to have nonfaculty participants with significant ties and connections to umd facilities management and environmental health & safety. immediately after the committee’s first meeting, committee individuals began communicating with on-the-ground supervisors of janitorial staff, and their responses to our plans were communicated back to the committee. furthermore, even prior to formation of the bms sunrise committee, regional campus leadership (regional campus dean and administrator) were communicating with their umd counterparts and also with the college of pharmacy duluth campus leadership. all of this was effective. however, we could have been more effective if we had also made connections at the mid-supervisory level. it may also have been useful for the entire committee to have a dedicated meeting with relevant individuals in umd administrative, regulatory, and facilities management roles to ensure that all connections to the umd community heard the same message from our regional campus. this would have been helpful because umd’s resumption of laboratory activities is largely taking place on a more delayed time frame than the medical school. • regional campus representation at the medical school level. leadership teams and committees of the university of minnesota medical school normally involve representation from both duluth and tc campuses. fig. 1b shows the regional campus leadership entities that are also part of larger medical school teams and committees. in particular, having the bms dh have membership on the larger medical school sunrise committee that was responsible for approval of returnto-work laboratory plans was critical for the rapidity at which we executed resumption of activities. early knowledge of the template to be issued for application to return to work was instrumental in the quick re-start of our laboratories without confusion. it was also important because the way that research is performed and important considerations on a regional campus can be vastly different from considerations and expectations of the research community of a large multi-building, multidepartment medical school. we found that representation by even a single person makes a big difference. • regional campus advantages. the reduced scope of the research mission on our regional campus permitted a more unified and less complex return to work. the size of the duluth community and the placement of the workplace in a less congested part of the city also makes travel to campus, and safety on campus, less of a concern than in a major metropolitan area. this may be a factor primarily for regional medical campuses physically located in smaller cities or towns. • traditional style of laboratory building advantages. the smed building is a traditional academic laboratory building with closed-off, individual laboratories. this architectural style is increasingly becoming replaced with open floorplan laboratory buildings that allow for efficient use of space and equipment between increasingly collaborative individual laboratories. however, in a pandemic situation, the traditional style of laboratory building is a great advantage when it comes to reducing transmission of an airborne virus. journal of regional medical campuses, vol. 3, issue 3 in summary, our regional medical school campus had unique challenges and advantages for resumption of laboratory activities during this pandemic but found a workable structure in which to execute resumption and minimize duplication of effort by bms department faculty. returning to the laboratory, even with a new normal, has allowed faculty to find some semblance of control of their careers and those of their trainees and has reduced angst over the indeterminate nature of the shutdown. we are not at full force, but we are operational and again collecting data in a safe environment. it is our hope that other institutions will extract useful nuggets in our experiences to apply to their own challenges. references 1. disaster planning: introduction: the scope and nature of the problem, categorizing disasters, definitions and terminology. https://emedicine.medscape.com/article/765495overview. accessed june 11, 2020. 2. coccolini f, sartelli m, kluger y, et al. covid-19 the showdown for mass casualty preparedness and management: the cassandra syndrome. world j emerg surg. 2020;15(1). doi:10.1186/s13017-02000304-5 3. cheifetz ce, mcowen ks, gagne p, wong jl. regional medical campuses: a new classification system. acad med. 2014;89(8):1140-1143. doi:10.1097/acm.0000000000000295 4. swerdlow dl, finelli l. preparation for possible sustained transmission of 2019 novel coronavirus: lessons from previous epidemics. jama j am med assoc. 2020;323(12):1129-1130. doi:10.1001/jama.2020.1960 5. wendelboe, phd am, miller, jd, crm a, drevets, md d, et al. tabletop exercise to prepare institutions of higher education for an outbreak of covid-19. j emerg manag. 2020;18(2):s1-s20. doi:10.5055/jem.2020.0464 6. mortell n, nicholls s. practical considerations for disaster preparedness and continuity management in research facilities. lab anim (ny). 2013;42(10):f18-f24. doi:10.1038/laban.391 7. boffa dj, judson bl, billingsley kg, et al. pandemic recovery using a covid-minimal cancer surgery pathway. ann thorac surg. may 2020. doi:10.1016/j.athoracsur.2020.05.003 microsoft word professionalidentityformationarticle.docx published by university of minnesota libraries publishing professional identity formation among college premedical students: a glimpse into the looking glass using a career eulogy reflective exercise william j. crump, md, r. steve fricker, mpa, allison m. crump, md doi: https://doi.org/10.24926/jrmc.v2i1.1683 journal of regional medical campuses, vol. 2, issue 2 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc dr. william crump; associate dean, university of louisville school of medicine trover campus at baptist health madisonville, madisonville, kentucky. mr. fricker; director of rural health/student affairs, university of louisville school of medicine trover campus at baptist health madisonville, madisonville, kentucky. dr. allison crump; research assistant at the time of this study, university of louisville school of medicine trover campus at baptist health madisonville, madisonville, kentucky. corresponding author: dr. crump, ulsom trover campus at baptist health madisonville, 200 clinic drive 3rd north, madisonville, ky 42431; email: bill.crump@bhsi.com; telephone: (270) 824-3515; fax: (270) 824-3590. all work in jrmc is licensed under cc by-nc volume 1, issue 6 (2019) journal of regional medical campuses original reports professional identity formation among college premedical students: a glimpse into the looking glass using a career eulogy reflective exercise william j. crump, md; r. steve fricker, mpa; allison m. crump, md abstract introduction pre-medical students are at the very beginning of their formation of a professional identity as a physician. working with these students early in their education can help them appreciate the importance of professional identity formation as well as inform educators on best methods to understand this process. methods a reflective exercise was used at the beginning of sessions with pre-medical students at their home campus who attended a medical school presentation on the admissions process. students were asked to reflect on what they wished to be said about them at the end of their career in the form of a “career eulogy.” a simple form was developed and administered to the students to capture their reflective writing and their basic demographics anonymously. qualitative data were blinded and then coded into clusters by the authors using an iterative process. results reflections from 79 pre-medical students indicated a preference to be remembered for quality and excellence in care, especially among upper level students and students from small towns. compassion, patient relationships, and the doctor as teacher terms were more likely to be written by juniors and seniors while freshmen and sophomores tended to focus on terms related to enjoyment of life and service. discussion this reflective exercise provided useful insight into professional identity formation among these college pre-meds and could be used with larger, more diverse groups to determine its value and clarify true differences among the demographic characteristics. involving similar pre-medical students in focus group settings could also further assist with interpretation of the meaning of these reflections. introduction as a more holistic approach to choosing students for medical school has developed, much has been written about the best premedical curriculum and the role of the new mcat.1,2 some have suggested more study of a broader view of the premedical college experience that includes the hidden curriculum and identity formation outside of the classroom.3 core pre-professional competencies have also been suggested.4 most previous publications on this issue have either focused on attrition or study of student attitudes about the caricature of the “premedical syndrome” of “cut throat” behavior by overachieving, selfish college students who see everything about their college experience as a competition.5,6 however, some have found in surveys that pre-meds both perceive themselves and are perceived by other students and faculty as altruistic and interested in making a difference in their future patients’ lives.7,8 in our 12-year experience of working with selected pre-meds in summer pathways rural immersion experiences we found some validity to both views. in group discussions of clinical cases and practical ethical dilemmas found in everyday practice, we observed college students at various levels of professional identity formation and could watch their development across the 2-3 summers we worked with them.9 we found that simple reflective exercises at the beginning of doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports each session greatly facilitated their discussion of the deeper aspects of their hopes and dreams. we found a simple exercise recently published as it was used with interns in a university hospital environment10 and field testing with our small selected group of pre-meds went well. in this exercise, the participants reflect and then record what they would like to be said about them at a retirement event far in the future. our goal in this study was to use the exercise in a larger group of less selected pre-meds to develop an understanding of the important components of professional identity formation. secondarily, we were interested in differences by gender, rural upbringing, and level in school. the study protocol was reviewed by the baptist health madisonville irb and approved as exempt. methods the career eulogy form was modified from a similar effort used with hospital-based interns.10 there were lines for demographics followed by the statement: “imagine that you are ready to retire from medicine in the distant future. write a short speech outlining what you would like to be said about you at the retirement ceremony. in about 50 words, write the speech below.” these were distributed in the fall of 2015 at the beginning of a one-hour session of a pre-medical club meeting hosting the trover campus associate dean for his annual presentation concerning the medical school admission process. anonymity was assured as was voluntary participation. the writings were completed in 5-7 minutes and were collected by the club officers and placed in a sealed envelope. two regional state universities in western kentucky were included, each about 90 miles in opposite directions from the trover campus. one had an enrollment of 11,000 based in a town of 18,000 (34 completed forms) and the other had an enrollment of 20,000 based in a town of 62,000 (45 completed forms). all 79 completed forms were included and legible enough to be coded. these had all demographics removed and were then classified and coded by the authors. one coder (amc) is a recent trover campus medical school graduate and also graduated from one of the included universities. one (rsf), has training as a medical anthropologist and 16 years in medical education including summer pre-med programs. the other (wjc) is the trover campus associate dean with 35 years of experience with both pre-med pathway programs and medical education. the authors used an iterative process where a rubric of terms was developed from reading the eulogies and then the text coded by each author individually and then reviewed by the group. during this process, the authors met and agreed by consensus on the correct coding for ambiguous or overlapping terms. table 1 shows the 10 clusters of terms the authors identified as recurring themes in the student eulogies. when the exact term did not occur, the synonyms shown were typical of those included in that cluster. table 1. terms used by students to describe themselves in their career eulogies terms used by students cluster seeking excellence; knowledgeable; seeking improvement; the best; quality of care; great doctor; contributed to medical knowledge; left a legacy quality vigor; excitement; love of medicine; impact on care; persistence; never gave up; never backed away from a challenge passion empathy; kind heart; sentimental; understanding; sympathetic; every patient mattered; gave patients hope; truly cared compassion connected with patients; puts patients’ needs first; made personal connections; personable patient relationships always happy; my life was a gift; the journey was fun; the joy of practice; always had a smile; positive attitude enjoy life brought better care to my town; legacy in my town; very involved in community; educated the community community taught colleagues; taught community members about their health; hosted medical students teacher genuinely sought to help others; payment not required service blessed to serve; faith is central; servant of god; displayed faith through care calling loyal to family; puts energy into relationship with spouse; love of family family results as shown in table 2, this group of pre-med students most frequently hoped they would be remembered for quality and excellence in clinical care. among upper level students (junior or senior) and those from small towns, this term was even more frequently used, with little difference by gender. juniors and seniors also included more frequent terms under the compassion, patient relationship, and doctor as teacher clusters. freshmen and sophomores more frequently included terms in the enjoy life and service clusters. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports table 2. demographic characteristics of students completing career eulogies aone student self-identified as a graduate student b5 students did not answer this question crural defined as coming from a hometown with a population <30,000 women more frequently included terms under the passion, compassion, and patient relationship clusters than did the men in the study population. in addition to terms under the quality cluster, rural students more frequently chose terms in the community and family clusters. discussion studying this larger group of less selected premeds enlarged our understanding of their professional identity and validated what we had perceived in our smaller more selected summer pathways groups. use of the career eulogy in larger more diverse groups will be needed to determine if the differences among school level, gender, and rurality are generalizable. the only studies available for comparison are much older and were survey-driven. mccranie, reporting 253 students attending 13 “more selective” liberal arts colleges in the midwest, found more “type a” behavior among students seeking any kind of doctoral degree, medical or not, than in those planning a masters or bachelors. they also found this negative stereotype more frequently in women, which is very different from our findings.5 conrad reported 30 student surveys from brandeis university weighted towards upperclassmen and found more agreement with the “cut-throat” stereotype among underclassmen while upperclassmen were less concerned about competition and felt more balanced in their lives.6 hackman reported 317 yale sophomores and seniors that included some non-pre-med students for comparison. the pre-meds more frequently reported interest in being helpful and making a contribution to society, but also selected job security and prestige as important to them. non-pre-med women indicated more interest in enjoying life and generally more optimism than the men in the study. pre-med women, however, chose answers much like the pre-med men.7 sade reported 498 students from 13 undergraduate campuses in south carolina, a population more likely to be similar in some ways to ours, as the other 3 reports were from ivy league schools or campuses described as “more selective” but unnamed. sade included faculty and non-premed students in the survey along with premeds. the most prevalent picture of premeds was one of altruism but also excessively competitive with narrow interests, and the student respondents did not differ in their perceptions by level in school.8 limitations our study is limited by population size and inclusion of two regional campuses with more rural students than a national sample would include. the study population is also racially homogeneous. the population of the region only has about 6% non-white citizens, and the pre-med groups are even more homogeneous. most of the clusters were easy to differentiate, but two groups were more difficult. ultimately, the coders agreed that service was an activity that occurred outside of the doctor’s workplace and was generally not revenue producing. “going the extra mile” was clustered with passion and “putting patients’ needs first” was clustered with patient relationships rather than either being included as service. likewise, the line between compassion and patient relationships was difficult to code with some wording used by the students. the terms clustered under patient relationships were seen as more bidirectional while empathy and kind heartedness were seen more as residing in the physician and were clustered with compassion. it would be interesting to compare students’ results who are from generation birth dates designated as millennials with those from birth dates designated as generation z, but we did not capture birth date or age on the anonymous eulogy forms. from talking with the pre-med advisors and surveying the audience, it did seem that almost all were in the typical college age of 18-23. as a rough estimate, there would have been more millennials in the upper class students and more generation z among the freshmen and sophomores, but any more precise comparison is not possible with these results. perhaps inferential statistics would be helpful with data like these. when we did that, only 2 clusters were significant, and 3 more were close. ultimately it seemed that given our group sizes and qualitative nature of the responses, chi-square and fisher exact tests did not add much to our understanding of the students’ responses. the use of focus groups might also shed light on the meaning of these clusters to the premedical students and help in our interpretation of these data. for example, a single focus group we conducted with a small group of summer program college pre-medical students who doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports had experienced additional reflective exercises tended to emphasize patient relationships and compassion easily. they also were comfortable broaching sensitive issues, such as the doctor’s role with discussing spirituality with the patient. this issue was something they entered our program thinking was off limits in the doctor’s office. in anonymous evaluations of summer programs, the reflective exercises were often listed as a favorite part of the program, with a typical quote: “i like the friday morning reflections because they pushed me … to pause ... think like a physician ... and treat the patient as a whole.” conclusion perhaps more important than precise classification is the value of the exercise as a reflection that forces the taskfocused, sometimes distracted pre-med to practice a moment of mindfulness. we have continued to use this exercise with pre-meds, medical students in all 4 years, and medical residents as an introduction to a session addressing professional identity development and personal health. the 5-7 minutes of silent, focused reflection seems to be welcomed by all. we continue to gather more responses, including focus groups de-briefing the process, and hope that others will begin to use this exercise and share their findings. references 1. dienstag jl. relevance and rigor in premedical education. nejm. 2008;359:221-224. doi: 10.1056/nejmp0803098. 2. kirch dg, gusic me, ast c. undergraduate medical education and the foundation of physician professionalism. jama. 2015;313:1797-1798. doi: 10.1001/jama.2015.4019. 3. gross jp, mommaerts cd, earl d, devries rg. after a century of criticizing premedical education, are we missing the point? acad med. 2008;83:516-520. doi: 10.1097/acm.0b013e31816bdb58. 4. koenig tw, parrish sk, terregino ca, williams jp, volsch jm. core personal competencies important to entering students’ success in medical school: what are they and how could they be assessed early in the admission process? acad med. 2013;88:603-613. doi: 10.1097/acm.0b013e31828b3389. 5. mccranie ew, lewis gl. prevalence of type a behavior among undergraduates with medical and nonmedical career plans. j med educ. 1987;62:926928. 6. conrad p. the myth of cut-throats among premedical students: on the role of stereotypes in justifying failure and success. j health soc behav. 1986;27:150-160. 7. hackman jd, low-beer jr, wugmeister s, wilhelm rc, rosenbaum je. the premed stereotype. j med educ. 1979;54:308-313. 8. sade rm, fleming ga, ross gr. a survey on the “premedical syndrome”. j med educ. 1984;59:386391. 9. whittington cp, crump wj, fricker, rs. an invitation to walk a mile in their shoes: a rural immersion experience for college pre-medical students. journal of regional medical school campuses. 2019;1(5). doi:10.24926/jrmc.v1i5.1565. 10. yu e, wright sm. “beginning with the end in mind”: imagining personal retirement speeches to promote professionalism. acad med. 2015;90:790-793. doi: 10.1097/acm.0000000000000690. microsoft word editor's note.docx published by university of minnesota libraries publishing editor’s note: a new book and the grmc meeting at learn serve lead paula termuhlen, md and alan johns, md, med editors-in-chief doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 1, issue 4 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc all work in jrmc is licensed under cc by-nc volume 1, issue 4 (2018) journal of regional medical campuses editor’s note editor’s note: a new book and the grmc meeting at learn serve lead paula termuhlen, md and alan johns, md, med editors-in-chief the editors are pleased to publish our fourth issue of the jrmc. you will find the published articles informative and inspiring. the jrmc continues to look for submissions that reflect the valuable work being performed on regional medical campuses. we would like to call attention to the regional medical campus, a new resource book by michael flanagan md with contributors from many of our regional campuses. please open the attached pdf announcement for further information. also, please note the attached schedule for the group on regional campuses meetings during the aamc learn serve lead in austin texas november 2nd and 4th. these are valuable sessions for faculty and administrators of regional campuses. we hope you can take time to attend. 500 internal server error internal server error the server encountered an internal error or misconfiguration and was unable to complete your request. please contact the server administrator at [no address given] to inform them of the time this error occurred, and the actions you performed just before this error. more information about this error may be available in the server error log. microsoft word longitudinalservicelearningarticle.docx published by university of minnesota libraries publishing longitudinal service-learning cultivates intrinsic motivation and protects against burn-out in medical students heather cassidy, md; erik wallace, md; chad stickrath, md z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc heather cassidy, md; director for community engagement, university of colorado school of medicine colorado springs branch, heather.cassidy@ucdenver.edu erik wallace, md; associate dean for colorado springs branch, university of colorado school of medicine, erik.wallace@ucdenver.edu chad stickrath, md; assistant dean for education, colorado springs branch, university of colorado school of medicine, chad.stickrath@ucdenver.edu all work in jrmc is licensed under cc by-nc volume 2, issue 3 (2019) journal of regional medical campuses abstract longitudinal service-learning cultivates intrinsic motivation and protects against burn-out in medical students heather cassidy, md; erik wallace, md; chad stickrath, md topic: burnout is rampant in health professionals—including medical students—and has consequences for patient care and clinician wellbeing. a robust sense of intrinsic motivation is correlated with enhanced physician wellbeing and may protect against burnout. service-learning may cultivate intrinsic motivation by tethering learners to their core values and allowing learners to make a direct impact on their communities. the liaison committee on medical education (lcme) now lists a specific standard for service-learning, but less than a quarter of american medical schools reported meeting this commitment in 2015. though medical schools are working to build service-learning curricula, limited data informs anticipated outcomes for learners and community partners participating in service-learning. we describe a longitudinal service-learning curriculum with attention to learners’ feedback on how participation impacted intrinsic motivation and prevented against burnout. short description: this session will explore intrinsic motivation as a protective force against burnout, and will describe medical students’ qualitative and quantitative feedback about how participation in a longitudinal service-learning curriculum impacted their intrinsic motivations for pursuing medicine. four questions that were posed to/considered by session participants: 1) how does burnout undermine professional identity development among medical trainees? 2) how does intrinsic motivation impact physician burnout and wellbeing, and is intrinsic motivation modifiable? 3) what is service-learning, and how does it differ from volunteerism? 4) how can service-learning be designed to cultivate intrinsic motivation and protect against trainee burnout? three take home points from our session: 1) a strong fund of intrinsic motivation is correlated with greater physician well-being. 2) service-learning is a curricular intervention incorporating student service to the community in response to community identified concerns; best practice incorporates ample student preparation for—and reflection on—the community engagement. 3) longitudinal, mentored service-learning curricula placing students in positions of agency in their communities may cultivate intrinsic motivation and protect against burnout during the core clinical year. microsoft word thedifferenceamissiondrivenarticle.docx published by university of minnesota libraries publishing the difference a mission-driven regional campus can make: serving american indian/alaska native communities paula m. termuhlen, md; mary j. owen, md; anna wirta-kosobuski, phd z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc paula m. termuhlen, md; regional campus dean university of minnesota medical school, duluth campus mary j. owen, md; director, center for american indian and minority health university of minnesota medical school, duluth campus anna wirta-kosobuski, phd; assistant professor university of minnesota medical school, duluth campus all work in jrmc is licensed under cc by-nc volume 2, issue 3 (2019) journal of regional medical campuses abstract the difference a mission-driven regional campus can make: serving american indian/alaska native communities paula m. termuhlen, md; mary j. owen, md; anna wirta-kosobuski, phd topic: in order to create physicians who resemble the people we serve, it is vital for all institutions to develop methods of engaging and supporting individuals who are underrepresented in medicine and science (urm) and who are interested in becoming physicians. a regional campus has the ability to focus its mission on serving these individuals to help diversify the overall faculty and student body at a medical school. this session will explore the best practices and lessons learned from working with american indian/alaska native communities. using a modified world cafe format, participants will explore how their campuses can recruit and support urm students and faculty and engage the communities from which they come. short description: in 2016, a letter to the editor entitled "are regional campuses more isolating for minority students" was published in academic medicine alleging that students who are underrepresented in medicine are socially isolated, potentially impacting their performance.1 they assert that this may be magnified in a regional campus setting and that further research is warranted. this prompted a rebuttal from the grmc steering committee.2 the university of minnesota medical school, duluth campus has had a mission to train physicians for rural and native american communities for over 40 years. the current aamc monograph, "reshaping the journey: american indians and alaska natives in medicine" lists the university of minnesota medical school as the second highest producer of native american physicians.3 the key to success has been a focused mission and engagement with an underserved community to develop programming that supports ai/an students throughout the education continuum from kindergarten to medical practice. four questions were considered by session participants using a world café model: 1) what do you want to accomplish? define your mission and desired outcomes. 2) who is your target population and how do you build relationships with them? 3) what are the needed resources for your work and how do you obtain them? 4) what do you need to sustain the effort? three take home points from our session: 1) trust with community is critical to success; get it and keep it! ask the community what they need/want. 2) eliminate “othering”; you cannot be what you cannot see. build inclusiveness. 3) many partners are available; to sustain the effort identify and engage stakeholders. more partners are likely available than you realize. references 1. campbell, kc and rodriguez, je. are regional campuses more isolating for minority students. acad med 2016; 91(7): 896-898. 2. carter, l, cooper, g and johns a. a closer look at regional medical campuses. acad med 2017; 92(9): 1221. 3. hill, g and poll-hunter, n. (2018) ‘learning from our community: effective practices’ in reshaping the journey: american indians and alaska natives in medicine. association of american medical colleges and association of american indian physicians, pp. 41-54. microsoft word article framework for faculty development .docx published by university of minnesota libraries publishing a framework for faculty development programming at va and non-va academic medical centers david r. topor, ph.d., ms-hped. andrew e. budson, md doi: https://doi.org/10.24926/jrmc.v1i3.1049 journal of regional medical campuses, vol. 1, issue 3 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc dr. topor is the associate director for healthcare professions education at the va boston healthcare system and an assistant professor at harvard medical school dr. budson is the associate chief of staff for education at the va boston healthcare system and a professor at boston university school of medicine. all work in jrmc is licensed under cc by-nc volume 1, issue 3 (2018) journal of regional medical campuses original report a framework for faculty development programming at va and non-va academic medical centers david r. topor, ph.d., ms-hped. andrew e. budson, md abstract va and non-va academic medical centers (amcs) serve as training environments for learners from many different professions and academic affiliates, including regional medical campuses. faculty members at these amcs need programming to help create and enhance the educational environment for learners. in this paper, we provide a framework for amcs to develop and implement faculty development programming and provide a case example of how this programming was implemented at one va amc. it is the hope that this framework and programming can be adopted by other amcs to provide faculty members with the programming needed to sustain high quality training environments. the department of veterans affairs (va) is the largest training environment for healthcare professionals in the united states. in 2016, over 127 000 learners trained at va medical centers, including over 43 000 medical trainees.1 the va has affiliation agreements with over 90% of american medical schools1, and about 30% of all medical residents in the united states rotate through va medical centers on an annual basis.2 further, the va has relationships with over 1800 training programs that span more than 40 health professions3, and include many regional medical campuses (rmcs). this large investment to train the next generation of healthcare professionals is directly related to their recruitment to the va workforce. for example, 60% of va physicians and approximately 70% of both va optometrists and psychologists trained at the va prior to their va employment.1 the va boston healthcare system (vabhs) educates a large number of trainees, with over 3200 educated in 2016. the vabhs is affiliated with over 350 training programs, over 100 affiliates, and has more than 500 faculty members. to support this large number of trainees, vabhs training program directors and faculty members need the following: training and support to use evidence-based teaching techniques, professional opportunities to develop as educators, a forum to share best practices as a community of educators, and a mechanism to develop a network of educators. however, in 2012 the vabhs — like most other va and non-va academic medical centers (amcs)4,5 — lacked a structured approach to developing and implementing faculty development programming. we initiated several successful faculty development programs, but the programs were not held on a regular basis and were not based on the specific needs of the faculty or the medical center. recognizing the need for a more strategic, organized approach, we worked to create a framework to conceptualize the different components required for comprehensive faculty development programming. use of a strategic framework can provide faculty at amcs with the knowledge and training they need to properly teach and supervise trainees in today’s interprofessional healthcare environment, and to facilitate educational improvements and innovations in the future. we hope that our experience at va boston can be helpful in the successful implementation of faculty development programming at other amcs, including those training learners from rmcs. the need for faculty development programs nationally: faculty members need initial and ongoing training on teaching, supervising, and evaluating healthcare professional trainees.6 currently, low percentages of faculty members report receiving training in effective teaching strategies, providing meaningful feedback to trainees, assessing learner journal of regional medical campuses, vol. 1, issue 3 original report performance, and teaching on interprofessional teams.7 for example, only 33% have received training in mentoring skills, 47% in how to use role play, 37% in time management, and 50% in outpatient precepting.6 these low percentages highlight the need for continued and sustained faculty development programming. faculty development programs are beneficial: although there are not enough faculty development programs, when such programs are provided they are generally found to be beneficial and effective. a systematic literature review showed that faculty members were satisfied with faculty development programming and believed the program content was useful and relevant to their teaching.8 as a result of participating, they experienced increased positive attitudes towards faculty development and teaching, increased knowledge of educational principles, greater establishment of faculty networks, and positive changes in teaching behavior (as identified by faculty and students).8 further, teaching effectiveness increased as a result of participation.8,9 in addition to providing benefit to teachers and students, faculty development programs also provide direct and indirect financial benefits to the amc.10 indirect benefits include decreasing employee turnover. employee turnover can be costly, as cost estimates for replacing one faculty member range from $250 00011 to $400 000.12 high turnover is linked to decreased employee morale and decreased productivity.13 faculty development programs increase job satisfaction and faculty retention, particularly of female and minority faculty members.11,14 such benefits are long lasting, with one study finding benefits for up to two years following participation in a program.15 faculty development programs may also directly financially benefit the amc through increased external grant funding.14,16 faculty development programs also lead to increased patient safety, satisfaction with care, quality of care, and the potential of reduced malpractice claims, all of which financially impact the amc.17,18 for instance, when faculty members teach learners more effective strategies to communicate with patients, it can result in increased doi: https://doi.org/10.24926/jrmc.v1i3.1049 patient adherence to treatment and a reduction in patient symptoms.19 this result, in turn, may lead to higher quality patient care and increased patient satisfaction with medical services received, decreased hospital re-admissions, decreased medical errors, and reduction of unnecessary procedures and medications. train framework: the current paper proposes a framework for faculty development programming at amcs focused on five areas: teaching, research, awards, interprofessional education, and networking (train). the framework was developed based on a review of the amc faculty development programming literature, a review of programming content at vabhs academic affiliates, consultation with vabhs educational leaders, and formal and faculty needs assessments. teaching a primary focus of train is to improve the quality of teaching and supervision. multiple skills to improve teaching are identified in the literature.4,8,9 these teaching and supervision skills include both core teaching competencies (e.g., providing feedback to learners, using evidencebased teaching techniques, faculty career development) and newer teaching competencies (e.g., interprofessional education, quality improvement). for example, faculty development programming can help training directors and faculty members assess trainee competencies through traditional assessment methods, such as observation and examination, or newer methods, including learner portfolios and reflective exercises.20,21 faculty development programming can also provide feedback to educators on their teaching and provide coaching to integrate new approaches to teaching and supervision. this programming might include how to use trainee feedback to improve future teaching.22 faculty development programming also helps educators teach emerging topics to meet the needs of trainees in certain educational and clinical settings. for example, as the va increases the number of trainees in rural areas, faculty will need journal of regional medical campuses, vol. 1, issue 3 original report instruction to teach topics of specific importance for rural and community health trainees. these topics include cost-effectiveness, health literacy, the use of health information technology to improve the health of individuals and populations, leadership skills and innovation, practice redesign, and quality improvement.23,24 research educational research is an important component of train. research is needed to develop and assess faculty development programming, teaching strategies, and assessments of learning, among other valuable topics. amcs benefit from this research in a number of ways, including improvement to educational programming. increased faculty publications may raise the amc’s visibility and prestige, and may result in increased grant funding and clinical revenue.14,25 greater prestige and focus on education may also increase donor financial contributions to the amc.25 faculty development programming and consultation are needed to support faculty education research agendas to achieve these benefits.26 programming can teach faculty how to write research grants, manage a research lab, supervise educational research fellows, present their research, and submit articles for publication in academic journals.11,14,16,27 programming can provide individual and group research mentoring. seed grants can facilitate the development of educational and other research projects.11,14,16 further, programing can be targeted to meet the needs of an individual amc. this could include a focus on research to improve medical practice, and education, both needs at amcs and rmcs28. awards educational awards increase the profile and value of educational excellence and recognize faculty for educational achievements.29 awards could be designated for faculty who excel in teaching, mentoring, educational research, or other educational areas. in a survey of faculty members who received awards, nearly all reported the award was personally valuable to them.30 doi: https://doi.org/10.24926/jrmc.v1i3.1049 in another study examining the impact of educator awards, faculty members reported that the awards had a positive impact on themselves and on the institution. faculty members reported that the awards increased self-reflection on teaching, increased passion for teaching, improved teaching skills, and may influence promotion.29 for the institution, faculty members reported that awards heightened the importance and recognition of teaching, increased recognition for the institution, and enhanced the teaching environment.29 interprofessional education healthcare is increasingly delivered by interprofessional healthcare teams, but trainees may have little prior experience working on these teams.31 this incongruity is due to outdated professional training models largely integrating learners from different professions later in their training experience or only after they are fully trained.31 as a result, faculty members need to teach trainees to provide both profession-specific (e.g., nursing) care and to work on interprofessional teams. faculty development programming can help faculty members develop the skills and knowledge they need to teach trainees how to work on these teams. these skills include interprofessional teamwork, communication, values and ethics, and understanding each profession’s roles and responsibilities for collaborative practice.32 networking a core component of faculty development programming is to increase a sense of support and community among faculty educators by increasing networking opportunities.14 participating in faculty development programming allows educators to interact with each other. multiple studies have found that faculty development programing participants report developing meaningful relationships with other faculty members as a result of the programming.33,34 the use of technology, including listservs and social media platforms, can augment networking opportunities, allowing faculty members in different programs and at different amcs to connect with each other. journal of regional medical campuses, vol. 1, issue 3 original report case study: va boston healthcare system the va boston healthcare system (vabhs) provides training for over 3200 health professions trainees each year. prior to adoption of the train framework, there was no organized plan to coordinate vabhs faculty development programming. we used the train framework to guide development and implementation of a variety of faculty development programs. the vabhs academy of health professions educators was established to coordinate and implement the train faculty development activities, with broader goals of improving the quality of health professions education and scholarship at the vabhs, and providing veterans with greater access to high quality, well-trained health professionals. teaching a needs assessment of the vabhs faculty members identified topics for programming to improve skills to teach and supervise. academy programming includes the first friday faculty development presentation series, the vabhs health professions education symposium, faculty development programming within individual clinical departments, collaborations with the academic affiliates, and individual consultations with faculty members. vabhs first friday faculty development presentation series the vabhs first friday faculty development presentation series began in september 2014 and is held at 12:00 pm eastern standard time on the first friday of each month. presentation topics focus on content areas core to educators, including strategies to provide feedback to learners, use spaced learning in education, increase critical thinking, use social media in education, and integrate cultural considerations into training and the provision of healthcare. future talks will focus on interprofessional learning environments, technology in education, simulation in training, and educational research. these presentations were initially developed as video conferences for vabhs faculty on the vabhs’s three main campuses. subsequently, va doi: https://doi.org/10.24926/jrmc.v1i3.1049 faculty members first regionally and then nationally expressed interest in participating. as a result, faculty members from all health professions at all va amcs nationwide and at va affiliate health professions training programs at rmcs were invited to attend. currently, faculty members participate in the presentations in person, via video-conference, teleconference, or an online conferencing program (microsoft lync). in january 2017, continuing education (ce) credits were offered to faculty members for participation. from january 2017 to june 2017, faculty members nationwide earned 387 ce credits by participating in the vabhs first friday faculty development presentations. this includes 141 ce credits for nurses (36.43%), 86 ce credits for pharmacists (22.22%), 59 ce credits for physicians (15.25%), 34 ce credits for social workers (8.79%), and 26 ce credits for psychologists (6.72%). other ce credits were earned by dieticians (6), speech pathologists (1), and occupational therapists (1). as part of earning ce credits, participants were asked to complete satisfaction surveys about the presentations. participants were asked to respond to nine questions on a five-point likert scale, with higher numbers indicating greater agreement with the statement. survey results are displayed in table 1. participants indicated that they believed the presentations were effective in teaching content, that they learned new knowledge, and can apply this knowledge in their teaching. participants reported they were satisfied with the training activities. further, participants found the content was presented in a fair and unbiased manner, the training environment was effective, and they would recommend the training to others. presentations are uploaded and archived on the vabhs education website, www.vabostoneducation.org. uploaded files allow faculty members to access the materials at times that are convenient for them. future plans include augmenting the online files with supplemental educational material, such as self-directed learning activities, to increase learning.8 table 1. doi: https://doi.org/10.24926/jrmc.v1i3.1049 journal of regional medical campuses, vol. 1, issue 3 original report vabhs health professions education symposium the vabhs health professions education symposium brings together faculty from different professions to discuss educational topics over the course of a half-day. the first symposium focused on strategies to provide feedback to trainees. the symposium featured an interactive lecture on best feedback practices, an experiential learning experience where participants role-played providing feedback, and a panel discussion on feedback with educational leaders at the vabhs. future symposia will focus on core educational topics and include a research poster session for educators to share educational innovations. department faculty development efforts in addition to the vabhs-wide programming, the academy assists clinical departments in establishing their own faculty development programming to meet needs unique to their department. for example, the academy works with and supports the mental health service in implementing faculty development programming specific to mental health educators. the vabhs mental health service has a monthly faculty development talk focused on needs identified by the faculty. collaborations with educators at the academic affiliates the academy serves as a conduit for sharing information about faculty development programming at the vabhs and the academic affiliates. a faculty email listserv, vabhs academy newsletter, and vabhs website advertises vabhs programming to both vabhs and affiliate faculty. further, the vabhs consults with a number of affiliates in rural areas and at rmcs, which is essential to strengthen the relationship with community and rural health clinics.23 these consultations are particularly important as the va works to implement initiatives to increase the number of trainees in these settings. individual consultations for training programs the academy offers individualized consultation to vabhs training programs to help improve the training environment and to assist programs in meeting accrediting body requirements. jan march april may june "overall, i was satisfied with this learning activity." 4.28 4.33 4.32 4.24 4.28 "i learned new knowledge and skills from this learning activity." 4.54 4.24 4.28 4.14 4.26 "i will be able to apply the knowledge and skills learned to improve my job performance." 4.08 4.22 4.28 4.05 4.21 "the scope of the learning activity was appropriate for me learning." 4.38 4.28 4.32 4.10 4.21 "the training environment was effective for my learning." 4.38 4.24 4.23 4.19 4.21 "i would recommend this training to others." 4.44 4.35 4.23 4.10 4.16 "the learning activities were effective in helping me learn the content." 4.13 4.09 4.16 4.07 4.20 "the content of the learning activity was current." 4.59 4.37 . 4.31 4.37 "the content was presented in a manner that was fair and unbiased." 4.62 4.35 4.38 4.40 4.44 journal of regional medical campuses, vol. 1, issue 3 original report for example, academy educators used a logic outcomes model to help one training program select appropriate data collection and assessment methods.35 consultations can also help programs submit funding proposals to initiate or expand training programs, create developmentally appropriate learning curriculum, recruit trainees and faculty members from diverse backgrounds, develop and assess an interprofessional learning curriculum, and develop education awards. these consultations are also offered to partner training programs at other va ams, rmcs, and affiliates. individual consultations for faculty members the academy provides individual consultation and mentorship to help faculty members develop as educators. the consultations may focus on improving specific teaching skills or on broader career development issues. examples include focusing on improving specific teaching skills or aiding in course re-design. vabhs faculty members can also request audio, video, or peer review of their teaching and supervision. research the academy actively promotes educational research through a number of initiatives, including individual consultation, presentation opportunities, and assistance in applying for funding for educational research trainees. academy staff consult with faculty to identify, write, and submit grants to internal and external funding agencies, such as the va office of rural health, the josiah macy foundation, the arnold p. gold foundation, and the health resources and services administration (hrsa).4 an example of a successful outcome of this effort is a presidential program grant from the gold foundation awarded to one of the authors (dt) to teach and promote reflective practice and narrative medicine among vabhs trainees and faculty members. this consultation extends to faculty members who are submitting research grants that include establishing a learning environment for trainees. grant funding agencies are increasingly interested in proposals that include interprofessional education initiatives, such as developing learning curricula to integrate learners from different doi: https://doi.org/10.24926/jrmc.v1i3.1049 professions and evaluating learning. the academy mentors researchers to incorporate these educational objectives into grant submissions. for example, the va specialty care education centers of excellence and the big data scientist training enhancement program (bd-step) requests for proposals required submissions to identify how interprofessional clinical and educational models would be created and how learning would be assessed. the academy provides funding for faculty members to present their research at local, regional, and national educational conferences. the academy also provides opportunities at the vabhs for faculty members to present their research. these opportunities include a research poster session at future vabhs health professions education symposia. future first friday faculty development presentations, along with other academy programming, will focus on research skills including grant writing skills and strategies to publish academic research. the academy also assists with proposal submissions to establish new research-oriented training programs. for example, the va recently developed health professions education research fellowships. the goals of this fellowship include teaching educational program evaluation, assessment of learners and of learning, curriculum development, system improvement strategies, and the development of leadership skills. academy staff consulted on a vabhs submission to develop one of these fellowships. faculty development programming can also increase collaboration between clinical and educational researchers. an increasing number of clinical program grant proposals require applicants to include educators to help with the design and implementation of their novel clinical program at an amc. funding agencies are increasingly interested in interprofessional education initiatives, welldefined learning curricula that integrates interprofessional learners, and detailed plans to evaluate learning. for example, the va office of patient centered care and cultural transformation request for proposals (rfp) required grant submissions to develop and integrate educational curricula. the va specialty care education journal of regional medical campuses, vol. 1, issue 3 original report centers of excellence rfp required a plan to develop interprofessional educational activities and assess their efficacy. the va big data scientist training enhancement program rfp required that an interprofessional didactic curriculum be integrated into the proposal. awards the vabhs academy educator awards recognize excellence in education. award criteria are based, in part, on the national va david m. worthen award for career achievement in educational excellence criteria. these awards highlight the unique contributions of educators and underscore the importance of the amc’s educational mission. consistent with the interprofessional nature of the academy, faculty members from all professions are eligible for the awards and members of the award selection committee reflect the diversity of health professions at vabhs. award criteria includes significant achievements that have enhanced educational programs within the vabhs. this can include excellence in teaching, mentoring, educational research, training program and curriculum design, mentorship, interprofessional work, and educational innovations. it can also include leadership on national taskforces, accreditation bodies, or educational organizations, publications combining education, learning, and healthcare, or the implementation of educational innovations that influenced other programs over time. interprofessional education the academy develops and implements interprofessional educational initiatives for trainees and faculty, including interprofessional training environments and the interprofessional health professions training program director collaborative meetings. programming to initiate or enhance interprofessional education the academy sponsors initiatives to increase faculty members’ skills and abilities to train interprofessional healthcare teams and supports the creation and enhancement of interprofessional training environments. the doi: https://doi.org/10.24926/jrmc.v1i3.1049 monthly first friday faculty development presentation series includes topics on interprofessional education. academy leadership consults with training programs and clinical programs to integrate interprofessional learning activities into learning curricula. individual consultations provide faculty members with a personalized learning plan to learn and enhance skills and abilities needed to provide this training. the academy provides support for several unique interprofessional clinical training initiatives. the acute rehabilitation service interprofessional dedicated education unit is an interprofessional training environment where learners from multiple professions, including physician assistants, pharmacists, nurses, social workers, speech pathologists, and physical therapists, train together. clinicians and trainees meet weekly to discuss interprofessional training and patient-centered care. similarly, the neurology memory disorders case conference and clinic hosts trainees including physician assistants, pharmacists, nurse practitioners, neuropsychologists, medical students, and physicians, the latter including psychiatry interns, neurology and internal medicine residents, and fellows from the fields of geriatrics, neuropsychiatry, and behavioral neurology. the academy supports protected staff time to develop and implement this programming. the harvard medical school south shore psychiatry residency training program integrates trainees from the vabhs mental health nurse practitioner mental health training program to provide shared didactic classes and learning experiences, and co-presentation of clinical cases. these experiences help trainees from both programs learn skills to both provide mental health services and interact with an interprofessional treatment team to provide optimal care for veterans. vabhs health professions training program director collaborative meetings interprofessional education is discussed and promoted during the monthly interprofessional vabhs health professions training program director collaborative meetings. the agenda for these meetings includes a brief 5 minute discussion of administrative issues impacting all training journal of regional medical campuses, vol. 1, issue 3 original report programs, a 25 minute presentation by a training program director on the profession, training program, and teaching innovations, a 20 minute active discussion of the training program and ways it can improve and collaborate with other programs, and a 10 minute teaching strategy identified in a recent education journal article. training program director collaborative meetings began in april 2014. from april 2014 to june 2017, 36 training program directors have presented. as a result of the interprofessional nature of these meetings, it is the hope that training program directors are better able to understand other professions’ history, clinical roles, and training model, and have the opportunity to network with educators from different professions. trainees interested in education are also invited to attend. networking the vabhs academy develops programs to increase networking opportunities for educators. the monthly vabhs health professions training program director collaborative meetings allow training program directors to meet each other, identify commonalities among the programs and the director roles, develop ideas for joint educational programming, and form an educational community. the vabhs health professions education symposium and monthly first friday faculty development presentations provide opportunities for educators to network. a vabhs faculty listserv allows faculty members to share knowledge and resources, identify educator events at vabhs and at academic affiliates, and learn about educational initiatives and educational grants. the listserv currently has 126 members. an academy newsletter allows for dissemination of information about various educational and faculty development and profiles vabhs faculty members and training programs. future plans to connect faculty and form a community of vabhs educators include developing online forums and social media platforms (e.g., twitter, facebook). diffusion to other amcs amcs need faculty development programs to ensure that high quality clinical training programs are developed and maintained, and that doi: https://doi.org/10.24926/jrmc.v1i3.1049 trainees are retained as future clinical providers. the train model provides a framework of the components necessary for a comprehensive amc faculty development program. the train model served as the basis for the creation of faculty development programming at the vabhs. amcs and rmcs are encouraged to use this framework to develop and implement their own faculty development programing. dissemination of this programming is especially needed to help develop and enhance training experiences in areas where there is a shortage of healthcare professionals.2 for example, as part of the veterans access, choice, and accountability act of 2014 (vacaa), an additional 1500 physician resident trainee positions were created, with a significant portion of these new positions allocated to facilities under-represented in health professions education.2 as these facilities are new to residency training, they will need support for their training program leadership and faculty members to teach these trainees. this support may not be readily available at their location, which poses a challenge to new training positions and programs.2 therefore, adopting the train framework, and partnering with other amcs and rmcs who have also adopted this framework, will provide these new and expanded training programs the support they need to ensure a successful training environment. as amcs adopt the train framework, educators should evaluate the impact of programming on faculty knowledge, skills, and abilities, on learning environments, and ultimately, on clinical care for veterans. further, amcs should measure the financial benefits of this programming to the amc.14 amcs are encouraged to use strategic planning strategies when encountering barriers to implementing the train framework. barriers may include limited dedicated staff time to plan, develop, and implement programming and competing demands on faculty time to attend this programming, given their clinical, research, and administrative responsibilities. doi: https://doi.org/10.24926/jrmc.v1i3.1049 journal of regional medical campuses, vol. 1, issue 3 original report 1. affiliations usvhaooa. 2016 statistics: health professions trainees. in. u.s. department of veterans affairs website2016. 2. chang bk, brannen jl. the veterans access, choice, and accountability act of 2014: examining graduate medical education enhancement in the department of veterans affairs. academic medicine : journal of the association of american medical colleges. 2015. 3. lee jmd, sanders kmmd, cox mmd. honoring those who have served: how can health professionals provide optimal care for members of the military, veterans, and their families? academic medicine. 2014;89(9):1198-1200. 4. clark jm, houston tk, kolodner k, branch wt, levine rb, kern de. teaching the teachers: national survey of faculty development in departments of medicine of u.s. teaching hospitals. j gen intern med. 2004;19(3):205-214. 5. hatem cj, lown ba, newman lr. the academic health center coming of age: helping faculty become better teachers and agents of educational change. academic medicine : journal of the association of american medical colleges. 2006;81(11):941-944. 6. houston tk, ferenchick gs, clark jm, et al. faculty development needs. j gen intern med. 2004;19(4):375-379. 7. holmboe es, ward ds, reznick rk, et al. faculty development in assessment: the missing link in competency-based medical education. academic medicine : journal of the association of american medical colleges. 2011;86(4):460-467. 8. steinert y, mann k, centeno a, et al. a systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education: beme guide no. 8. medical teacher. 2006;28(6):497-526. 9. lee sm, lee mc, reed da, et al. success of a faculty development program for teachers at the mayo clinic. j grad med educ. 2014;6(4):704-708. 10. topor dr, roberts dh. faculty development programming at academic medical centers: identifying financial benefits and value. medical science educator. 2016:1-3. 11. pololi lh, knight sm, dennis k, frankel rm. helping medical school faculty realize their dreams: an innovative, collaborative mentoring program. academic medicine : journal of the association of american medical colleges. 2002;77(5):377-384. 12. schloss ep, flanagan dm, culler cl, wright al. some hidden costs of faculty turnover in clinical departments in one academic medical center. academic medicine : journal of the association of american medical colleges. 2009;84(1):3236. 13. collins sk, mckinnies rc, matthews ep, collins ks. a ministudy of employee turnover in us hospitals. health care manag (frederick). 2015;34(1):23-27. 14. emans sj, goldberg ct, milstein me, dobriner j. creating a faculty development office in an academic pediatric hospital: challenges and successes. pediatrics. 2008;121(2):390-401. 15. herrmann m, lichte t, von unger h, et al. faculty development in general practice in germany: experiences, evaluations, perspectives. medical teacher. 2007;29(23):219-224. 16. jagsi r, butterton jr, starr r, tarbell nj. a targeted intervention for the career development of women in academic medicine. arch intern med. 2007;167(4):343-345. 17. hickson gb, clayton ew, githens pb, sloan fa. factors that prompted families to file medical malpractice claims following perinatal injuries. jama. 1992;267(10):1359-1363. 18. starmer aj, spector nd, srivastava r, et al. changes in medical errors after implementation of a handoff program. n engl j med. 2014;371(19):1803-1812. doi: https://doi.org/10.24926/jrmc.v1i3.1049 journal of regional medical campuses, vol. 1, issue 3 original report 19. quirk m, mazor k, haley hl, et al. how patients perceive a doctor's caring attitude. patient educ couns. 2008;72(3):359-366. 20. webb tp, merkley tr. an evaluation of the success of a surgical resident learning portfolio. journal of surgical education. 2012;69(1):1-7. 21. webb tp, merkley tr, wade tj, simpson d, yudkowsky r, harris i. assessing competency in practice-based learning: a foundation for milestones in learning portfolio entries. journal of surgical education. 2014;71(4):472-479. 22. gilman sc, chokshi da, bowen jl, rugen kw, cox m. connecting the dots: interprofessional health education and delivery system redesign at the veterans health administration. academic medicine : journal of the association of american medical colleges. 2014;89(8):1113-1116. 23. rieselbach re, rockey ph, phillips rl, jr., klink k, cox m. aligning expansion of graduate medical education with recent recommendations for reform. annals of internal medicine. 2014;161(9):668-669. 24. armstrong eg, barsion sj. creating "innovator's dna" in health care education. academic medicine : journal of the association of american medical colleges. 2013;88(3):343-348. 25. cooke m, irby dm, debas ht. the ucsf academy of medical educators. academic medicine : journal of the association of american medical colleges. 2003;78(7):666-672. 26. scott k, caldwell p, schuwirth l. ten steps to conducting health professional education research. the clinical teacher. 2015;12(4):272-276. 27. yarris lm, jordan j, coates wc. education scholarship fellowships: an emerging model for creating educational leaders. journal of graduate medical education. 2016;8(5):668-673. 28. cathcart-rake w, robinson, m. promoting scholarship at regional medical campuses students. journal of regional medical campuses. 2018;1(1). 29. searle ns, teal cr, richards bf, et al. a standards-based, peer-reviewed teaching award to enhance a medical school's teaching environment and inform the promotions process. academic medicine : journal of the association of american medical colleges. 2012;87(7):870-876. 30. brawer j, steinert y, st-cyr j, watters k, wood-dauphinee s. the significance and impact of a faculty teaching award: disparate perceptions of department chairs and award recipients. medical teacher. 2006;28(7):614617. 31. thibault ge. reforming health professions education will require culture change and closer ties between classroom and practice. health affairs. 2013;32(11):1928-1932. 32. schmitt m, blue a, aschenbrener ca, viggiano tr. core competencies for interprofessional collaborative practice: reforming health care by transforming health professionals' education. academic medicine. 2011;86(11):1351. 33. pololi lh, knight sm, dennis k, frankel rm. helping medical school faculty realize their dreams: an innovative, collaborative mentoring program. academic medicine. 2002;77(5):377-384. 34. knight am, carrese ja, wright sm. qualitative assessment of the long-term impact of a faculty development programme in teaching skills. medical education. 2007;41(6):592-600. 35. armstrong eg, barsion sj. using an outcomes-logic-model approach to evaluate a faculty development program for medical educators. academic medicine. 2006;81(5):483-488. 1. microsoft word impactofaprimarycarearticle.docx published by university of minnesota libraries publishing impact of a primary care focused regional medical campus on recruitment into primary care residencies amanda davis, md; stoney abercrombie, md; nathan bradford, md doi: https://doi.org/10.24926/jrmc.v2i1.1780 journal of regional medical campuses, vol. 2, issue 2 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc amanda davis, md; dr. davis is the assistant dean for student affairs for musc-anmed health clinical campus and on the faculty of the anmed health family medicine residency program. stoney abercrombie, md; dr. abercrombie is the campus dean of musc-anmed health clinical campus and director of medical student education at anmed health. nathan bradford, md; dr. bradford is the internal medicine site director for musc-anmed health clinical campus, and on the faculty of the anmed health family medicine residency program. corresponding author: dr. amanda davis; anmed health family medicine residency program 2000 east greenville street suite 3600, anderson, sc 29621 phone: 864-512-1473 fax: 864-224-8100 email: amanda.davis1@anmedhealth.org all work in jrmc is licensed under cc by-nc volume 1, issue 6 (2019) journal of regional medical campuses original reports impact of a primary care focused regional medical campus on recruitment into primary care residencies amanda davis, md; stoney abercrombie, md; nathan bradford, md abstract anmed health is a community-based nonprofit hospital system in anderson, south carolina with a single residency in family medicine. in july 2014, a class of 12 third-year medical students associated with medical university of south carolina-charleston (musc-c) and edward via college of osteopathic medicine-carolinas campus (vcom-cc) began their clinical training at anmed. since that time, 58 medical students have completed their clinical training at anmed health, 71% have entered primary care residencies, and 38% have matched into family medicine. according to a health resources and services administration report, the growth in primary care physician supply will not be adequate to meet demand in 2020, with a projected shortage of 20 400 physicians.1 one way to increase medical student enrollment in primary care residencies may be through primary care focused regional medical campuses. important factors in primary care specialty choice include longitudinal primary care experiences, an institutional culture which supports primary care, and student exposure to primary care faculty as leaders in the institution.2 regional medical campuses are uniquely positioned to provide all of these factors. anmed health, founded in 1908, is a 461-bed, 3 hospital system located in anderson, south carolina. this city of 27 000 with county population of 198 000 is located in the northwest corner of south carolina halfway between atlanta and charlotte.3 we are 225 miles north of the main campus of the medical university of south carolina (musc), located in charleston. anmed health has a single residency program in family medicine that dates back to 1975 and has graduated 353 residents. starting in 1976, the residency clinic served as a rural family medicine rotation site for musc thirdyear medical students. in 2014, musc-c and anmed health committed to an exclusive academic relationship to develop a clinical campus mainly for students interested in primary care. the goal was to have a total of 24 students at the regional campus (12 thirdand 12 fourth-year medical students). realizing how long it would take to develop a new campus and receive lcme accreditation, a joint decision was made to invite vcom-cc clinical students to train at our site as we developed our campus. vcom-cc was appreciative of this opportunity but fully understood that the commitment would only be for 5 years. we began with an initial musc-c pilot class of 2 students, followed by 6 students for the next few years. these classes were supplemented with vcom-cc students to reach a class size of 12. in july 2020, we will have 24 students from musc (12 thirdand 12 fourth-year students). in 2015, the lcme gave us initial accreditation as a parallel clinical campus. the lcme accreditation process involved a site visit. the goal of the lcme visit was to ensure that we were providing a comparable academic experience. we could also highlight what made the regional medical campus unique. we were tasked to show that all core clinical rotations completed in anmed health share the same objectives, requirements, and evaluation process as rotations completed at musc-c. we also had to show how we planned to track objective measures between both campuses (scores on shelf exams, procedure logs, etc.) to prove comparability of the academic experience. to accomplish this, we have site directors for each required rotation who work closely with their clerkship director counterpart at musc-c. this involves a yearly face to face meeting, with the musc-c clerkship directors visiting our clinical site. in addition, as a large group we have a monthly teleconference with musc-c clerkship directors and academic leadership, and 2 retreats per academic year (one in-person). all third-year rotations are completed in anderson. our dedicated group of site directors is supplemented by almost 200 additional medical staff members. all core fourth-year rotations can be completed in anderson. some students choose to return to musc-c for additional rotations in their specialty choice with many doing acting internships at other doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports sites around the country. on average, we have 5 of our 12 fourth-year students doing away rotations per block. unique to our regional campus, all of our third-year medical students participate in a longitudinal primary care rotation at anderson free clinic. the clinic is a nonprofit entity, open monday through friday, staffed almost entirely by volunteers. there is a fully stocked pharmacy, and the clinic also provides mental health counseling, drug and alcohol counseling, and dental health services. each student spends 20 sessions (every other thursday afternoon) seeing 2-4 patients each session. the students follow a consistent set of patients for the year, with an average usual provider continuity rate of 67%. they serve as the primary care physician for their patients by writing prescriptions, ordering diagnostic tests, making referrals, and writing notes. they learn chronic disease management and hone their motivational interviewing skills related to drug and alcohol abuse, smoking cessation, diet, and exercise. there are 5 core preceptors for the medical student clinic (2 attend each clinic session). all are primary care physicians; 4 trained in family medicine and one in internal medicine-pediatrics. in addition to their time at the anderson free clinic, our medical students are also involved with primary care community outreach. they volunteer at the local hispanic health fair, have started to conduct influenza vaccination clinics at the local salvation army, and serve on local community boards and hospital committees. as of june 2019, we have graduated 58 students (5 classes: 7 musc-c and 51 vcom-cc students). of these, 71% have matched into primary care residencies (family medicine, internal medicine, pediatrics, or obstetrics and gynecology) and 38% matched in family medicine. in 2019, musc-c matched 41% of its graduates into primary care residencies, and 8% in family medicine.4 from 2015-2018, vcom’s combined campuses (carolinas, auburn, and virginia) matched 64% into primary care residencies, and 25% into family medicine.5 we will continue to track the 19 students who matched in pediatrics, internal medicine, and obstetrics to see if they specialize within their field. several factors have led to this relatively high percentage of graduates in primary care, especially family medicine. most of our graduates to date are from vcom-cc, which has a reputation for matching a high percentage of students in primary care. also, students who are interested in primary care from both musc and vcom self-select to our campus. finally, the primary care focus of our campus maintains and promotes student interest in primary care. another goal of our medical student education program is to recruit 1-2 graduates for our family medicine residency each year (out of an intern class of 11). from 2015-2019, we have had 6 of our medical student graduates join our nationally competitive residency program. many students entering family medicine choose to return to their home states to do residency training. this is being addressed presently by recruiting students for our clinical campus at the time of admission to medical school. emphasis is given for interest in primary care and connection to south carolina. we also hope to recruit our medical students to return to anderson to practice once they complete their residency training. we will have our first graduate (family medicine) join our medical staff this year. most of our medical student graduates are still in residency training. musc-c, a large academic health center and medical school since 1824, desires to produce greater numbers of primary care physicians for south carolina. with limited clinical space for additional students in the charleston area, the decision was made in 2014 to develop a clinical campus at anmed health in anderson, sc with an emphasis on primary care education. after 5 graduating classes of students (58) from musc and vcom-cc, we are pleased to have 71% of our graduates entering primary care residencies with 38% in family medicine. our goal is to maintain this high percentage as we transition to an exclusive musc campus. primary care focused regional medical campuses appear to be successful in attracting graduates to enter primary care residencies. references 1. hrsa, projecting the supply and demand for primary care practitioners trough 2020, https://bhw.hrsa.gov/healthworkforce-analysis/primary-care-2020. accessed february 12, 2019. 2. bland cj, meurer ln, maldonado g. determinants of primary care specialty choice: a non-statistical meta-analysis of the literature. acad med. 1995 jul;70(7):620-41. https://journals.lww.com/academicmedicine/citation/1995/1 2000/academic_medicine.1.aspx accessed march 3, 2019. 3. united states census bureau, https://www.census.gov/quickfacts/fact/table/andersoncoun tysouthcarolina/pst045217. accessed february 14, 2019. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports 4. medical university of south carolina, https://education.musc.edu/colleges/medicine/about/facts. accessed june 5, 2019. 5. edward via college of osteopathic medicine https://vcom.cld.bz/vcom-outcomes-report/26/. accessed june 5, 2019. microsoft word it'snotaboutthefeetcover.docx published by university of minnesota libraries publishing it’s not about the feet erik a. wallace, m.d.; nikki d. bloch, b.a.; heather cassidy, m.d. doi: https://doi.org/10.24926/jrmc.v2i4.2160 journal of regional medical campuses, vol. 2, issue 4 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc erik a. wallace, m.d.; associate professor of medicine, associate dean for colorado springs branch, university of colorado school of medicine nikki d. bloch, b.a.; medical student, university of colorado school of medicine heather cassidy, m.d.; assistant professor of medicine, assistant dean for community-based medical education, university of colorado school of medicine corresponding author: erik a. wallace, m.d.; associate professor of medicine, associate dean for colorado springs branch, university of colorado school of medicine, 4863 n. nevada ave., room 426 colorado springs, co 80918; 719-255-8084; erik.wallace@cuanschutz.edu all work in jrmc is licensed under cc by-nc volume 2, issue 4 (2019) journal of regional medical campuses perspectives it’s not about the feet erik a. wallace, m.d.; nikki d. bloch, b.a.; heather cassidy, m.d. abstract the authors at a regional medical campus reflect on the positive impact of implementing a free foot care clinic at a local homeless shelter. although basic foot care services were provided, the humanistic conversations between medical students providing the care and the people who were homeless had a profound impact on both parties. medical students connected with a patient population that they have little in common with and were enlightened and rewarded through these conversations. in the satirical video “it’s not about the nail,”1 a woman confides in her partner that she is suffering from a terrible headache. the partner, noticing a nail protruding from her forehead, offers to remove the nail to relieve her pain. the woman snaps back, “it’s not about the nail…you always try to fix things when what i really need is for you to just listen.” embedded in the absurdity, the video illustrates how our human impulse to solve “problems” can overshadow other unique and critical human abilities: listening and empathizing. this solution-finding impulse is perhaps even more profound among clinicians, who are often called to the profession from a deep desire to heal. yet while focusing intently on the most obvious problem at hand, we risk overlooking the person bearing the “problem.” while our patients may be looking for solutions, they are also looking to be heard and for their experiences to be witnessed and validated. in our rush to fix the “problem,” do we risk rendering our patients invisible? and what do we do when our patients’ challenges are much greater than our capacity to solve? for people experiencing homelessness, their “nails” are manifold. these wounds often go unnoticed as they are forced into the fringes of society, met with the downturned faces of a public too disturbed by—or judgmental of—the reality of their misfortune to acknowledge it. they suffer from physical, mental, and emotional ailments; we focus on “solving homelessness,” epidemics of homelessness, and wars on homelessness (or the homeless)…all while we hope for the “problem” of homelessness to simply disappear.2 homelessness can be borne from illness and will foster illness. as kushel et. al described, “homeless people have higher rates of premature death, a greater burden of acute and chronic physical health conditions, a higher prevalence of psychiatric and addictive disorders, and a higher risk of being sexually or physically assaulted than do people who have a home.”3 access to health services by people experiencing homelessness is limited, and repeated mistreatment by the healthcare system has caused them to lose their trust in us; the imperative to secure food and shelter may outweigh traveling to a scheduled clinic appointment. unique to the medical management of people experiencing homelessness are the pathologies of their feet. people who are homeless spend hours each day on their feet as their primary mode of transportation: learners participating in our medical school’s poverty immersion in colorado springs (picos) quickly discovered that several miles separate our community’s central homeless shelter, soup kitchen, and social services center. despite the critical role feet play in survival, basic foot care is often impeded by the tyranny of the moment; daily and urgent survival needs can lead to chronic neglect of minor and major foot problems. nail pathologies, blisters, corns, tinea pedis, and foot deformities are all common among this population; limited access to hygiene and ambulating in ill-fitting shoes or wet socks can lead to ulcers, infections, frostbite, and amputations, especially in people with underlying diabetes and diabetic neuropathy.4 the feet of those experiencing homelessness hold stories. however, for those of us living with the privilege of stable housing, putting on our socks and shoes may simply be a reflex, our thoughts limited to the color coordination of our socks, matching shoes to the day’s tasks or outfit. long nails or mild lesions might easily be addressed by the supplies in our medicine cabinet, or via access to a podiatrist. our feet usually don’t tell a compelling story. for people who are homeless, their feet speak of their daily lives and struggles. they tell of the last time shoes were removed—sometimes weeks or months ago. they tell of the miles walked, the weather endured, the pain withstood. they tell of deprivation, prioritization, and impossible choices. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 perspectives dedicated foot care clinics provide the opportunity to uncover the narratives hidden beneath the well-worn shoes of people who are homeless; the privilege to peer past their soles and into their souls. although foot care clinics for homeless individuals are not new, they are not common in our communities. trimming nails, filing calluses, and applying athlete’s foot powder might seem like small solutions for small problems, but, similarly to preventive dental care, diagnosis and treatment of minor foot problems can avoid major pain, disability, and costs down the road. while these medical services may be rendered at primary care clinics or even in emergency departments, traditional settings cannot consistently afford the time and personal attention to make connections and unravel stories. dr. jj o’connell, in his book stories from the shadows: reflections of a street doctor, reflects on his own experiences providing foot care for the homeless: “the footsoak inverts the usual power structure and places the caregiver at the feet of each patient and far from the head. this gesture of respect for the literal and figurative personal space of each homeless person is critical and a marked contrast to how i was taught to take charge in clinical encounters.” 5 unlike addressing foot complaints in most traditional clinical settings, when running a foot care clinic for the homeless, it’s not about the feet. during our quarterly foot clinic at a local homeless shelter, medical and allied health professional students undergo training and supervision from local volunteer physicians and podiatrists. the students arrive apprehensive, with outsized nerves: here is a new clinical skill to master and the unknown of engaging with a person experiencing homelessness. students welcome each guest by name, settling the patients in chairs while they take their places on stools at the guests’ feet. they ask about their feet, inquire about their likes and dislikes, and hear about their worries. quickly, students’ attentions shift from apprehensions about how to correctly trim toenails and choose appropriate tools for shaving a callus, to the surprising ease of conversation with their guests. stories unfold. there is listening and empathy. human connection is forged. humility is discovered, and humanity is restored. over the course of a two-hour clinic, the room shifts from awkward quiet to the ease of warm chatter and laughter. the students, most of whom had little previous desire to care for feet, wear profound, unselfconscious smiles by the end. after thirty minutes of cleansing, care, and lotion application, each guest leaves with fresh feet, a new pair of socks, and a smile. sure, there is a cost, and cost-savings, to providing foot care to people who are homeless. basic foot care can improve quality of life by avoiding future pathologic foot complications. however, the true value in these clinics rests in the opportunity to listen and empathize. the privilege to hear stories and in doing so provide visibility to a population that too often goes unseen. to reaffirm their dignity and humanity though the simple act of service, and for them to reaffirm our own. ultimately, it’s not about the feet. references 1. headley j. it’s not about the nail. accessed at https://youtu.be/-4edhdahrog on august 7, 2019. 2. gellafante g. are we fighting a war on homelessness? or a war on the homeless? new york times. accessed at https://www.nytimes.com/2019/05/31/nyregion/ho melessness-shelters.html?searchresultposition=3 on august 7, 2019. 3. kertesz sg, baggett tp, o’connell jj, buck ds, kushel mb. permanent supportive housing for homeless people – reframing the debate. n engl j med. 2016;375(22):2115-17. (doi: 10.1056/nejmp1608326) 4. to mj, brothers td, van zoost c. foot conditions among homeless persons: a systematic review. plos one. 2016;11(12):1-14. (doi: 10.1371/journal.pone.0167463) 5. o’connel jj. stories from the shadows: reflections of a street doctor. boston ma, usa: bhchp press; 2015. microsoft word postgraduate trainee views article.docx published by university of minnesota libraries publishing postgraduate trainee views on ehealth at a distributed medical campus sophiya benjamin, hugh kellam, jeff alfonsi and joanne ho doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 1, issue 5 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc sophiya benjamin, mcmaster university, degroote school of medicine, waterloo regional campus hugh kellam, ontario telemedicine network (otn) jeff alfonsi, university of western ontario joanne ho, mcmaster university, degroote school of medicine, waterloo regional campus, schlegel research institute for aging all work in jrmc is licensed under cc by-nc volume 1, issue 5 (2019) journal of regional medical campuses original reports postgraduate trainee views on ehealth at a distributed medical campus sophiya benjamin, hugh kellam, jeff alfonsi and joanne ho abstract purpose: e-health is a rapidly evolving field that cuts across specialties. graduating physicians are expected to use e health technologies to help their patients obtain specialized services that may not be available in their region of practice. given that there are few if any formal curricula to teach ehealth practice in our region, we sought to understand the current level of comfort and learning needs in this field among post graduate trainees. this is a multicentre, collaborative effort among faculty from the departments of psychiatry, geriatrics and internal medicine in partnership with ontario telehealth network to assess the current learning opportunities in ehealth and the needs of postgraduate residents to become competent in the practice of telemedicine. methodology: we conducted a needs assessment through an online survey to investigate the self-perceived knowledge, gaps and barriers to ehealth of medical resident physicians at the mcmaster university degroote school of medicine waterloo regional campus (wrc), kitchener, ontario, canada. results: almost all respondents identified that they would be interested in education in telehealth and all of them felt that they would have to use telehealth in their future practices. however, 83.3% did not feel confident using telemedicine in clinical practice. the authors do not have any conflicts of interest to disclose. this project received no funding. as all data were completely anonymized thought the internet survey and no patients were involved, this was not reviewed by an ethics board. introduction telemedicine has the potential to alleviate access barriers, such as geographical, scheduling, administrative, and financial issues.1 this is pertinent to this region as a current priority for ontario is to increase accessibility of specialist services in rural and remote settings as wait times to see specialists are longer in canada compared to 11 other commonwealth fund (cmwf) countries 2 and one way to increase access to specialists is to increase the uptake of ehealth. 3 the royal college of physicians and surgeons of canada identifies ehealth as a “hot topic” in their milestone search 4. numerous milestones are specified with the intention that physicians will be competent in these prior to practice. examples include “use technology to facilitate consultation for patients who may have limited or delayed access to care” 4 and “use technology to enhance collaboration in health care”. 4 while recent work has further defined telehealth skills in the canmeds framework, 5,6 there remains a need to develop training opportunities in telemedicine.5 one of the mandates of canadian medical schools is to direct their education toward the priority health concerns of the community .7 as there were no formal training experiences in telemedicine in our region, we sought to understand the learning needs and barriers to using telemedicine among residents at waterloo regional medical campus as the first step to developing a local ehealth curriculum. methods we conducted a needs assessment through an online survey to investigate the self-perceived knowledge gaps in ehealth education and barriers to future practice among medical resident physicians at the mcmaster university degroote school of medicine waterloo regional campus (wrc), kitchener, ontario, canada. the waterloo regional campus is mcmaster’s first fully distributed site for medical education and was started in the year 2007. in february 2017, we sent the open internet-based survey to a purposive sample of 46 residents (11 psychiatry and 34 family medicine). we chose family medicine residents as family physicians are the primary referrers in our medical system and their referral patterns would depend of whether they were comfortable with the modality, particularly with asynchronous consultation such as econsults.8 psychiatry was chosen as the specialist group as tele psychiatry has been established as a feasible form of quality care with outcomes as good as in-person care.9 pragmatically, it was one of the specialty residency programs at this distributed campus. we obtained informed consent from participants. we indicated the length of the survey would be < 5 minutes and disclosed the investigators and the purpose of the needs assessment. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 5 original reports we utilized the google forms® online survey platform. participant responses and personal information were deidentified. as no personal information was collected or stored and this was a voluntary survey, ethics review was not required. results from our sample 25 residents (54%) responded. 12 residents (48%) answered that they definitely anticipated using telemedicine as part of their practice, and the other 13 (52%) answered that they may have to use telemedicine. (figure 1) all of the resident respondents felt they would use telemedicine as part of their practice. figure 1: trainee responses to anticipated need, confidence with an interest in ehealth training. when asked about their comfort level with telemedicine; however, 83.3% did not feel confident using telemedicine in clinical practice. (figure 1) trainees were asked to provide qualitative feedback in a free text box about barriers to using telemedicine. examples of barriers included operating equipment, billing, privacy, how to troubleshoot problems with connections, and, in general, a lack of exposure in postgraduate training. in analyzing the answers, four themes emerged (table 1). these were lack of experience with technology and equipment, lack of practical exposure to this type of practice, medico legal concerns, and questions about how to integrate such practices into existing systems. 75% were interested in more telemedicine teaching in residency and 20.8% answered that may be interested. only one respondent expressed no interest in engaging in further training in telemedicine. table 1 : self-reported barriers to using telemedicine after graduation discussion this needs assessment demonstrated a significant interest but lack of comfort in using ehealth among resident physicians. based on the feedback received on our needs assessment, we developed an elective rotation for postgraduates in psychiatry, internal medicine, geriatric medicine, clinical pharmacology and toxicology and family medicine at our consultation service gerimedrisk. we used the canmeds milestones in ehealth as our starting point and added learning objectives from work done by other groups in defining goals for such a rotation. 4,5,6,10 this training has taken place in the context of the clinical service, gerimedrisk developed by two of the authors (jh and sb). gerimedrisk is an interdisciplinary, technology-based geriatric pharmacology consultation service that aims to optimize a patient’s medications to improve cognition, mobility, function, and mental health. referring clinicians can easily access gerimedrisk nurses, pharmacists, and physicians specializing in geriatric medicine, clinical pharmacology, and geriatric psychiatry by telephone or through telemedicine. clinicians receive electronic consultation (econsult) reports and concise, user-friendly drug information knowledge translation materials. when necessary, in-person or otn videoconference consultations with specialist physicians are available. the feasibility of this model has been tested 11 and it is currently being scaled provincially in ontario. trainees have the opportunity practice various ehealth related skills in this clinical context. since the initiation of this rotation in may 2017, we have had 15 residents train with us. their clinical training programs doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 5 original reports include family medicine, psychiatry, clinical pharmacology and toxicology, medical undergraduate and internal medicine. while majority of these residents were from the waterloo regional campus, three were from a large urban academic health sciences centre. a proportion of their learning goals included learning about econsults and their clinical and financial roles in the health care system and identifying patient cases suitable for econsult compared to those who need to be seen either through videoconferencing or in person. we are continuing to refine the learning goals (table 2) and develop new material in keeping with advances in the field. we hope to continue to gather feedback from trainees to further develop and modify this training experience that equip them to be proficient in telemedicine. table 2: examples of learning goals: 1) identify appropriate cases that can be answered by electronic consultations 2) how to make an effective electronic consultations referral 3) how to draft an electronic consultations note that balances evidence contextual factors. 4) impact of electronic consultations on financial costs to the health system 5) how to set up and conduct an evisit to assess a patient remotely 6) how to build and work within virtual interdisciplinary team our needs assessment has a few limitations. first, it is possible that our sample from a distributed medical campus are more interested in ehealth than resident physicians in general, since our graduates are more likely to choose rural or remote locations for practice. however, this issue further highlights the importance of including these types of curricula in distributed systems. conclusion: this medical education project developed from a canadian regional medical campus highlights the strong awareness of ehealth and self-perceived educational needs of resident physicians, and a pilot response to those needs. ongoing support and future quality improvement projects regarding ehealth competencies among resident physicians are warranted to maximize ehealth’s potential benefit to rural and urban communities. references 1) hilty dm, rabinowitz t, mccarron rm, et al. an update on telepsychiatry and how it can leverage collaborative, stepped, and integrated services to primary care. psychosomatics. 2018;59(3):227-250. doi:10.1016/j.psym.2017.12.005 2) canadian institutes of health research and canadian institute for health information. 2015. "how canada compares: results from the commonwealth fund 2014 international health policy survey of older adults." canadian institute for health information. 3) liddy c, moroz i, mihan a, nawar n, keely e. a systematic review of asynchronous, provider-toprovider, electronic consultation services to improve access to specialty care available worldwide. telemed e-health. june 2018:tmj.2018.0005. doi:10.1089/tmj.2018.0005 4) the canmeds milestone guide © 2015 royal college of physicians and surgeons of canada http://canmeds.royalcollege.ca/guide. ( “ehealth entered as a milestone for search) 5) crawford a, sunderji n, lópez j, soklaridis s. defining competencies for the practice of telepsychiatry through an assessment of resident learning needs. bmc med educ. 2016;16:28. 6) hilty dm, crawford a, teshima j, et al. a framework for telepsychiatric training and e-health: competency-based education, evaluation and implications. int rev psychiatry. 2015;27(6):569-592. 7) health canada. 2001. social accountability. a vision for canadian medical schools. ottawa: public works and government services canada. 8) liddy c, moroz i, afkham a, keely e. sustainability of a primary care-driven econsult service. ann fam med. 2018;16(2):120-126. doi:10.1370/afm.2177 9) hilty dm, rabinowitz t, mccarron rm, et al. an update on telepsychiatry and how it can leverage collaborative, stepped, and integrated services to primary care. psychosomatics. 2018;59(3):227-250. doi:10.1016/j.psym.2017.12.005 10) sunderji n, crawford a, jovanovic m. telepsychiatry in graduate medical education: a narrative review. acad psychiatry. 2015;39(1):55-62. 11) ho jm-w, tung j, maitland j, et al. gerimedrisk, a telemedicine geriatric pharmacology consultation service to address adverse drug events in long-term care: a stepped-wedge cluster randomized feasibility trial protocol (isrctn17219647). pilot feasibility stud. 2018;4(1):116. doi:10.1186/s40814-018-0300-x microsoft word do regional medical campuses contribute.docx published by university of minnesota libraries publishing all work in jrmc is licensed under cc by-nc do regional medical campuses contribute to the production of general surgeons? a study of 789 medical school graduates from 3 campuses who matched into general surgery residencies over 40 years: 1974 to 2015 daniel m. avery, md, charles e. geno, md, joseph c. wallace, md, catherine skinner, md, john burkhardt, psyd, andrew g. harrell, md, garrett taylor, and gregg bell, phd journal of regional medical campuses, vol. 1, issue 2 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc daniel m. avery, jr, md, professor of surgery and pathology, professor of community & rural medicine, college of community health sciences, the university of alabama corresponding author: danial m. avery. davery@cchs.ua.edu. all work in jrmc is licensed under cc by-nc volume 1, issue 2 (2018) journal of regional medical campuses original report do regional medical campuses contribute to the production of general surgeons? a study of 789 medical school graduates from 3 campuses who matched into general surgery residencies over 40 years: 1974 to 2015 daniel m. avery, md, charles e. geno, md, joseph c. wallace, md, catherine skinner, md, john burkhardt, psyd, andrew g. harrell, md, garrett taylor, and gregg bell, phd abstract background a regional medical campus (rmc) is a medical school campus separate from the main medical school at which a portion of preclinical or clinical training of medical students is carried out. the college of community health sciences of the university of alabama in tuscaloosa, alabama is the tuscaloosa regional campus of the university of alabama school of medicine (uasom). the question we sought to answer with this study is whether or not regional campuses produce general surgeons. design, setting and participants publicly available data for 6271 graduates of the university of alabama school of medicine from the birmingham, tuscaloosa and huntsville campuses from 1974 to 2015 was obtained by using google search engine. the list was expanded to include the data described by the variables in table 1. results between 1974 and 2015, 789 graduates of the university of alabama school of medicine assigned to the birmingham, tuscaloosa and huntsville campuses matched into categorical surgery. all three campuses matched similar percentages of students ranging from 10.4% to 13.3% (table 2). the main campus at birmingham matched 599 medical students into general surgery and 202 practice general surgery. the tuscaloosa regional campus matched 88 medical students into general surgery and 47 practice general surgery. the huntsville regional campus matched 103 medical students into general surgery and 41 practice general surgery (table 2). conclusions a comparable percentage of medical students at each campus matched into general surgery. the main campus contributed a larger absolute number of practicing general surgeons while regional medical campuses contributed a higher percentage of practicing general surgeons. regional medical campuses contribute significantly to the deficit of general surgeons in this country. introduction a regional medical campus (rmc) is a medical school campus separate from the main medical school at which a portion of pre-clinical or clinical training of medical students is performed. rmcs take on a variety of configurations, and may provide from one to four years of basic science and/or clinical training for either rotating students or for a cohort assigned to that campus for all rotations. the most common model for a rmc is one that focuses on the clinical training in the 3rd and 4th years (1, 2). the college of community health sciences of the university of alabama in tuscaloosa, alabama is the tuscaloosa regional campus of the university of alabama school of medicine (uasom), whose main campus is in birmingham, alabama. the college was founded in 1972 principally to address the need for family physicians in rural alabama. it continues to train medical students in their clinical years, family medicine residents and family medicine/specialty fellows, all with a focus on rural, underserved communities of alabama and the region (2). many medical schools have expanded using regional medical campuses to address the predicted shortage of primary care physicians, especially in rural, underserved areas (2, 3). as of 2013, 55 medical schools in the united states and canada have produced 111 regional medical campuses (1, 4). regional campuses may be a key strategy to continue the effort to address the primary care workforce shortages (2). but, do regional medical campuses contribute to the production of general surgeons which we are desperately short of in addition to primary care physicians? all work in jrmc is licensed under cc by-nc original report there is a critical shortage of general surgeons in the united states (5-21). this deficit especially affects rural hospitals where the lack of surgery services threatens the hospital’s survival (5-9). the number of practicing general surgeons has decreased over the last three decades with a 26% decrease in the last 25 years (5-21). approximately, 80% of graduating chief residents in general surgery pursue fellowship training for a variety of reasons, leaving only 20% or about 200 surgeons to practice general surgery nationwide (19). this study sought to determine the extent to which regional medical campuses in the uasom system contribute to the production of general surgeons. since the montgomery campus only opened to medical students in 2014, it was not included in the study. design, setting and participants this study was approved by the institutional review board of the university of alabama. financial support was provided by the university of alabama institute for rural health research. a list of 6,271 graduates of the university of alabama school of medicine from the birmingham, tuscaloosa, and huntsville campuses from 1974 to 2015 was obtained from the published records of the main campus in birmingham. graduates assigned to the montgomery campus were not included since this campus opened only recently. this list contained the years of matriculation and graduation, full names, specialty choice, name and location of pgy1 institution, and name and location of residency. this database was expanded to include the additional information listed in table 1. information sources were primarily identified using google search engine. publicly available data from internet sources was selected as the primary source of information, with verification from other sources when feasible. the investigators recognize the positives as well as the limitations of internet-based data. information was obtained for 6,238 (99.5%) graduates assigned to the three campuses from 1974 to 2015. physicians were identified by their practice website. the data were then configured into a spss database for the purpose of producing descriptive statistics. this study included graduates who matched into general or categorical surgery but changed into another specialty, were dismissed, left medicine altogether, specialized early into an integrated program or completed general surgery followed by a subspecialty fellowship and practiced a surgical subspecialty. graduates who matched into non-5 year categorical positions (i.e. one year of surgery before ent) were not included. results between 1974 and 2015, 789 graduates of the university of alabama school of medicine assigned to the birmingham, tuscaloosa and huntsville campuses matched into categorical surgery. over the 40 years studied, all three campuses matched comparable percentages of students ranging from 10.4% to 13.3% (table 2). the main campus at birmingham matched 599 medical students into general surgery and 202 (35.1%) of the 572 residents who have completed residency training practice general surgery. the tuscaloosa regional campus matched 88 medical students into general surgery and 47 (59.5%) of the 79 residents who have completed residency training practice general surgery. at the huntsville regional campus, 103 medical students matched into general surgery and 41 (46.0%) of the 89 residents who had completed training practice general surgery (table 2). the study only included surgery clerkship data from the tuscaloosa regional campus. conclusions a similar percentage of medical students at each campus matched into general surgery. the main campus contributed a larger final number of practicing general surgeons while regional medical campuses contributed a higher percentage of practicing general surgeons. the higher percentage of production of practicing general surgeons at the tuscaloosa regional campus is likely related to the high quality and excellent ratings of the surgery clerkship which has been a favorite among students for many years. student evaluations list outstanding teachers, more hands-on, first assist experience and more variety (20). lectures were described as excellent. the course director was receptive to student concerns. one large surgery group has a surgeons’ assistant who takes a very active role in teaching students and was described as very helpful. mentoring is the primary reason that this clerkship is popular. small groups for those interested in surgery are important. there is also a lot of student involvement in patient care. there are no surgery residents except for a single trauma surgery resident from a nearby surgery residency. medical students get to be the first assistant on most operations. most of the teaching is one-on-one. the tuscaloosa regional campus surgery clerkship director (agh) spends considerable time counseling medical students interested in a surgery career. the director also strongly encourages students to rotate or do an acting internship at a teaching institution that has a general surgery residency, preferably an academic one. students are also exposed to privatepractice general surgeons. third year clerkships enhance the choice of residency and career (21). surgery clerkships can enhance a career in general surgery (21). all work in jrmc is licensed under cc by-nc original report table 1: expanded database of tuscaloosa regional campus of the university of alabama school of medicine graduates (1974-2015) table 2: students matching into and practicing general surgery 1974-2015 references 1) cheifetz ce, mcowen ks, gagne p, wong jl: regional medical campuses: a new classification system. acad med 2014; 89:1140-1143. 2) avery dm, stewart jg, skinner ca, williams n, weida tj, higginbotham jc, streiffer rh: is there a regional medical campus effect that could increase the number of primary care physicians? submitted to j regional medical campuses 11/5/17. 3) norris te, coombs jb, house p, moore s, wenrich md, ramsey pg: regional solutions to the physician workforce shortage: the wwami experience. academic medicine 2006; 81(10):857862. all work in jrmc is licensed under cc by-nc original report 4) aamc: official list of rmc-aamc. available @ aamc.org/down.load/…/official-regional-medicalcampuses-my2013.xlsx. 5) avery dm, jr, wallace jc, avery dm, iii, harrell ag, burkhardt j, henderson c, higginbotham jc: attrition of general surgery residents during training. jacobs journal of surgery 2017; 4(1):031. 6) burkholder hc, cofer jb: rural surgery training: a survey of program directors. j am coll surg 2007; 204:416-421. 7) doty b, heneghan s, gold m, bordley j, dietz p, finlayson s, zuckerson r: is a broadley based surgical residency program more likely to place graduates in rural practice? world j surg 2006; 30:2089-2093. 8) deveney k, hunter j: education for rural surgical practice: the oregon health & science university model. surg clin n am 2009; 89:1303-1308. 9) anderson rl, anderson ma: rural general surgery: a review of the current situation and realities from a rural community practice in nebraska. online journal of rural research and policy 2012; 7(2):1-19. 10) musunuru s, lewis b, rikkers lf, chen h: effective surgical residents stringly influence medical students to pursue surgical careers. am j coll surg 2007; 204:164-167. 11) evans s, sarani b: the modern medical school graduate and general surgery training. arch surg 2002; 137:274-277. 12) schroen at, brownstein mr, sheldon gf: comparison of private versus academic practice for general surgeons: a guide for medical students and residents. j am coll surg 2003; 197:1000-1011. 13) doescher mp, lynge dc, skillman sm: the crisis in rural general surgery. rural health research and policy centers. april, 2009. available @ www.ruralhealthresearch.org. 14) fischer je: how to rescue general surgery (editorial opinion). am j surg 2012; 204:541-542. 15) deveney k, deatheridge m, oehling d, hunter j: association between rural training year and the likelihood of becoming a general surgeon in a small town. jama 2013; 148(9):817-821. 16) moesinger r, hill b: establishing a rural surgery training program: a large community hospital, expert subspecialty faculty, specific goals and objectives in each subspecialty, and an academic environment lay a foundation. j surg ed 2009; 66:106-112. 17) gillman lm, vergis a: general surgery graduates may be ill prepared to enter rural or community surgical practice. am j surg 2013; 205:752-757. 18) stain sc, cogbill th, ellison ec, britt ld, ricotta jj, calhoun jh, baumgartner wa: surgical training models: a new vision. curr probl surg 2012; 49:565-623. 19) cogbill th, cofer jb, jarman bt: contemporary issues in rural surgery. curr probl surg 2012; 49:263-318. 20) taylor g, wallace jc, harrell ag, burkhardt j, avery dm, jr, geno ce, skinner ca and bell jg: how can we attract more medical students to general surgery residencies? a study of medical student evaluations of a general surgery clerkship for 10 years: 2005-2015. clinics in surgery 2017; 2:1722. accepted for publication in clinics in surgery 11/6/17. published 11/9/17. o’herrin jk: why do students choose careers in surgery? j surgical research 2004; 119(2): 124. microsoft word comparison of two regional campus article.docx published by university of minnesota libraries publishing a comparison of two regional campus systems and their impact on addressing health care needs of the underserved. sandeep rahangdale, md, maspc* journal of regional medical campuses, vol. 1, issue 2 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc sandeep rahangdale, md, maspc* all work in jrmc is licensed under cc by-nc volume 1, issue 2 (2018) journal of regional medical campuses reflective humanities a comparison of two regional campus systems and their impact on addressing health care needs of the underserved. sandeep rahangdale, md, maspc* abstract a major impact of the late 1970s carnegie commission on higher education’s report titled higher education and the nation’s health was the funding and development of area health education centers (ahecs).1 ahecs were located in rural and medically underserved areas in the states, with a goal of developing medical education programs to improve the manpower needs of these underserved communities.1 the university of north carolina school of medicine (unc som), developed such a network in the 1970s to accomplish this task,2 and this paper reflects upon the success of the unc ahec system as well as the florida state university college of medicine (fsu com), regional campus distributive education model in achieving this goal. the legislature of the state of florida specially created fsu com with a mission focused on producing primary care doctors and physicians who serve the needs of rural, geriatric, underserved, and minority populations.3 fsu com’s distributive medical education system has successfully accomplished this mission.3,4 i completed medical school and residency in the unc ahec system, and i am currently a regional campus dean at fsu com. key words: area health education centers, unc school of medicine, fsu college of medicine, regional medical campuses, underserved populations, underrepresented racial and ethnic minorities (urms), rural medicine, distributive medical education introduction nationally, in 2016, 22 md-granting u.s. medical schools had regional medical campuses (rmcs), that had been present for at least a decade.5 a major goal in the creation of rmcs is to deliver medical manpower to rural and underserved areas of our country and to increase the number of primary care physicians who will practice in rural areas.5,6,7 improving diversity in the physician workforce is also a critical need as these doctors may be more willing to practice in rural areas where many minority and underserved patients reside. unfortunately, underrepresented racial and ethnic minorities in medicine represent less than twelve percent of the physician workforce, while representing about thirty percent of the population of the united states.8 distributive models of medical education, with regional medical campuses located in underserved areas, are vital to correcting this imbalance in medical providers for rural, minority, and geriatric populations.6,7 the university of north carolina school of medicine created ahec programs in the 1970s to address this imbalance, and i started medical school in 1989 at unc chapel hill with little understanding of this regional medical education structure. i completed my clerkships and electives at various ahec programs across the state of north carolina, and later completed an internal medicine residency program at the greensboro, nc, ahec program, before moving to florida to practice general internal medicine. in 2003 i moved to tallahassee, fl, to practice medicine and become a clinical faculty member at fsu com. fsu com quickly developed a regional campus system as well. this article details the benefits of having a regional medical education system in both states with respect to developing physicians who will choose to serve rural and underserved communities. it also comments on similarities and differences experienced during my studies at unc journal of regional medical campuses, vol. 1, issue 2 reflective humanities som versus the structure of medical education at fsu com. regional medical campuses and distributive medical education there is a burgeoning belief that regional medical campuses and community based distributive medical education can significantly impact the healthcare delivered in rural and underserved communities.9,10,11 medical student exposure to rural practice settings makes them more likely to eventually practice there.6,11,12 communities that have regional medical campuses are also better able to access the developing physician workforce, and better recruit as well as retain medical graduates in their communities.6,12 only 1 percent of medical care in the united states occurs at tertiary care centers, and a one to one studentclinical preceptor community teaching model exposes students to physicians who they may emulate by going into practice in similar rural and underserved communities.6 unc som regional ahec system as a third-year medical student at unc, i traveled from one ahec to another across the state while completing my 3rd year clerkships at various community hospital sites. i had more medical encounters with patients in their own communities in this system. the unc system had residencies at each ahec so most of the time i was a medical student on a clinical team comprised of 3rd and 4th year students, interns, residents, and the attending faculty. we also worked day to day with community preceptors on some rotations, and had more one on one time with attending faculty at the ahec campuses. this one on one studentattending preceptor relationship did not occur on rotations at the main medical campus in chapel hill. the distributive medical education at unc som also enabled me to complete rotations in small towns across rural north carolina, in pittsboro and red springs, for outpatient family medicine. this was a transformative experience showing me the tremendous needs of rural and underserved patients, especially in red springs, where native lumbee indians suffered the highest rates of infant mortality and other maladies in the state of north carolina. this ahec training system had, and continues to have, many positive impacts on addressing disparities in care in north carolina. ahec programs do a better job of enhancing diversity of the health professions workforce through outreach efforts in middle and high schools across north carolina.2 rotating through ahec sites leads to the production of more primary care physicians in north carolina.2 residents who train at unc’s ahec sites also remain in north carolina to practice in greater percentages versus non-ahec residency programs in north carolina.2 furthermore, more cost-effective training may occur at ahec sites due to the broader use of technology to expand access to health education.2 on a personal level, my time as a medical student and resident gave me greater exposure to rural and underserved patient populations. this made me more comfortable with the idea of practicing medicine in the panhandle of florida where there are tremendous shortages of general internists. also, while i am not a member of an underrepresented minority in medicine, i learned cultural competencies and the challenges underrepresented minority populations face as a medical student and resident through the unc som system. training i received in medical school as well as residency through the ahec system at unc som succeeded in giving me the confidence to know i could help address the needs of rural and geriatric patients in an underserved area. fsu com regional medical campus system as impactful as the ahec education model was for me at unc, florida state university college of medicine’s innovative educational program has had an even greater impact on producing primary care physicians, and leading to residents returning to florida to practice in rural areas.3,4 fsu com utilizes community-based clinical training at six statewide regional campuses and two rural sites. it is a culmination of planning how to meet a critical journal of regional medical campuses, vol. 1, issue 2 reflective humanities national need to create primary care physicians, especially those who will care for the elderly and underserved.3,4 the florida state university college of medicine was established in 2000 when it was the first new md-granting medical school in the u.s. in over a quarter century. the clinical medical education for fsu medical students is done in communities across the state in local clerkship faculty members’ offices and operating rooms, with over 2,300 fsu com clerkship faculty teaching students across six regional campuses.4 after the second year of medical school, fsu’s 120 medical students leave the main teaching campus at florida state university in tallahassee, florida, to go to one of six statewide regional campuses located in pensacola, tallahassee, daytona beach, orlando, ft. pierce, or sarasota. additionally, students can be placed at two rural track locations in marianna and immokalee, fl, as well as at a rural training site in adjacent thomasville, georgia. figure 1: map of fsu com regional campus system the foundation for fsu com’s regional campus system is the importance of the local community. a community board exists at each campus and comprises the key stakeholders with respects to healthcare delivery in the community. this board helps to select each regional campus dean and then helps to vet physicians who are chosen to be regional faculty, while also developing widespread community support for fsu com. the regional dean then recruits campus clerkship directors from practicing community physicians, who then recruit community doctors to serve as clerkship faculty (clinical preceptors), for medical students at each regional campus. what this means for students at fsu com is that they receive their education in the community, obtaining a one-on-one education with community doctors, where they can see the needs of patient populations, many of whom are minority, geriatric, or underserved, throughout the state. fsu com students consistently receive higher percentile marks on usmle step 2 ck and cs examinations than they do on step 1, and this helps validate the clinical training model.3 the students also have done well in matching to residency programs of their choice, and residency program directors consistently rate fsu com graduates as very well-prepared for graduate medical education.3 finally, fsu com graduates are entering primary care residencies at much higher rates than the national average, with more than 55% of all graduates entering primary care residencies when obstetrics-gynecology is included with family medicine, internal medicine, and pediatrics in that calculation.3,4 graduates of other u.s. medical schools during this time have matched in those specialties 44.2 percent of the time.4 through 2014, 53 percent of fsu alumni matching in internal medicine residency programs did not subspecialize.4 data from 2012 indicate that nationally about 79 percent of graduating internal medicine residents pursued fellowship training.4 family medicine is another specialty where fsu com has excelled in terms of match day data.4 between 2005-2017 13.7 percent of fsu com graduates matched in family medicine, while all other u.s. medical schools matched 8.1 percent of their graduates into family medicine residency programs.4 liaw, cheifetz, et al. looked at match rates into family medicine among rmc graduates from 2007-2009 and found the rmc match rate to be 14.2 percent vs. 7.9 percent when comparing rmc vs. non-rmc medical school match rates into journal of regional medical campuses, vol. 1, issue 2 reflective humanities family medicine.13 this supports the data from fsu com’s match day results in family medicine, and is further evidence that medical schools with regional medical campuses have a much greater likelihood of matching students into family medicine residency programs. fsu com has developed a highly popular and successful community-based model through the regional campus system. it has been strongly supported by both physician preceptors as well as medical students. match rates into primary care, and the creation of general internists vs. internal medicine subspecialists, have both exceeded national averages over the past decade, again validating fsu com’s mission statement.3,4 conclusion addressing gaps in healthcare delivery must include training physicians and other health care professionals who will meet the needs of rural, minority, underserved, and geriatric populations. the regional medical education i received during medical school and residency through the unc ahec system, succeeds in addressing these critical needs, as does fsu college of medicine’s regional campus structure.2,3,4 common learning methods and conditions leading to these results include the one to one student-clinical preceptor teaching model utilized by both systems. another similarity is the placement of medical students in rural and community settings where there are shortages of medical professionals. finally, exposure to rural and manpower shortage areas also gives these communities the opportunity to recruit future physicians, and medical students who train in such settings are more comfortable with returning to such non-urban environments. if medical schools truly intend to create more primary care physicians, fsu and unc can serve as successful models of how to develop regional medical campuses/education that meet the needs of underserved populations. this comparison highlights some of the differences between unc and fsu, while also showing how both regional medical campus systems help produce physicians who will address critical healthcare manpower needs. references 1. odegaard, c.e. area health education centers, the pioneering years, 1972-1978: a technical report for the carnegie council on policy studies in higher education. berkeley, ca: carnegie council on policy studies in higher education; 1979. 2. chen, elizabeth. tar heel footprints in health care. ncmj. 2014: 75(1):7. 2014. 3. fogarty jp, littles ab, et al. florida state university college of medicine: from ideas to outcomes. acad med. 2012: dec;87(12):1699-704. 4. 2017 annual report: florida state university college of medicine (in publication). 5. phillips jp, et al. the effect of a communitybased medical school on the state and local physician workforce. acad med. 2017 july 3. doi: 10.1097/acm.0000000000001823. [epub ahead of print] pmid: 28318061. 6. farnsworth tj, frantz ac, mccune rw. community-based distributive medical education: advantaging society. medical education online. 2012;(17):1-10. 7. brokaw jj, et al. the influence of regional basic science campuses on medical students’ choice of specialty and practice location: a historical cohort study. bmc med educ. 2009: jun 6;9:29. 8. national center for health workforce analysis. sex, race, and ethnic diversity of us healthoccupations (2010-2012). rockville, md: us dept of health & human services; 2015. 9. rabinowitz hk, diamond jj, markham fw: medical school programs to increase the rural physician supply: a systematic review and projected impact of widespread replication. acad med. 2008;(83):235-243. 10. chiefetz ce, mcowen ks, gagne p, wong jl. regional medical campuses: a new journal of regional medical campuses, vol. 1, issue 2 reflective humanities classification system. acad med. 2014: aug;89(8):1140-3. 11. wheat, j. r., leeper, j. d., murphy, s., brandon, j. e. and jackson, j. r. (2017), educating physicians for rural america: validating successes and identifying remaining challenges with the rural medical scholars program. the journal of rural health. doi:10.1111/jrh.12236 12. raymond jr, maurana ca, kershner je. expanding the health-care pipeline through innovation: the mcw model. transactions of the american clinical and climatological association. 2017;(128):90-107. 13. liaw, w, et al. match rates into family medicine among regional medical campus graduates, 2007-2009. j am board fam med. 2012;(25):6894-907. microsoft word recruitingfacultyfromwithinarticle.docx published by university of minnesota libraries publishing recruiting faculty from within: filling the growing need for academic medicine faculty g. anthony wilson md, justin m. jenkins do, mba, gregory h. blake md, mph doi: https://doi.org/10.24926/jrmc.v3i1.2149 journal of regional medical campuses, vol. 3, issue 1 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc g. anthony wilson md; associate professor of family medicine at the university of tennessee graduate school of medicine in knoxville, tennessee. email: gwilson@utmck.edu justin m. jenkins do, mba; clinical assistant professor of family medicine at the university of tennessee graduate school of medicine in knoxville, tennessee. email: jjenkins@utmck.edu gregory h. blake md, mph; professor and chair of family medicine at the university of tennessee graduate school of medicine in knoxville, tennessee. email: ghblake@utmck.edu all work in jrmc is licensed under cc by-nc volume 3, issue 1 (2020) journal of regional medical campuses perspectives recruiting faculty from within: filling the growing need for academic medicine faculty g. anthony wilson md, justin m. jenkins do, mba, gregory h. blake md, mph abstract the predictions point toward increasing difficulty in recruiting academic faculty in family medicine. the 2017 aamc final report, “the complexities of physician supply and demand: projections from 2015 to 2030” predicts significant physician shortages by 2025.1 changes in practice styles, patient demographics, delivery models, retirement goals, and economic trends make the recruitment of academic faculty more challenging as the physician workforce shrinks. the purpose of this descriptive report is to share how we developed and implemented an academic faculty model that would nurture residents from our program to become members of the family medicine faculty, rather than rely on traditional recruiting practices that had proven to be unsuccessful. this process incorporates a faculty/resident needs assessment, development of a customized third-year rotation in academic medicine, completion of faculty development training, a specialized mentorship program, and focused orientation. following this plan, we successfully recruited 3 new faculty physicians for our residency program. implementation of a plan to recruit residency graduates may bring new faculty to other residency programs that are facing challenges recruiting academic physicians, especially in regional medical campuses that are not associated with a medical school. introduction: family medicine residency education involves a broad range of medical knowledge and experience obtained through hospital and ambulatory settings. it is a demanding process for learners and educators. the absence of educators is among the greatest threats to the long-term training of competent family medicine physicians. guidance from seasoned practitioners is essential to ensure that nascent physicians are able to translate facts into evidence-based, patient-orientated actions. what has changed? in response to both internal and external forces, practice profiles have changed dramatically over the last 2 decades. before the mid-nineties, most family physicians joined private practices or group practices with a shareholder option, and practiced in full-scope family medicine models. now, as revealed in one study in 2014, 58% of family medicine physicians are employed by a group or hospital,3 and their practices are strictly ambulatory models. physicians are less involved in national academies, limiting their ability to advocate for themselves. market changes have had a significant impact. prior to the mid-nineties, private payer insurance provided the best return for physicians. today government sponsored programs are the leading payers. changes in national healthcare policy are leading to increased uncertainty in developing new practice models. now, with the majority of family medicine physicians practicing in primarily outpatient settings with no obstetrics, or choosing specific practice models, physicians who have been out of residency for a number of years have not retained the fullscope family medicine skills that are essential in academic medicine. the supply and demand mismatch with an aging population there is an increased need for primary care physicians. by the year 2030, primary care workforce is projected to be understaffed by 7 300 to 43 100 physicians.1 the supply component of the equation is partially addressed by the increase in medical schools in recent years, and a slight increase in family medicine residency positions in the past 2 decades. however, these increases in supply alone have not and will not adequately satisfy the demand. the average family medicine physician, retiring at age 65, will create an absence that will be felt in both private and academic arenas.4 the academic family medicine workforce faces immense hurdles in providing faculty with a broadbased clinical experience. family medicine programs across the country have been recruiting faculty in increasing numbers in the past 5 years. when asked, the participants of the association of family medicine residency directors (afmrd) annual meetings, “how many family medicine physician faculty are you currently recruiting?” more than half of the respondents since 2012 have indicated that they are recruiting at least one, and by 2016 that percentage had risen to nearly 75%. further, not only are more programs recruiting faculty, but the time it takes to fill a position is increasing. during the doi: https://doi.org/10.24926/jrmc. journal of regional medical campuses, vol. 3, issue 1 perspectives same afmrd annual meetings, more than half of respondents reported that the positions took more than a year to fill. methods: needs assessment our program at a regional medical campus recently faced a shortage of 3 faculty, with 5 more contemplating retirement in the next 5 years. such a shortage would make fulfilling our mission as a department more difficult, and put excessive stress on the remaining faculty. knowledge of the broader academic scope was rare among our first round of applicants. we recognized that recruiting experienced faculty from other residency programs is not a sustainable option and poses its own challenges and consequences, as residency programs around the country are facing the same challenges. family medicine residents are typically groomed for careers in outpatient primary care since their residency places an emphasis on longitudinal patient-centered care. it is therefore important that perceived interest in academics is stoked. faculty in our department are expected to take part in teaching in the hospital inpatient setting, but are not expected to take call for obstetrical deliveries. recent graduates from our program are proficient in all clinical expectations of a faculty member. a needs assessment was performed to identify current and upcoming gaps in faculty skill sets (table 1). with this information we were able to identify specific residents with particular interest in skills that fit our anticipated needs for the future. we then approached them about joining our department upon graduation. table 1: needs assessment—faculty skill sets survey faculty members marked all that applied to them board certification family medicine preventive medicine .preventive medicine .occupational medicine hospice & palliative care disaster medicine psychiatry certifications and added qualifications sports medicine geriatrics medical licensure allopathic osteopathic certifications acls pals also atls awls hypertension wound care and hyperbaric medicine adls procedural skills obstetrics .c-section .vaginal delivery .forceps .vacuum extraction .ultrasound .amniotomy .internal monitors .episotomy & repair soft tissue orthopedics .prp .ultrasound .joint injection .casting .strapping .omt women’s health .colposcopy .leep .endometrial biopsy .iud placement .ultrasound general family medicine .toenail extraction .colonoscopy .egd .vasectomy .lump/bump excision .laceration repair .bone marrow biopsy .nasopharyngoscopy occupational medicine .faa exams .dot exams .audiograms .medical review officer doi: https://doi.org/10.24926/jrmc. journal of regional medical campuses, vol. 3, issue 1 perspectives .yellow fever vaccination .independent medical examiner academic certifications .academic medicine fellowship .program directors institute .citi academic rank .professor .associate professor .assistant professor approaching and mentoring residents in our process, once a faculty candidate was identified we matched them with a current faculty member to nurture skills and foster growth of professional interests. we sought an early partnership that carried potential to evolve into mentorship at the faculty level, knowing that the value of mentorship in the early development of academic physicians has been recognized.5 faculty who already had a mentorship relation with the resident continued as faculty mentors throughout the process, as a good fit between mentor and mentee had already been established. mentors did not receive extra remuneration. we worked with the resident to create a customized third year curriculum aimed at exposure to academics and support for professional interests. this academic rotation was created in partnership with a sister residency program in a nearby city, allowing for a reciprocal partnership that allowed the learner to practice an academic role with residents who were not their peers. previous work in military family medicine programs has shown this to be effective in increasing skill and interest in academic family medicine.6 the first 2 weeks were comprised of “precepted-precepting” of other resident colleagues. in this capacity the resident functioned as what we affectionately referred to as the "pre-tending." this occurred in both inpatient and outpatient settings where the “pre-tending” was directly observed while completing the duties of a faculty attending. the “pre-tending” would oversee patient care, offer feedback and instruction to resident colleagues, and model billing and coding. actual billing was completed under the established faculty attending. by arranging for a one-week away experience with a partner family medicine program, residents had a unique opportunity to pursue the same learning objectives while working with non-familiar faculty and overseeing unfamiliar residents. the resident obtained a unique perspective on residency education without the comfort and connection to one's home institution. the remaining time was allotted for personal clinic, assigned readings on teaching (table 2), discussion with the faculty mentor, meetings with hospital leadership, and participation with the hospital’s medical executive committee. feedback was delivered at regular intervals by the faculty mentor and in the moment as needed. for a timeline of the process, please see figure 1. table 2: reading assignments for resident academic rotation figure 1: timeline for training and onboarding of residents to faculty outcomes: through this process, our program recruited efficiently and seamlessly on-boarded 3 new faculty members. two of new faculty members trained under us for 3 years as residents, and one trained with us for one year as a sports medicine fellow. right from the start, the new faculty members were well in tune with personal professional goals and were armed with experience and education regarding the function of academic medicine faculty. this was not the end of our process, as new faculty are shown to benefit from early faculty development.7 we have established an individualized approach to faculty development where each new faculty member pursues further training on the timeline most relevant to their role and department needs. our 3 new faculty completed a formal faculty development fellowship. of the 3 faculty that were recently recruited in this fashion, 2 have remained for 4 years, and one joined a non-academic clinical practice within 2 years. benefits and challenges to recruiting from within we identified several benefits of recruiting from within our residency program. at the culmination of residency, the potential future faculty members demonstrated a known level of academic performance and teaching ability. milestones were measured assuring important competencies and inferring readiness for full-scope practice. residency graduates have fresh experiences doing scholarly activity, an aspect of academic medicine that can be particularly challenging for someone who has been out of residency for a few years. additionally, they are well-integrated into the associated healthcare network, assuring familiarity with system protocols, staff, physicians, culture, and community. doi: https://doi.org/10.24926/jrmc. journal of regional medical campuses, vol. 3, issue 1 perspectives in this light, family medicine residency could be seen as a 3year interview process. it is apparent that other industries utilize this approach, considering that general electric, for example, hires 85% of its executives internally.8 academic family medicine department leadership must continuously evaluate recruitment strategies to meet department needs. sending new faculty to an academic fellowship provides a network of faculty from other residency programs with whom to collaborate, diminishing the absence of a broader outlook brought by bringing new faculty from outside your own program. all of the faculty in our department have fellowship or other advanced training in academic principles, and the new faculty members have acknowledged the training as an asset to help them become more quickly knowledgeable of the roles of an academic physician. on the other hand, our approach was not without challenges. it may still be years before the resident is ready to graduate and assume the role of faculty once the need is identified. in that time, their priorities may change, and they may ultimately decide on a different practice model. recent residency graduates have limited ‘real-world’ experience applying their fund of knowledge and familiarity with evidence-based medicine to a broad range of patients with widely varying comorbidities. having worked together closely, former resident colleagues may have unique biases and insights into a newly recruited faculty member’s strengths and weaknesses. the perception or assumption of knowledge and skill deficiencies can be points of exploitation by learners. in addition, care must be taken to balance professional and personal relationships with former residents as the new position of authority could obscure professional boundaries. a faculty development fellowship may present financial and logistical barriers, but there are numerous other options to consider in further refining a newly graduated resident into a fully-functioning faculty member.9 next steps: efforts to promote a pathway to academic family medicine in medical school may yield greater attention and enthusiasm from early physicians. at least one of our new faculty members, as a senior resident, had never even considered a career in academics until we opened a discussion. attention to the virtues and challenges of junior faculty mentorship and objective measures of performance at the junior faculty level can help highlight best practices for early faculty development. furthermore, as we refine our process, we must balance the need for individualized faculty development with assurance that new faculty are gaining the common skills and knowledge to best serve their role in the department. at times when faculty positions are all filled, we will still offer the resident rotation to allow for residents to gauge their own interest in becoming a faculty at a later date when positions become available. conclusions: our success in recruiting new faculty is a result of a methodical process of identifying residents in our program with interest in academic medicine and with skill sets that augment the mission of our department. a key to the success of our recruiting program is a mentorship plan focused on helping our new faculty members to develop and mature their skill sets in teaching, scholarly activity, and patient care. it is essential to continue to seek faculty from outside the residency program. recruiting from within should not be the only means to fill faculty positions, as diversity of training leads to a stronger faculty. in our model, academic faculty are full-time teachers in the residency program. however, academic faculty in other residency programs may include physicians who dedicate a significant portion of their time to resident education, even if not full time. we feel that a broad range of residency models, including those in larger academic settings as well as smaller, regional campuses will find our approach useful. with diligent effort, practical application of these principles can be used by many departments to fill open faculty positions successfully. references 1. ihs markit, the complexities of physician supply and demand 2017 update: projections from 2015 to 2030. 2. cooke m, irby dm, sullivan w, and ludmerer km. american medical education 100 years after the flexner report. n engl j med 355: 1339–1344, 2006. 3. singleton t, miller p. the physician employment trend: what you need to know. fam pract manag. 2015 jul-aug;22(4):11-15. 4. petterson sm, rayburn wf, liaw wr. when do primary care physicians retire? implications for workforce projections. annals of family medicine. 2016;14(4):344-349. 5. margaret m. steele, sandra fisman & brenda davidson (2013) mentoring and role models in recruitment and retention: a study of junior medical faculty perceptions, medical teacher, 35:5, e1130e1138. 6. brian v. reamy, pamela m. williams, cindy wilson, jeffrey l. goodie & mark b. stephens (2012) who will be the faculty of the future? results of a 5-year study growing educators using an immersive third postgraduate year (pgy-3) faculty development minifellowship, medical teacher, 34:6, e459-e463. 7. gjerde, c, et al. long-term outcomes of a primary care faculty development program at the university of wisconsin. fam med. 2008;40(8):579-84. doi: https://doi.org/10.24926/jrmc. journal of regional medical campuses, vol. 3, issue 1 perspectives 8. marsh jd, chod r. recruiting faculty leaders at u.s. medical schools: a process without improvement? academic medicine, published online ahead of print,doi: 10.1097/acm.0000000000001710. may 2, 2017. microsoft word nationalresidencymatchingprogramarticle.docx published by university of minnesota libraries publishing national residency matching program (nrmp) results for students at the main campus versus the regional medical campus: a 6-year comparison at a single medical school jeffrey g. wong, md; michael p. flanagan, md; kristen m. horn doi: https://doi.org/10.24926/jrmc.v3i1.2971 journal of regional medical campuses, vol. 3, issue 1 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc jeffrey g. wong, md; penn state college of medicine, university park regional campus, office of medical education state college, pa michael p. flanagan, md; penn state college of medicine, university park regional campus, office of medical education state college, pa kristen m. horn; penn state college of medicine, university park regional campus, office of medical education state college, pa all work in jrmc is licensed under cc by-nc volume 3, issue 1 (2020) journal of regional medical campuses original reports national residency matching program (nrmp) results for students at the main campus versus the regional medical campus: a 6-year comparison at a single medical school jeffrey g. wong, md; michael p. flanagan, md; kristen m. horn abstract introduction: anecdotally, some students and faculty members alike have at times expressed concern that medical students who train at regional medical campuses (rmc) will be disadvantaged in the national residency matching program (nrmp), and may not achieve the same level of success as their peers at the main academic medical center. this project was undertaken to examine the validity of these concerns at the rmc affiliated with the penn state hershey college of medicine (pscom). methods: results from the annual nrmp process were analyzed over a 6-year period (2014-2019), for both the main hershey campus (hc) and university park regional campus (uprc). comparisons included the types of residencies selected, percent of students matching instate, percent matching in primary care specialties, and number having to participate in the supplemental offer and acceptance process (soap). no attempt was made to control for baseline student variables and all results were expressed as simple percentages. results: during the study period, 819 students graduated from pscom (723 hershey campus, 96 uprc). in total, 28 of the 723 hershey campus graduates (3.9%) and one of the 96 uprc graduates (1%) went through the soap process. a higher percentage of uprc students matched into primary care specialties (44.8% (uprc) vs 33.2% (hershey campus), defined as medicine, pediatrics, family medicine and obstetrics-gynecology. additionally, more uprc students matched within the state of pennsylvania for their residency (34.4% uprc vs 31.7% hershey campus). finally, uprc students were also successful in matching into highly competitive specialties, including ophthalmology, orthopedic surgery, otolaryngology, diagnostic radiology, and neurosurgery. conclusions: concerns frequently expressed regarding a successful match for students studying at regional medical campuses are not supported by our findings. compared to their main campus peers, the uprc medical students have been equally successful in the nrmp match introduction regional medical campuses (rmcs) are becoming an increasingly important part of many medical schools in the united states and canada. prior to 1970, there were 4 registered rmcs in all of the united states and canada. in the 5 decades since then, there has been an uneven but substantial increase in the number of rmcs. in the decade of 1970-1979, 35 rmcs were born; from 1980-1989, only 1; from 1990-1999 rmcs there were 4; in 2000-2009, there were 44, and in 2010-2019 there were 26 additional new rmcs founded, for a total of 120.1 the large growth since the 2000 millennium may have in part been due to a response to the aamc’s president at the time, jordan j. cohen, and his call for a 30% increase in medical schools to address anticipated physician shortages.2 the washington, wyoming, alaska, montana, idaho (wwami) program3 and the campuses associated with michigan state university4 are examples of the regional campus response to this call. at present, there are a total of 107 rmcs in the united states and 13 in canada. in the us, 52 medical schools have at least one regional medical campus (34%) and 9 canadian schools have at least one rmc (53%). this large growth in the past 20 years has led to an increase in the total number of medical students who perform at least a portion of their training at these rmcs (presently estimated at over 6 800 students).1 doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 original reports despite the growing number of medical students receiving their training at rmc’s, there persists a strong parochial attitude by many in academic medicine that the training in such sites may be “substandard” when compared to the main medical campus. anecdotal reports suggest that attitudes of some faculty and medical students, whose focus is at the central “academic medical center” (amc) campus, are generally unfavorable toward the training that students receive at the rmc. they may at times opine that the educational experience at the community-based rmc deemphasizes the academic experience, results in a more limited patient care experience, and overall provides training that is of lesser quality than the experience delivered at the amc.5 in contradistinction to these prevailing attitudes, educational reports from rmcs suggest quite the opposite picture. medical students who train at rmcs frequently comment on the close-knit personalized attention that they receive from their community-based clinical teachers.6 this close-knit relationship between teacher and learner that is so often fostered at the rmc has resulted in meaningful feedback for improving performance and often more personalized lettersof-recommendation for students training at the rmc. additionally, the routine amount of “hands-on” learning that medical students experience at the rmc often exceeds that of their peers who train at the amcs – there are simply fewer learners competing for the clinical opportunities provided in the care of patients. finally, the idea of training medical students in a location more similar to a facility where they may ultimately practice medicine has become increasingly valued. medical school training, however, is not an end goal – it is merely a step in the long process of developing the clinical skills necessary for the competent and compassionate care of patients. for us-trained medical students, both from amcs as well as rmcs, the national residency matching program (nrmp) annually matches them into residency positions in most all of the medical disciplines. given that successfully obtaining a residency position is the overarching goal for medical students, we sought to objectively discover how medical school graduates from a single college of medicine (both the medical school’s rmc and amc) compared in their nrmp outcomes. setting and methods in 1965, the penn state college of medicine (pscom) was founded in hershey, pa. the town of hershey is 100 miles southeast of the main campus of penn state university, located in state college, pa. in 2011, a rmc was established in state college and the founding dean, e. eugene marsh, m.d., helped to establish community-based clinical education. a small cohort of students, who were initially admitted to the hershey campus, were invited to apply to university park campus in state college, pa and form the inaugural class of the new regional medical campus. the first group of medical students arrived in 2012 and graduated in 2014.7 since then, the university park regional campus (uprc) of the penn state college of medicine has matched students in the 6 subsequent years of the nrmp. the annual reports for pscom from the nrmp were analyzed for the years 2014-2019, inclusive. students who participated in the military matches were excluded from this analysis. the frequency of students matching into a medical specialty was tabulated for each penn state graduate over the 6-year period. there was a distinction made between those students who performed their clinical rotations at the uprc in state college, pa and those who were at the central medical school campus in hershey, pa. the residency disciplines were categorized according to nrmp definitions. additionally, the total number of students going into primary care specialties (defined as family medicine, internal medicine, medicinepediatrics, and pediatrics specialties) was tabulated. moreover, the residency location (within or outside the state of pennsylvania) was noted for each student. finally, a review on whether any particular student remained “unmatched” after the initial process, and thus was required to go through the supplemental offer and acceptance process (soap), was tabulated. since there was no attempt to control for factors on why students choose the regional campus over the main campus and vice-versa, this descriptive study sought only to express findings in terms of raw percentages of the whole for the respective campuses (university park or hershey). results the relative distribution of students matching into the various specialties is illustrated in table 1. the total raw frequency of students matching into a specialty is followed by the percentage of students noted in parentheses. for the 6 graduating classes of medical students, there were 723 students who performed their clinical work at hershey (387 [53.5%] women, and 336 [46.5%] men) and 96 students who performed their clinical work at the uprc (52 [54.5%] women and 44[45.5%] men) for a total number of graduates of 819. based on raw percentages, the students who completed clinical rotations at the uprc were more likely to choose primary care specialties [44.8% (uprc) versus 33.2% (hershey)]. also, based on raw percentages, they were slightly more likely to stay within the state of pennsylvania for their residency [34.4% (uprc) versus 31.7% (hershey)]. while our observation is that the uprc students entered primary care specialties more frequently, there were also students who successfully matched into some of the most highly competitive specialties,8 including ophthalmology, orthopedic surgery, otolaryngology, diagnostic radiology, and neurosurgery. in total, 28 of the 723 hershey graduates (3.9%) and one of the 96 uprc graduates (1%) went through the soap process. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 original reports table 2 match results for graduating years 2014-2019 (%) *alternative career included research or non-patient care careers after medical school discussion since the report of abraham flexner in the early 1900s, the general expectation was that the bulk of medical students’ training ought to be performed at the amc with its emphasis on expertise in the biomedical sciences.9 however, preparing students for work in the 21st century goes beyond the biomedical sciences and present-day students should be wellversed in the science of the community health system in which their patients live. rmcs, by the nature of their setting, are more likely to have their medical learners engaged within the nearby community and participate in health advocacy than those at amcs.10 providing medical training in a community where most patients actually live may provide learners with a more authentic experience than one wholly derived from a tertiary or quaternary care center. in our study, more of the rmc students selected primary care specialties (44.8% uprc vs. 33.2% hershey campus). other investigators have noted that graduates of rmcs are somewhat more likely to go into primary care specialties as well.11 a potentially erroneous conclusion that could be drawn from this finding is that students who train at rmcs can “only go into primary care” and that they will be at a disadvantage when applying for residency positions in nonprimary care specialties. our results suggest that the student’s ability to match into other, non-primary care specialties, even highly competitive ones, is not impaired by training at the rmc. whether or not this finding is generalizable to other medical schools and their rmc-trained students is an open question and could be a logical extension of this initial work. other potential areas of study include documenting the value of the close-knit relationships between teachers and learners that frequently develop at the rmc and whether or not this close relationship translates into stronger letters of recommendation. certainly, the issue of student affairs support and career advising can play an important role in the residency choices of medical students. one reference suggests that the geographical distance between students and advisors is one of the key differences in career advising that often exists between main and regional campuses.12 on our regional campus, one of the authors (mpf) serves as the career advisor on-site and so this concern is mitigated. also, the up regional campus students had full access to the aamc careers in medicine website13 as did the students at the main academic campus. one further positive aspect of training at a rmc is in the potential for trainees to return back to the rmc catchment area. these areas are often physician workforce shortage areas and the rural communities located there are frequently struggling to attract and retain physicians.6 studies looking at graduate medical education suggest that many residents end up practicing close to where they trained.14 the experience with medical students training at rmcs is less well-studied, but is another area ripe for investigation. conclusions a comparison of nrmp match results over a 6-year period (2014-2019) between the students who performed core clinical rotations at the academic medical center versus the regional medical campus showed that while the rmc cohort tended to match into primary care specialties at a higher rate than their amc counterparts, they had no appreciable differences in matching into non-primary care and other highly competitive specialties. our manuscript supports the notion that there are strengths at both campus that should be recognized and that can impact our learners’ overall success. references 1. aamc 2019 group on regional medical campuses business meeting presentation, spokane, wa, april 2019 doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 original reports 2. sabharwal r, salsberg e. projections of future medical school enrollment. analysis in brief publication of the aamc; 2008; 8(3): 1-2. 3. norris te, coombs jb, house p, et al. regional solutions to the physician workforce shortage: wwami experience. academic medicine 2006; 81: 857-862. doi: 10.1097/01.acm.0000238105.96684.2f 4. phillips jp, wendling al, fahey ca, mavis be. the effect of a community-based medical school on the state and local workforce. academic medicine 2018; 93(2): 306-313. doi: 10.1097/acm.0000000000001823 5. penner c. a tale of two campuses: lessons learned in establishing a satellite campus. medical teacher 2018; 45(5): 527-528. doi: 10.1080/0142159x.2018.1439577to 6. crump wj, fricker rs, ziegler c, et al. rural track training based at a regional campus: equivalency of training, residency choice, and practice location. academic medicine 2013; 88(8): 1120-1128. doi: 10.1097/acm.0b013e31829a3df0 7. marsh, ee, flanagan, mp. penn state college of medicine, university park campus in the regional medical campus: a resource for faculty, staff and learners (m. flanagan editor in chief) 2018 atlantic publishing group, inc. ocala, fl 244-250. 8. national resident matching program, results and data: 2019 main residency match®. national resident matching program, washington, dc. 2019 9. flexner a 1910 medical education in the united states and canada. the carnegie foundation new york, ny 10. belkowitz j, sanders lm, zhang c, et al. teaching health advocacy to medical students: a comparison study. j public health management practice 2014; 20(6): e10-e19. doi: 10.1097/phh.0000000000000031 11. liaw w, cheifetz c, luangkhot s, et al. match rates into family medicine among regional medical campus graduates, 2007-2009. j am board fam med 2012; 25: 894-907. doi: 10.3122/jabfm.2012.06.110336 12. linder je, underkofler k . career couseling and mentoring at a regional medical campus in the regional medical campus: a resource for faculty, staff and learners (m flanagan editor in chief) 2018 atlantic publishing group. inc. ocala, f 149.154. 13. https://www.aamc.org/cim/ accessed march 23, 2020. 14. cowley ds, keeble t, jones j, et al. educating psychiatry residents to practice in smaller communities: a regional residency track model. academic psychiatry 2016; 40: 846-849. doi 10.1007/s40596-016-0558-3 microsoft word a residency professional identity curriculum article.docx published by university of minnesota libraries publishing a residency professional identity curriculum and a longitudinal measure of empathy in a community-based program william j. crump, m.d.; craig h. ziegler, ph.d.; r. steve fricker. m.p.a. doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 1, issue 4 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc william j. crump, m.d., associate dean of the university of louisville trover campus at baptist health madisonville, madisonville, ky craig h. ziegler, ph.d., biostatistician with the university of louisville school of medicine office of graduate/undergraduate medical education, louisville, ky r. steve fricker. m.p.a., director of rural health/student affairs of the university of louisville trover campus at baptist health madisonville, madisonville, ky corresponding author: william j. crump, m.d.;associate dean, university of louisville trover campus at baptist health madisonville; 200 clinic drive, third north madisonville, ky 42071; p. 270.824.3515; f. 270.824.3590; e. bill.crump@bhsi.com all work in jrmc is licensed under cc by-nc volume 1, issue 4 (2018) journal of regional medical campuses original report a residency professional identity curriculum and a longitudinal measure of empathy in a community-based program william j. crump, m.d.; craig h. ziegler, ph.d.; r. steve fricker. m.p.a. abstract background empathy as an attribute of physicians is considered desirable, and most studies have shown a progressive decline of measured empathy during residency training. development of a professional identity during residency is also considered desirable. to study this process, empathy measures were used before and after implementation of a structured professional identity curriculum to determine the effect of the curriculum on empathy among a group of family medicine residents. methods the jefferson scale of empathy was completed by 18 residents at all 3 years of training before, immediately after a 6 month professional identity curriculum intervention, and six months after the curriculum was completed. the curriculum included one-hour luncheon sessions on concepts of profession, burnout, and cynicism as well as thoughtful use of electronic medical records, prevention and management of burnout, mindfulness techniques, and reflective writing and drawing. results similar to previous publications, a decline in empathy across the academic year was found, with a significant decline six months after the end of the curriculum. residents who attended more professional identity sessions showed a non-significant smaller decline, and there were large standard deviations among each training level with some individual residents showing little change across the year. evaluations of the curriculum were largely positive. conclusions this professional identity curriculum in this group of residents may have temporarily mitigated the decline in measured empathy that has been described among residents in other settings. results support some aspects of empathy as a trait in some residents rather than a state that is amenable to a training effect. alternatively, some residents show little change in high empathy scores across time, suggesting resilience despite the stress of training. further study in this residency including longitudinal empathy measurements, an individual resident’s preference for strategies for burnout prevention and the association with changes in empathy, and focus groups is ongoing. other programs’ experience with these issues is needed to add to the sample size and diversity of training environments to discern which changes are significant and generalizable. introduction empathy is often listed as a desirable attribute for physicians, but attempts to define it are challenging and measuring it is even more difficult. the developers of the jefferson scale of empathy assign the more emotional aspects to the concept of sympathy, while empathy is more cognitive and includes an inquisitiveness to understand others’ feelings without completely joining with them or feeling the full depth of their emotion.1 in this view, empathy is something that can be developed but requires significant effort and is more accurate and less affected by the physician’s own emotional state. oversimplified, empathy is “i understand your suffering,” doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original report while sympathy is “i feel your pain.”1 several publications have shown a significant decline in empathy during the clinical years of medical school1-2 and a small decline across all years of residency training.3 professional identity is also an important concept in understanding the process of medical education. professionalism is a code of behavior that physicians in training can learn and follow without internalizing. professional identity is the state of actually becoming a physician when the values of the profession are internalized. at the final stage of identity development, the self is defined by thinking, feeling, and acting like a physician.4 this process is complex and is dependent on one’s pre-existing identity, socialization including availability of role models, and symbols and rituals. the working definitions used during the development of our professional identity curriculum were that professionalism is what you do when someone is watching, and professional identity is who you are.5 there is current interest in studying the experience of medical trainees as they develop identities and learn empathy. reflective exercises such as composing narratives, participation in organized study of art, film, music, and literature, and opportunities to learn and practice mindfulness have been used to facilitate this development.6-8 efforts directed specifically to enhance empathy have included those for medical students9 and residents in training .3,10-11 the general trend regardless of the instrument used was that measured scores increased after the intervention, and some have shown that the change was sustained for at least 10 weeks.9 our intent with this project was to determine the change in empathy among a group of family medicine residents as they were exposed to a structured professional identity (pi) curriculum. our hypothesis was that the expected decrease in empathy during an academic year would be moderated by the pi curriculum and that the more sessions a resident attended, the effect would be larger. method the 3 year family medicine residency is a community-based program with 6 residents at each level, unopposed, established in the mid-1970s, and set in a town of 20,000 in western kentucky. all 18 residents participated in this project during the 2015-2016 academic year. the host hospital and outpatient facilities were established in the 1950s as an early rural integrated health system, and have also supported a regional medical school clinical campus since 1998.12 the hospital has 80 physicians representing most specialties of secondary care, but also provides cardiac bypass procedures and a regional cancer center, serving as a referral site for portions of 5 surrounding counties. as part of a regular lunchtime residency conference series, the first author, who is the dean of the regional medical school campus, provided 6 monthly 45-minute sessions as the basis for the professional identity (pi) curriculum during the 2015-2016 academic year. a family physician, he serves as the primary faculty for the residency in obstetrics and teaches occasionally in both the residency clinic and on the general adult medicine hospital teaching service, and staffs most resident deliveries. these sessions were interspersed with more typical sessions taught by him that were focused on obstetrics topics and actual case reviews of resident patients. the curriculum is shown in table 1. the conference series is required for all residents on in-town rotations barring true emergencies or documented illness. residents do have inpatient pediatric and dermatology rotations out of town, and occasionally the inpatient service in town is so busy that the senior resident and intern on service are not able to attend the noon conference. attendance was recorded by a senior resident each session. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original report table 1 a professional identity curriculum at the beginning of the first session of the academic year, the jefferson scale of empathy (jse)24 was completed by all attendees. each form had the resident’s name included for later matching, but a senior resident placed each into an envelope confidentially, and participants were assured that a research assistant unknown to them would place an id number and subsequently no one would be able to connect their responses to their name. a residency staff member then had each resident who missed this conference complete the survey within 3 days, again with confidentiality preserved. anonymous curriculum evaluations were completed after the fifth session. the jse was completed again after all 6 pi sessions were completed and no sessions were held in the second half of the academic year. the jse was then completed again at the end of the academic year, approximately 6 months after the last pi session. the baptist health madisonville irb approved the protocol as exempt. ibm spss statistics for windows (version 24.0, 2016, ibm corporation, armonk, ny, 877-426-6006) was used to analyze the data. between groups repeated measures analysis of variance methods were used to analyze the jse data across the academic year time points and between number of sessions attended (coded into two groups) and academic year of residents. statistical significance was set by convention at p <0.05. results all absences from pi sessions were excused absences because of verified illness, clinical responsibilities, or out of town rotations. among all 18 residents, 1 resident attended all 6 sessions, 7 attended 5, 4 attended 4, 4 attended 3, and 2 attended 2 sessions. as shown in table 2, the anonymous evaluations were largely positive. table 2. professional identify project evaluation results the overall jse scores are shown in figure 1, with a significant decline across the year, with a much larger decline after the pi curriculum ended. the standard deviations were quite large, so we looked at each individual resident by year of training, as shown in figure 2. the variations were dampened with each doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original report succeeding year with an exception of one pg-2 showing a large decrease, and one pg-3 showing an intermediate decrease. comparing differences of means, there were no significant differences comparing pg-1 to pg-2 to pg-3 at any of the time points. across the academic year, there were no significant changes in the means in the pg-1 and pg-2 classes. in the pg-3 class, there was a significant decline in jse scores from baseline (mean=117.50) to completion of the pi curriculum (mean=109.17, p=0.037) as well as baseline to 6 months after the conclusion of the pi curriculum (mean=105.50, p=0.029). the decrement in empathy scores was variable after the pi curriculum based on how many of the 6 sessions the individual resident attended, but none were statistically significant. residents who only attended 3 or fewer sessions decreased by a mean of 6.83 points while residents who attended 5 or more decreased only by a mean 0.38 points. residents who attended 4 or fewer sessions decreased an intermediate degree, by a mean of 4.50 points. discussion the professional identity curriculum was well received by these residents and may have partially mitigated the decrease in empathy measured by the jse that accelerated in the second half of the year. we did not use a measure of professional identity itself and it is possible that our sessions facilitated that development. our findings highlight the issue of whether empathy is a trait that does not change much (inborn, or developed at a very young age) or truly a state (as supported by the developers of the jse) that could be strengthened as a physician’s identity coalesces. of the few previous reports using the jse among residents, a crosssectional study measuring jse scores showed a nonsignificant downward trend across the three years in an internal medicine residency, but there were no longitudinal surveys to show how individual residents changed over time.3 in studies of medical students, jse scores in the m-3 year correlated to ratings of empathy by residency program directors 3 years later, but this could again support that empathy is a trait with little change over time.25 longitudinal studies in one medical school did show a decrease during the m-3 year when compared with measures done in the m-2 year.1 with such large standard deviations and marked individual changes, inferential statistics for differences of means may not give the best view of empathy among groups of residents. supporting our prediction that pi curriculum would have a positive effect on empathy was the “dose effect” of the number of sessions attended showing a differential more positive jse score, but again the difference of means was not significant. this may simply be a problem with small sample size or the fact that means hide the important individual variability. empathy for some residents may be predominantly a trait that will be changed little by a curriculum and for others it may be more of a state that is changed both by their everyday experiences and curriculum. one pg-1 showed a large drop in jse in the first half of the year despite attending 3 pi sessions, and recovered somewhat. one pg-2 showed a large drop in the second half of the year, after attending 5 pi sessions. conversely, it appears that some residents are resistant to the expected decline in measured empathy during training. further detailed analysis of these residents’ attitudes and experiences prior to and during residency merit further study. the 2 reflective exercises in the pi sessions were collected and recorded by id number, and further studies of their content may also provide insight into how these residents differ from the mean. limitations generalization of our findings must be limited to similar residents in similar environments. the effects of having a faculty member facilitate the “softer” pi elements who is also doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original report recognized as an experienced clinician in the hospital and clinic may make a difference in both acceptability and effectiveness. with our findings of clear trends in means without statistical significance, small group size may be an issue. other programs can add to our understanding by replicating our efforts with similar measures. already mentioned is the possibility that using group means may obscure important individual differences in such a nonquantitative concept as empathy. the jse is well validated, but it may not measure exactly what is intended. we have group focus sessions scheduled where we will ask participants to predict what changes should be seen at all 3 levels of postgraduate training, share with them what we found, and then listen to their interpretations of their meaning. as with any educational intervention that is not randomized, there is a possibility of systemic bias, where residents who are predisposed to be affected by the topic choose to attend, or vice versa. the lack of a true control group is an important limitation, but the number of sessions attended is as close to randomly assigned as possible in this environment. the sessions were deliberately held on different days of the week at different points in the month, and there was no systemic pattern for which residents were assigned to out of town rotations or otherwise were unable to attend, and attendance was mandatory. we do not have historical controls in the year before the pi curriculum was begun, but in subsequent years the pi curriculum was diluted and spread across an entire year, and we continue to measure the jse at the beginning of each academic year. further research needed use of the jse in other residency programs along with published details of their pi curriculum would be helpful. in our program we will use focus groups to understand the process better as well as to design studies to describe more carefully the residents who appear to be resistant to the expected decline in measures of empathy as training proceeds. references 1. hojat m, vergare mj, maxwell k, brainard g, herrine sk, isenberg ga, veloski j, gonella js. the devil is in the third year: a longitudinal study of erosion of empathy in medical school. acad med. 2009;84(9):1182-1191. doi: 10.1097/acm.0b013e3181b17e55. erratum in: acad med. 2009 nov;84(11):1616. 2. newton bw, barber l, clardy j, cleveland e, o’sullivan p. is there hardening of the heart during medical school? acad med. 2008;83(3):244-9. doi: 10.1097/acm.0b013e3181637837. 3. mangione s, kane gc, caruso jw, gonnela js, nasca tj, hojat m. assessment of empathy in different years of internal medicine training. med teach. 2002;24(4):370-3. 4. cruess rl, cruess sr, boudreau jd, snell l, steinert y. a schematic representation of the professional identity formation and 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regional campus approach to culinary medicine for inter-professional students angel holland*, pt, dpt, edd; jonell hudson, pharmd, bcps, adces; lauren haggard-duff, phd; audra butler, ba; christopher r. long, phd; linda worley, md; pearl mcelfish, phd, mba doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 3, issue 2 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc angel holland*, pt, dpt, edd; director of clinical education, associate program director, assistant professor, department of physical therapy; associate director ipe – nw campus, university of arkansas for medical sciences, northwest campus, fayetteville, arkansas. jonell hudson, pharmd, bcps, adces; associate professor, college of pharmacy, student board advisor , north street clinic, pharmacotherapy specialist uams family medicine clinic, university of arkansas for medical sciences, northwest campus, fayetteville, arkansas. lauren haggard-duff, phd, clinical assistant professor, college of nursing, university of arkansas for medical sciences, northwest campus, fayetteville, arkansas. audra butler, ba; community health coordinator, university of arkansas for medical sciences, northwest campus, fayetteville, arkansas. christopher r. long, phd, senior director of research & evaluation, office of community health & research; assistant professor, division of health services research, department of psychiatry, college of medicine, university of arkansas for medical sciences, northwest campus, fayetteville, arkansas. linda worley, md, faclp, regional associate dean, college of medicine, professor of psychiatry and behavioral sciences, university of arkansas for medical sciences, northwest campus, fayetteville, arkansas; adjunct professor of medicine, vanderbilt center for professional health. pearl mcelfish, phd, mba, vice chancellor northwest arkansas region, university of arkansas for medical sciences, northwest campus, fayetteville, arkansas. corresponding author: angel holland, pt, dpt, edd department of physical therapy uams northwest campus 1125 n college avenue fayetteville, ar 72703 tel: 1-479-713-8603 fax: 1-479-713-8606 email: amholland@uams.edu all work in jrmc is licensed under cc by-nc volume 3, issue 2 (2020) journal of regional medical campuses original reports a regional campus approach to culinary medicine for inter-professional students angel holland*, pt, dpt, edd; jonell hudson, pharmd, bcps, adces; lauren haggard-duff, phd; audra butler, ba; christopher r. long, phd; linda worley, md; pearl mcelfish, phd, mba introduction many chronic health conditions including obesity, diabetes, hypertension, and cancer can be prevented or reduced through proper nutrition.1-3 in the last decade, an acknowledgement that many medical professionals lack a practical understanding of nutrition, eating behaviors, and culinary skills has resulted in a movement to include culinary medicine curricula in healthcare education programs.4 culinary medicine is the integration of the art of food preparation, specifically cooking, with the science of medicine.5 culinary medicine teaches healthcare professionals and students to recognize the holistic benefits of food and how diet can aid in the treatment and prevention of specific health conditions. tulane university was one of the first u.s. medical schools to integrate culinary medicine into their medical curriculum. in 2013, tulane opened the goldring© center for culinary medicine, which now licenses its culinary medicine curriculum, “health meets food,” to more than 50 medical schools in the u.s.5-6 established in 2007, the university of arkansas for medical sciences (uams) northwest regional campus trains third and fourth year medical and pharmacy students, doctor of physical therapy students, graduate level nursing and genetic counseling students, and undergraduate level radiological imaging students.7 the uams northwest regional campus trains approximately 300 students on campus each year. more than 200 miles separate uams main campus (little rock) and the uams northwest regional campus (fayetteville). the uams northwest regional campus has built research and community-based programs focused on healthy food consumption and the prevention and treatment of chronic conditions, especially diabetes.8-13 in addition, the campus has a strong inter-professional education (ipe) program,14 where students from all professions work and “learn about, from, and with each other to enable effective collaboration and improve health outcomes”.15 students on both campuses complete the ipe curriculum based on the 3 goals of the triple aim approach to healthcare: improving the patient care experience, improving the health of those we serve, and discovering how to reduce the cost of care. in 2018, the uams northwest regional campus began a process to expand its ipe program to include culinary medicine and wanted to do so in a unique inter-professional way while working within the financial constraints of a regional campus. to our knowledge, uams northwest regional campus is the first regional medical campus to implement a culinary medicine curriculum with ipe requirements, and to implement the goldring© curriculum. implementing an ipe culinary medicine program on a regional campus may create financial challenges that prohibit or limit the learning experience. the model demonstrated by the uams northwest campus reflects the advantages of doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports partnering with local organizations to overcome financial and operational barriers to implementing a culinary medicine program. this article describes the implementation process and preliminary results of an inter-professional culinary medicine pilot program on a regional medical campus. regional campus and cross-institutional approach to implement a culinary medicine program, uams northwest regional campus partnered with northwest arkansas community college’s program, brightwater: a center for the study of food. brightwater offers academic and career training in the areas of culinary nutrition, artisanal food, beverage management, and food entrepreneurship. northwest arkansas community college is the first community college and first nursing program to utilize the “health meets food” curriculum licensed by the goldring© center. the partnership with brightwater provides students and faculty on the uams northwest regional campus with access to a fully operational teaching kitchen, dieticians, and culinary professionals during ipe student events. the vice chancellor of the uams northwest campus facilitated a meeting in early 2018 between the leadership of uams northwest regional campus and brightwater to discuss potential partnership opportunities in culinary medicine. participants in this meeting identified opportunities for collaboration, with a primary goal of inter-professional education for students on the northwest campus in the area of culinary medicine. the goal included the development of a series of student events that incorporate both the goldring© culinary medicine curriculum and the uams ipe triple aim curriculum14 framework throughout an immersive culinary experience. in this article, we will discuss the development of an ipe student program detailing the implementation process and preliminary feedback from students. implementing culinary medicine ipe for regional campus students to better understand the “health meets food” curriculum,1617 faculty from the uams northwest regional campus attended a culinary medicine demonstration at brightwater. ipe leadership and faculty members from multiple academic programs (e.g. medicine, pharmacy, and physical therapy) participated in an active learning discussion and immersive cooking experience focused on food allergies and intolerances. following this experience, uams faculty worked with brightwater to make minor changes to the program so that it would meet the ipe competency requirement of application of the knowledge by an inter-professional team. other changes included incorporating simple recipes with basic culinary skill requirements to accommodate the level of students’ culinary knowledge and basic cooking skills. the training also required inter-professional students to apply didactic knowledge to patient case scenarios. from october 2018 to february 2020, three groups of uams regional campus students (see table 1) participated in an ipe culinary medicine workshop at brightwater. didactic the “health meets food” module selected was the introduction to culinary medicine that included mediterranean diet principles and the use of mindfulness when preparing and consuming meals. the didactic portion included a flipped classroom approach to case study and review. the flipped classroom design focuses on application of didactic material during the face to face session by providing guided readings, online lectures, or study guides prior to the learning experience.18 students received readings and study guides by email during the week prior to the culinary program to allow them to prepare for the face-toface session. brightwater and uams northwest regional campus faculty facilitated inter-professional discussion of the readings and case study with the student participants prior to the hands-on culinary training. students were divided into small (2-4 students) interprofessional groups to discuss readings and complete questions about the case study. students were engaged in the discussion but expressed hesitancy to answer nutrition and dietary questions because of their inexperience with nutrition and culinary topics. table 1. demographic data characteristic number (percentage) health professions program medicine (md) 7 (21.21) pharmacy (pharmd) 9 (27.27) physical therapy (dpt) 9 (27.27) nursing (apn) 2 (6.06) radiology imaging 5 (15.15) genetic counseling 1 (3.03) age category ages 20-24 15 (45.45) ages 25-29 16 (48.48) ages 30-34 1 (3.03) ages 35-39+ 1 (3.03) race/ethnicity non-hispanic black 0 (0) non-hispanic white 26 (78.78) hispanic/latino 3 (9.09) asian 3 (9.09) native american 1 (3.03) gender female 20 (60.60) male 13 (39.39) culinary immersion training doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports immediately following discussion of the didactic material, students moved from a classroom to a teaching kitchen on the brightwater campus to begin the culinary immersion training. the culinary immersion training focused on how simple modifications to a recipe can improve nutritional value. each student group was assigned a cooking station prepared with a recipe, cutting board, knives, and the required ingredients. for the first student program the recipe focused on preparing spaghetti bolognese. for the 2 other student programs, the recipe was for tacos. this change in recipe was due to choosing a simpler recipe for students to complete during the learning experience. both focused on learning simple recipe modifications to improve the nutritional content for each dish. a brightwater chef began the session with an introduction to basic knife and cooking skills. recipe modifications were discussed in all programs. the spaghetti bolognese recipe program had one student group, consisting of a practicing vegan and a vegetarian, who both raised concerns over vegan options for their recipe. working quickly to exchange the pasta with a vegan spinach pasta, the brightwater staff demonstrated both the ease in which recipes can be adapted to individual needs but also the need to be flexible when cooking. in all events, students discussed the impact that a simple change could have on the overall nutrition and accessibility of healthy foods for their patients. during the culinary medicine program, students experienced many foods for the first time or utilized familiar foods in a new way. recipes modifications came from the “health meets food” curriculum. each group of students prepared a variation of spaghetti bolognese or tacos that included substitutions and additions that could easily be communicated to patients. for the spaghetti bolognese, one recipe consisted of a traditional meat sauce that substituted ground beef with ground turkey and plain pasta with whole grain pasta, simple and inexpensive substitutions with increased fiber and vitamin content. another recipe called for the addition of vegetables to the meat sauce. carrots and peppers added to the sauce decreased the amount of meat needed and increased vitamins and fiber. the third group eliminated meat completely and replaced it with lentils. lentils, the students agreed, would be an easier transition into a meatless meal for patients hesitant to try tofu or other meat alternatives. the final recipe, including the last-minute substitutions, was a vegan recipe with green spinach noodles and meatless tempeh crumbles. high in nutrients, fiber, and protein, the vegan spaghetti bolognese was a favorite of the group for taste and texture. the students recognized that without the experience of cooking and sampling these ingredients it would be difficult to recommend a vegan option to patients accustomed to meat and potato meals. throughout the cooking demonstration students mentioned repeatedly how cooking was a mindful experience that left little time for them to think about finals or clinical rotations. during the event where the taco recipe was utilized, the first recipe was a traditional, beef taco high in sodium and saturated fat served with a flour tortilla. the second recipe was a combination of meat and vegetables. it reduced the meat by half, added vegetables to the taco filling, used saltfree seasonings, and substituted the flour tortilla with a corn tortilla. the third recipe was a combination of meat and beans. it also reduced the beef by half, added beans to the taco filling, utilized salt-free seasoning, and was served with a corn tortilla. the final recipe was a bean and vegetable combination using salt-free seasoning and was served with a corn tortilla. all tacos were served with traditional toppings such as cheese, lettuce, and tomatoes. additional spices varied for each recipe. as with the spaghetti recipes, the chef presented all 4 variations to the class as a whole to compare and contrast how specific modifications influenced nutritional value, preparation effort, and appearance. in all 3 programs, students sampled each recipe variation of the prepared dish to compare and contrast the impact of recipe modification on taste and pleasure. the students plated on varying sized and shaped plates, prompting a discussion about the impact these differences could have on caloric intake, potentially weight loss, the management of chronic diseases such as diabetes and hypertension, and overall health. the purpose was to help students witness firsthand how a popular household dish can be modified to be more nutritious yet remain delicious to a wide variety of patients. additionally, students were able to see how modifications can be accomplished progressively to acclimate to healthier eating. this flexibility in food preparation provides opportunity to empower patients in creating their own dishes through small or large modifications to impact their health. roles and responsibilities the integration of the “health meets food” curriculum into the uams ipe framework required a close collaboration between uams faculty and brightwater staff. table 2 outlines the roles, credentials, and responsibilities of key faculty and staff members. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports table 2. roles and responsibilities methods and results students volunteered for the opportunity to complete the ipe pilot project culinary medicine event, with the exception of the medical students who were assigned the experience by their department. all students received full disclosure the event would count for ipe required credit. immediately following the learning experience, students completed a learner survey which consisted of 3 quantitative questions with responses on a 5-point likert scale and 3 open-ended qualitative questions. the qualitative questions were designed with a case study strategy of inquiry and participants were given an unlimited response box for written answers. the learner survey was developed by the primary investigator. the majority of the students provided positive feedback about the learning experience (table 3). students reported strongly agree (81.81%) or agree (15.15%) that the experience was “valuable in my growth as a healthcare professional”. in determining if the students found the learning experience helpful in learning the role of other disciplines during the event, 54% of students rated as “strongly agree” with 30% of students rated as “agree”. the value of the information in patient care for each student’s discipline was rated 72% “strongly agree” and 15% “agree”. the open-ended survey question responses were analyzed via hand-coding the qualitative data by the primary investigator. the primary investigator analyzed text segments to determine coding for 3 quantitative questions. coding revealed 3 general themes: 1) the novelty of the information learned, 2) the relevance of the information for patient care, and 3) the value of teamwork. these 3 emerging themes were found in the majority of student responses, regardless of healthcare discipline. during the learning experience, students developed strategies to educate patients in simple food choices and/or food exchanges to promote overall patient wellness. examples of student responses based on the theme of information novelty included: • “today i learned that making healthy substitutions for meals is easy and delicious.” • “i learned that many of us have the same problems of food or diet recommendations for our patients.” examples of student responses based on the theme of relevance of the information included: • “i think by being more knowledgeable about healthy food choices/recipes, i will be able to help my patients make better food choices.” • “i learned a lot about how to increase the nutritional content of simple meals which will help me when talking about nutrition with future patients. i think it will be much more beneficial to the patient to be able to give concrete, easy examples or changes they can make.” • “i enjoyed the interactive aspect of this and getting to learn some tangible ways i can encourage my patients to improve their diet!” examples of student responses based on the theme of teamwork included: • “there are things that each of us are better at and we can teach each other” • “it was a valuable experience because we had to work together to complete a task. it would have been hard for me to complete on my own.” • “i learned how to work better with a partner. delegation skills on who is going to do what, as well as effective communication are important so we knew that we did not miss any steps in the recipe.” doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports table 3. student responses to learner survey discussion learning through immersive, interactive experiences, beyond side-by-side content mastery, is core to the success of interprofessional education. constructivism is the learning theory which embraces the idea that knowledge is constructed not only through contextual learning, but also through the experiences of the learner and interaction with other learners.18 the learning experience described fits the constructivism theory and includes the inter-professional dynamic within the immersive experience. this type of learning promotes both understanding and appreciation for health professions beyond the students’ chosen profession and catalyzes the skills necessary to successfully work within inter-professional healthcare teams.19 students recognized the culinary medicine training as new and different from their respective didactic curriculums, but also recognized the value in the knowledge obtained. the importance of teamwork in patient care was highlighted by the student responses as teamwork was stressed during the culinary activities of completing the recipe. after utilizing the culinary medicine information to discuss patient scenarios, students identified the information as being useful across the boundaries of each healthcare discipline. the culinary medicine program on a regional campus was strengthened through collaboration with the community partner. brightwater provided the students with a professional kitchen and the lessons in culinary skills not readily available on the regional medical campus. this partnership created a unique educational environment for both experiential learning with inter-professional learners. the contextual learning prior to the experiential component promoted the application of knowledge. the experiential learning removed any barriers between students and allowed for meaningful discussions at the conclusion of the event. during the educational debrief, students discussed the importance for healthcare professionals at all levels of patient care to openly communicate both with the patient and with members of other healthcare professions about the nutrition and dietary health of their patients. students discussed the general interventions and measures each of the represented health professions could take with patients and how health professionals could coordinate nutritional interventions for patients through inter-professional teams, referrals, and communication to accomplish a task. conclusion sixty percent of american adults live with at least one chronic health condition, and many of those conditions can be prevented or treated with proper nutrition.20-21 therefore, it is imperative that healthcare professionals address nutrition and dietary recommendations with their patients. student learning programs as described provide an important teambuilding opportunity to train the next generation of health care professionals in the knowledge of culinary medicine. the program’s combination of didactic and culinary immersion training in inter-professional teams was found to be a valuable experience by the students. implementation of a culinary medicine experience on a regional campus should not be limited due to lack of on-campus resources. collaborations with community partners can provide rich and meaningful learning opportunities for students. this article provides an example of how a regional campus can partner with local organizations to implement an innovative culinary medicine program that meets students’ ipe requirements. references 1. healthy living is the best revenge: findings from the european prospective investigation into cancer and nutrition–potsdam study. arch intern med. 2009;169(15):1355–1362, doi:10.1001/archinternmed.2009.237. 2. watzl b. anti-inflammatory effects of plant-based foods and of their constituents. int j vitam nutr res. 2008 dec;78(6):293–8, doi: 10.1024/03009831.78.6.293. 3. barnard nd, cohen j, jenkins dj, et al. a low-fat vegan diet improves glycemic control and cardiovascular risk factors in a randomized clinical trial in individuals with type 2 diabetes. diabetes care. 2006 aug;29(8):1777–83, https://doi.org/10.2337/dc06-0606 4. vetter ml, herring sj, sood m, shah nr, kalet al. what do resident physicians know about nutrition? an evaluation of attitudes, self-perceived proficiency and knowledge. j am coll nutr. 2008;27(2):287-98, https://www.ncbi.nlm.nih.gov/pmc/articles/pmc277 9722/ doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports 5. polak r, phillips em, nordgren j, et al. health-related culinary education: a summary of representative emerging programs for health professionals and patients. glob adv health med. 2016;5(1):61–68. doi:10.7453/gahmj.2015.128. 6. partner sites using health meets food courseware. culinarymedicing.org https://culinarymedicine.org/about-us/partnerschools/ 7. mcelfish pa, kohler, po, schulz, t., (2018). university of arkansas for medical sciences northwest arkansas regional campus. in m. p. flanagan (ed.). the regional medical campus: a resource for faculty staff and learners (pp. 291-294). ocala, fl: atlantic publishing. 8. mcelfish pa, kohler po, smith c, warmack s, buron b, hudson js, bridges md, purvis rs, rubon-chutaro j. community-driven research agenda to reduce health disparities. clin transl sci. 2015 dec; 8(6):6905. doi: 10.1111/cts.12350. pubmed pmid: 26573096; pmcid: pmc4703475. 9. mcelfish pa, goulden pa, bursac z, hudson j, purvis rs, yeary khk, aitaoto n, kohler po. engagement practices that join scientific methods with community wisdom: designing a patient-centered, randomized control trial with a pacific islander community. nurs inquiry. 2016 june. doi: 10.1111/nin.12141. pubmed pmid: 27325179. 10. mcelfish pa, hudson j, schulz tk, warmack ts, moore r, purvis rs, dalke m, buron b. developing an interprofessional student-led clinic to address health disparities in a pacific islander migrant community. j stud run clin. 2017; 3(1):1-7. available at: <http://journalsrc.org/index.php/jsrc/article/view/4 1>. 11. mcelfish pa, moore r, buron b, hudson j, long cr, purvis rs, schultz tk, rowland b, warmack ts. integrating interprofessional education and cultural competency training to address health disparities. teach learn med. 2018 apr-jun; 30(2):213-222. doi: 10.1080/10401334.2017.1365717. pubmed pmid: 29190158. 12. mcelfish pa, post j, rowland b. a social ecological and community-engaged perspective for addressing health disparities among marshallese in arkansas. int j nurs clin pract. 2016 jul; 3(191). doi: 10.15344/2394-4978/2016/191 13. mcelfish pa, long cr, stephens rm, spencer n, rowland b, spencer hj, stewart mk. assessing community health priorities and perceptions about health research: a foundation for a communityengaged research program. j higher educ outreach & engagement. 2018; 22(1):107-128. available at: http://openjournals.libs.uga.edu/index.php/jheoe/ar ticle/view/2002 14. holland a, butler a, mcelfish p, hudson j, jordan l, warmack s. a customized approach to interprofessional education on a regional campus. j reg med campuses. 2019;2(4). doi:10.24926/jrmc.v2i4.2145 15. world health organization. framework for action on interprofessional education and collaborative practice. geneva, switzerland: world health organization; 2010:7. 16. lawrence jc, knol ll, clem j, de la o r, henson ; c suzanne, streiffer rh. integration of interprofessional education (ipe) core competencies into health care education: ipe meets culinary medicine. j nutr educ behav. 2019;51:510-512. doi:10.1016/j.jneb.2019.01.013 17. wetherill ms, davis gc, kezbers k, et al. development and evaluation of a nutrition-centered lifestyle medicine curriculum for physician assistant students. med sci educ. 2019;29(1):163-172. doi:10.1007/s40670-018-00655-4 18. merriam, sb, bierema, ll. adult learning: linking theory and practice. san francisco, ca: jossey-bass. 19. schmitt mh, gilbert j, brandt bf, weinstein rs. the coming of age of interprofessional education and practice (ipep). am j med. 2013;126:284–288. 20. buttoroff c, ruder t, bauman m. multiple chronic conditions in the united states. santa monica, ca: rand corporation; 2017 21. dieleman jl, baral r, birger m, et al. us spending on personal health care and public health, 1996-2013. jama. 2016;316(24):2627–2646. microsoft word ems providers level article.docx published by university of minnesota libraries publishing ems providers’ level of comfort with opioid overdose treatment brycen ratcliffe, mba, md; robin danek, mph, phd; ellen ireland, mph, phd; eric reyes, phd doi: https://doi.org/10.24926/jrmc.v5i1.4388 journal of regional medical campuses, vol. 5, issue 1 (2022) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc brycen ratcliffe, mba, md, pgy1, general surgery resident, university of missouri, columbia, missouri; graduate, indiana university school of medicine rural medical education program robin danek, mph, phd, associate professor, rural medical education program, indiana university school of medicine, terre haute, indiana ellen ireland, mph, phd, clinical assistant professor, rural medical education program, indiana university school of medicine, terre haute, indiana eric reyes, phd, associate professor, department of statistics, rose-hulman institute of technology, terre haute, indiana corresponding author: brycen ratcliffe, md, mba 1433 n. 6 ½ st. terre haute, in 47807 812-202-3226 bryratcl@indiana.edu all work in jrmc is licensed under cc by-nc volume 5, issue 1 (2022) journal of regional medical campuses original reports ems providers’ level of comfort with opioid overdose treatment brycen ratcliffe, mba, md; robin danek, mph, phd; ellen ireland, mph, phd; eric reyes, phd abstract this study aimed to determine how comfortable rural and urban emergency medical services (ems) providers are with treating drug overdoses in the field, adjusting for various factors. this qualitative and quantitative crosssectional survey included 90 respondents from urban and rural demographics and found no evidence (p = .126) that the likelihood of being extremely comfortable with administering naloxone differed for urban and rural ems workers when accounting for certification level, years of experience, and amount of training. we also found no evidence (p = .859) of a difference between rural and urban ems workers administering secondary doses of naloxone. the study demonstrated that although rural ems providers have an increased transit time to get an overdose patient to the hospital and were less likely to have an advanced provider available to them at the response scene, rural providers feel equally comfortable with treating an opioid overdose with naloxone as do their urban counterparts when certification level, years of experience, and number of hours of training are considered. background previous research has shown that america’s rural counties have greater age-adjusted rates of drug overdoses and deaths than their urban counterparts.1,2 patients utilizing emergency services with a chief diagnosis of suspected opioid overdose outpaced the growth of all emergency medical services (ems) and emergency department encounters from 1997 to 2002.3 one contributing factor to this discrepancy may be that personnel dealing with rural substance abuse treatment may be less prepared for the epidemic than their urban counterparts.4,5 in 2015, rural areas had an opioid overdose rate that was 45% higher than in urban areas, and the rate of naloxone administration in rural areas was 23% higher than in urban areas.6 studies have also found that the odds of naloxone administration were significantly higher among emergency medical technician (emt) intermediates than emt basics, suggesting that levels of emt training may play a role in rural naloxone treatment.6,7 the amount of time it takes from the 911 call being placed until the ambulance arrives at the hospital with the patient (“call time”) is another important measure of differences in ems responses in rural and urban areas. the average call time for rural communities was 80.16 minutes, compared with 62.38 minutes in urban communities in the same year.8 with a serum, the half-life of naloxone is approximately 64 minutes, making rural transports particularly problematic because they may require subsequent dosing for an opioid overdose.9 there are currently four levels of emt certification status. the emergency first responder training certification requires a 50.5-hour training course.10 the emt basic course requires a minimum of 159 hours of training.10 the emt intermediate certification requires 160 hours of training, including proficiency with starting an intravenous line.10 lastly, emt paramedics have the highest level of training, with more than 452 hours required.10 statistically, rural areas are less likely to have higher-level ems personnel, provide less oversight, and have less journal of regional medical campuses, vol. 5, issue 1 original reports access to skill maintenance such as medical direction and training services.11 nationwide, rural areas were more likely to be staffed only by volunteers (53% for isolated small rural areas; 14% for urban areas).8 emt training differences indicate that more highly certified prehospital providers work in urban areas than in rural areas.8 emts’ confidence in their skills related to treating opiate overdoses is also important. kilwein et al12 assessed paramedics’ confidence in their skills for dealing with opiate overdose and found that 94% of paramedics are somewhat or very confident in their ability to recognize an opioid overdose, treat it successfully, and provide follow-up care. conversely, slightly more than 50% of emt basic providers felt the same. rural community ems providers may encounter the complex situation of having more naloxone-treatable opioid overdose cases alongside extended call times that will potentially require additional naloxone administrations. in addition, there is an increasing prevalence of stronger opioid agonists such as carfentanil, which is reportedly nearly 100 times more powerful than fentanyl, requiring larger doses of naloxone.13 overall, the increased prevalence of opioid drugs such as carfentanil and other synthetic opioids that have a much higher potency than oxycodone or fentanyl; the extended call times that rural providers face; and the predominance of emt basic-certified ems providers mean that rural ems providers will likely face a higher frequency of needing to administer additional doses of naloxone but feel less comfortable with treatment, leading to more opioid deaths.14 methods a cross-sectional study from three locations within indiana was conducted from january 2021 through april 2021. this study compared two rural ems districts and one urban district; one district had 79% of the population designated as “rural” per the 2010 u.s. census, the other was designated as 49.8% rural, and the final had only 23.8% of its population classified as rural.15 there were 90 surveys given to ems providers (47 for providers from rural tracts and 43 from urban areas). participants were asked a total of 19 questions about certification level, number of doi: https://doi.org/10.24926/jrmc.v5i1.4388 years of experience, and personal involvement with overdose treatment and naloxone administration. furthermore, participants were questioned on personal knowledge of overdose-related deaths, number of education hours they received, and continued education they receive as trends evolve regarding overdoses and treatment. demographics of the study’s participants are summarized in table 1; categorical variables were summarized using counts and relative frequencies, and quantitative variables were summarized using the sample mean and standard deviation. few participants in our survey did not express some comfort with administering naloxone; therefore, we focused on the likelihood of a provider being “extremely comfortable” with administering naloxone (compared with all other comfort levels). a logistic regression model was used to compare this likelihood for rural and urban providers while accounting for their level of certification, number of hours training with naloxone, and the number of years of experience. there was only one emergency medical responder (emr) in our sample; therefore, for modeling purposes, the emr and emt basic certifications were grouped, meaning that our models adjusted for whether the respondent had an emt paramedic certification. table 2 summarizes urban and rural providers’ experience with naloxone. a poisson regression model was used to compare the average number of patients that rural and urban ems providers treated with naloxone per year of experience, adjusting for level of certification and number of hours of training with naloxone administration. finally, a binomial regression model was used to compare how likely rural and urban ems providers were to treat patients with a second dose of naloxone; this model also adjusted for level of certification and number of hours of training with naloxone administration. this model does not consider the comfort level as a predictor because we felt its effect would be captured primarily by the ems providers’ training hours and levels of certification. results our results indicate that fewer rural ems workers (17%) than urban ems workers (58.1%) had an journal of regional medical campuses, vol. 5, issue 1 original reports advanced provider available within 15 minutes of responding to a drug overdose. for the purposes of this questionnaire, advanced providers were designated as any provider at the level of nurse practitioner, physician assistant, or physician. this finding may help shape the view of what resources our rural ems providers have available to them compared with urban ems providers. this study found no evidence (p = .126) that the likelihood of being extremely comfortable with administering naloxone differed between urban and rural ems workers when accounting for certification level, years of experience, or amount of training (figure 1). furthermore, emt paramedics were more likely (odds ratio [or]: 8.25; 95% ci for or: [1.85, 61.89]) to state they were extremely comfortable with naloxone administration compared to those with basic-level ems certifications (table 3). this effect was present even when accounting for hours of training and years of experience. we also found no evidence (p = .859) of a difference between rural and urban ems workers administering secondary doses of naloxone. similar percentages of rural ems workers (27.7%) and urban ems workers (27.9%) reported having lost a patient to a drug overdose. firsthand experience with negative outcomes of opioid overdoses, such as death and disability, was reported by more than 1 in 4 of the respondents in this study and even higher percentages in other studies. discussion the current study demonstrates that 86% of ems providers in urban areas and 76.6% in rural areas stated they were “extremely comfortable” with naloxone administration. this finding differs from prior research by kilwein et al,12 which found that only 53.7% of all emt basic providers were comfortable with naloxone administration. at the time that study was conducted in wyoming, emt basic providers were not allowed to administer naloxone. kilwein et al12 did not compare rural and urban providers’ comfort levels with regard to administering naloxone. the finding of no difference in likelihood of a second dose administered by rural versus urban ems providers is unexpected. rural providers’ increased transit time from scene to doi: https://doi.org/10.24926/jrmc.v5i1.4388 hospital had no significant impact on the likelihood of a second dose of naloxone being needed. because of this context and the advent of stronger opiates such as carfentanil and other synthetic opioids, our hypothesis was that these ems providers would administer subsequent doses of naloxone en route to the hospital; however, the current study did not support this theory after accounting for emt certification levels. our study also found that paramedics were more likely to state that they were extremely comfortable with naloxone administration compared with those who had basic-level emt certifications, which is consistent with previous studies. interestingly, this study had a higher percentage of survey respondents who were paramedics than what is accounted for in literature reviews as discussed previously. 8,11,,12 this could be due to the national requirement for advanced life support–certified ambulances that are used by many ambulance services staffed with one paramedic-level provider and one basic-emt provider per shift, thereby increasing the exposure of paramedic-level respondents to the survey. in addition, this study found that fewer rural ems providers had an advanced provider (nurse practitioner, physician assistant, or physician) available within 15 minutes of responding to a drug overdose at the response scene than did urban ems providers, although this finding had little impact on the responses concerning rural ems providers’ level of comfort. rural ems providers felt as comfortable as their urban counterparts when it came to treating overdoses. the finding that rural ems providers were extremely comfortable with administering naloxone was unexpected when considering the increasing opioid epidemic facing rural counties, along with the prevalence of more potent synthetic opioids and longer transit times, as discussed earlier. this finding accounts for variables that address the level of comfort with overdose treatment, including certification level, years of experience, and amount of training. these findings of insignificant difference between rural and urban areas demonstrate an association that providers feel equally prepared to treat an opioid overdose despite differences in exposure to overdoses, number of training hours, response times, and other variables. rural ems journal of regional medical campuses, vol. 5, issue 1 original reports providers are thought to be working under more austere conditions but feel just as comfortable as their urban counterparts with treating opioid overdose patients, potentially due to field experience and on-the-job training that results in comfort, or perhaps demonstrating a similar level of training across all dynamics that adequately instructs providers on naloxone administration. this finding provides insight into prehospital care and monitoring effectiveness of treatments for all populations and locations across the united states. finally, this study found no association between experience treating opioid overdoses and the location of an ems provider. this was unusual, as rural areas experience a higher incidence of opioid-related overdoses at a population level.2 among both our urban and rural ems providers, 25% had experienced contact with an opioid-related death. given our finding that 1 in 4 of the providers in this study experienced an opioid-related death, as well as the current state of the opioid epidemic facing our rural communities, a focus on mental health and wellness has become an important aspect of health care and provider well-being.16 limitations this study was cross-sectional and therefore had several limitations. first, because of our limited study locations, it is difficult to generalize our results to other populations. including other sites with a larger incidence of opioid-related deaths (of which indiana ranked 16th in 2020, with 17.5 deaths per 100,000 residents)17 could substantially vary the exposure ems providers have to opioid overdose patients who require a second naloxone dose and therefore would increase the study’s external validity. second, this study was aimed at increasing personal experience and response data related to ems opioid overdose treatment; as such, it is susceptible to personal and recall biases from participants. as a limitation, objective data on the number of overdoses treated by each ems provider (including experience level and the time period in which overdoses occurred) could provide specificity to the timeline and validity to our data; however, to the current investigators’ knowledge, there is no such data collection. additionally, due to the cross-sectional nature of this doi: https://doi.org/10.24926/jrmc.v5i1.4388 study, results cannot be interpreted as causal, only as associations between data. conclusion this study demonstrated that although rural ems providers have an increased transit time to get an overdose patient to the hospital and are less likely to have an advanced provider available to them at the response scene, they feel similarly comfortable as their urban counterparts with treating an opioid overdose with naloxone when certification level, years of experience, and number of hours of training are considered. interestingly, this study found that rural ems providers were not more likely to provide a second dose of naloxone, despite the differences between rural and urban areas in opioid use prevalence (as demonstrated on a national basis) and extended call times. table 1. study demographics (n = 90) journal of regional medical campuses, vol. 5, issue 1 original reports categorical variables are summarized using counts and relative frequencies, and quantitative variables are summarized using the sample mean and standard deviation. table 2. summary of experience with naloxone for rural and urban ems workers (n = 90) quantitative variables are summarized using the sample mean and standard deviation. table 3. summary of characteristics of providers who are “extremely comfortable” administering vs. those who are not categorical predictors are summarized using the count and relative frequency. figure 1. relationship between ems workers’ comfort in administering naloxone and number of hours of training received the one ems worker who had not received training for administering naloxone was excluded. doi: https://doi.org/10.24926/jrmc.v5i1.4388 references 1. centers for disease control and prevention. rural americans at higher risk of death from five leading causes. january 12, 2017. accessed august 31, 2021. https://www.cdc.gov/media/releases/2017/p0 112-rural-death-risk.html 2. hedegaard h, minino a, warner m. urbanrural differences in drug overdose death rates by sex, age and type of drugs involved. nchs data brief. 2019(345):1-8. 3. alexander j, burton j, bradshaw j, colin f. suspected opioid-related emergency medical services encounters in a rural state, 1997– 2002. prehosp emerg care. 2004;8(4):427-430. 4. u.s. drug enforcement administration. 2016 national drug threat assessment summary. homeland security digital library. november 1, 2016. accessed august 31, 2021. https://www.hsdl.org/?abstract&did=797265 5. havens j, oser c, leukefeld c, et al. differences in prevalence of prescription opiate misuse among rural and urban probationers. am j drug alcohol abuse. 2007;33(2): 309-317. 6. faul m, dailey m, sugerman d, sasser s, levy b, paulozzi l. disparity in naloxone administration by emergency medical service providers and the burden of drug overdose in us rural communities. am j public health. 2015 jul; 105(suppl 3):e26-e32. doi: 10.2105/ajph.2014.302520 7. belz d, lieb j, rea t. naloxone use in a tieredresponse emergency medical services system. prehosp emerg care. 2006;10(4):468-471. 8. king n, pigman m, huling s, hanson b. ems services in rural america: challenges and opportunities. national rural health association policy brief. national rural health association; 2018. https://www.ruralhealth.us/nrha/media/eme rge_nrha/advocacy/policy%20documents/0511-18-nrha-policy-ems.pdf 9. berkowitz ba. the relationship of pharmacokinetics to pharmacological activity: morphine, methadone and naloxone. clinpharmacokinet. 1976;1(3):219-230. doi: 10.2165/00003088-197601030-00004 doi: https://doi.org/10.24926/jrmc.v5i1.4388 journal of regional medical campuses, vol. 5, issue 1 original reports 10. indiana department of homeland security. ems course requirements. july 2018. https://www.in.gov/dhs/files/ems-courserequirements-07-13-18.pdf 11. patterson d, skillman s, fordyce m. prehospital emergency medical services personnel in rural areas: results from a survey in nine states. wwami rural health research center, university of washington; 2015. final report #149. 12. kilwein t, wimbish l, gilbert l, wambeam r. practices and concerns related to naloxone use among emergency medical service providers in a rural state: a mixed-method examination. prev med rep. 2019;14:100872. doi:10.1016/j.pmedr.2019.100872 13. moss r, carlo d. higher doses of naloxone are needed in the synthetic opioid era. subst abuse treat prev policy. 2019;14. https://doi.org/10.1186/s13011-019-0195-4 14. green t, bowman s, zaller n, ray m, case p, heimer r. barriers to medical provider support for prescription naloxone as overdose antidote for lay responders. subst use misuse. 2013;48(7):558-567. 15. united states census bureau. 2010 census urban and rural classification and criteria. https://www2.census.gov/geo/docs/reference/ ua/county_rural_lookup.xlsx 16. green t, heimer r, grau l. distinguishing signs of opioid overdose and indication for naloxone: an evaluation of six overdose training and naloxone distribution programs in the united states. addiction. 2008;103(6):979-989. 17. national institute on drug abuse. indiana: opioid-involved deaths and related harms. revised april 2020. https://nida.nih.gov/download/21957/indianaopioid-involved-deaths-relatedharms.pdf?v=09605ae15a1f0b1175604ae051b 32125 microsoft word the diffusion of an innovation.docx published by university of minnesota libraries publishing the diffusion of an innovation: implementing an ultrasound curriculum across a state-wide campus tasha wyatt, rebecca j etheridge, paul m wallach, matthew lyon doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 1, issue 5 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc tasha wyatt rebecca j etheridge paul m wallach matthew lyon all work in jrmc is licensed under cc by-nc volume 1, issue 5 (2019) journal of regional medical campuses original reports the diffusion of an innovation: implementing an ultrasound curriculum across a state-wide campus tasha wyatt, rebecca j etheridge, paul m wallach, matthew lyon abstract educational research that describes the curricular development and implementation of point-of-care ultrasound (pocus) has expanded exponentially in the last ten years as medical schools design and deliver ultrasound curricula.1 however, much of the published literature in this area describes the design and delivery process within centralized u.s. medical schools, leaving regional campuses guessing on how best to approach their efforts. in an attempt to build capacity for pocus in schools with regional campuses, this article describes the medical college of georgia’s (mcg) two-year effort to implement and disseminate a pocus curriculum across three regional campuses and a partnership campus in athens. although there are several studies that have described the implementation of pocus elsewhere,2-5 previous descriptions of similar efforts have not had the challenges of incorporating regional campuses into their efforts. innovation dissemination brings its own set of issues regardless of the educational context, however the inclusion of regional campuses raised the complexity of our effort. in this article, we offer our insights on how to implement pocus across all four years of students’ undergraduate medical education (ume) as a way to assist other medical schools interested in the same effort. our goal is to help other schools plan for and address potential challenges that can make implementation difficult. to frame our process, we utilize a diffusion of innovations theory,6 a well-established framework often used in a variety of fields to describe how new ideas and innovations are spread across a system. a diffusion of innovations framework can be applied to both educational7 and clinical settings8 as a way to understand how individual and institutional change is achieved. specifically, the framework is useful in describing our process provides a systematic way to understand why and how the innovation was successful. see figure 1 for an overview of the diffusion of innovations framework and where we will be focusing our description. figure 1. diffusion of innovations framework stages implementation overview founded in 1828, mcg is the 13th oldest and the 8th largest medical school in the u.s. with approximately 230 ume students enrolling per year. located in augusta, georgia, mcg is an integrated health system with shared leadership between the medical school and hospital. given mcg’s large class size, our institution collaborates with hospitals and clinical care sites across the state of georgia to ensure all students have adequate training for their clerkships and have access to a variety of patient populations. in total, there are 200 sites across the state where 3rd and 4th-year students are placed on their rotations. although mcg is comprised of a main campus in augusta, three regional campuses and a 4year partnership campus in athens, the clerkship coordinators in augusta are responsible for ensuring all students meet standardized clerkship requirements. see figure 2 for an graphic overview of mcg’s regional campuses and clinical sites across the state. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 5 original reports figure 2. map of mcg’s distributed campuses and clinical sites implementing ultrasound education into mcg consisted of multiple challenges given the distance between each of the dispersed clinical sites and the main campus in augusta. for simplicity, we describe our implementation process as occurring in three distinct phases: medical school year 1 & 2 (m1/m2), residency, medical school year 3 & 4 (m3/m4). the clinical integration in m3/m4 was by far the most challenging given that this is when students are distributed across the state for their clinical clerkship rotations. successful implementation of pocus into mcg’s residency programs was critical for achieving the final stage, therefore we describe our process at the graduate medical education (gme) level, too. the following sections describe mcg’s efforts, with attention paid to both our initial iterations of adoption and final programmatic details. figure 3 provides an overview of our educational process. figure 3 overview of mcg’s ultrasound/pocus training undergraduate medical education (ume) m1 & m2 with changes in ultrasound technology and the development of smaller hand-held devices, our institution was interested in integrating pocus into ume. the first phase of pocus integration was to implement ultrasound training in the undergraduate medical curriculum (m1-m2) where students spend two years learning basic science concepts. the overarching goal at this point was to allow ultrasound to serve as an adjunct to students’ courses, as a way to help them retain classroom material. it was also intended to enable readiness to incorporate ultrasound into later clinical practice when students would start their clerkships. the majority of this phase occurred in 2013-2015. to accomplish this goal, one of mcg’s ultrasound educators was given responsibility for identifying curricular opportunities where ultrasound could be incorporated into the m1 & m2 curriculum. however, the first challenge was realized because faculty could not be persuaded to implement ultrasound in the midst of lcme re-accreditation. from the faculty perspective, ultrasound was not an lcme requirement, and faculty members were hesitant to make substantial curricular changes prior to re-accreditation. pocus was also perceived as having high complexity, and difficult for faculty members to use. a task force was convened and recommended that the first year of ultrasound training occur in m1 and m2 ultrasound labs (2014-2015) where students scanned each other during a one-hour session. m1 students learned to identify structures in the musculoskeletal system, cardiopulmonary system, abdomen, and pelvis. the m2 labs were more advanced and included scanning of the abdomen, vascular system, and the cardiopulmonary system. in both m1 and m2 labs, students received tailored feedback by an experienced faculty member who commented on students’ image quality, and identification of organs and other markers. eventually, several more labs were added to each section, totaling six for the m1s and six for the m2s. these labs became the core ultrasound courses for students, which continue to serve as a curricular foundation for ultrasound learning in the m1 and m2 years. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 5 original reports looking forward, future implementation for m1 and m2 learning includes integrating pocus into mcg’s physical diagnosis (pd) as a supplement to students’ pd skills. in these sessions, students will advance their ultrasound skills and practice using the pocus equipment in ways they will be expected to use it in the clinic. for example, students will take a blood pressure reading using a cuff and then watch the artery close off to better understand what is happening in the body when a blood pressure reading is taken. other examples include students percussing the liver and then verifying its size against ultrasound images. see table 2 for a complete description of the student labs. in all cases, students use either philips sparq or lumify handheld ultrasound devices. table 2. description of student labs graduate medical education (gme) – emergency medicine the second phase of dissemination occurred in gme after students’ ultrasound education was established in m1 and m2 years. pocus training had initially been established in 2013 within the emergency medicine department because it was a requirement in emergency medicine for the accreditation council for graduate medical education (acgme). soon after, other residencies were interested in pocus training, but implementation was immediately halted because there was no centralized training equipment for residents to use. everything the hospital owned belonged to individual departments. additionally, it was difficult to coordinate the residents’ schedules given their clinical duties, and when they were able to come, residents frequently missed their time slot when their clinical duties ran over. recognizing that individualized residency training sessions were not building capacity at the institution, stage two of the implementation process officially began in 2016 with the creation of the center for ultrasound education. at this time, re and ml, the second and third authors, were brought together to conserve institutional resources, and build capacity for ultrasound within the institution. unrelated, but around that same time, phillips alliance approached mcg with the agreement that would allow physicians to use their equipment in the hospital, which provided the center for ultrasound education with an opportunity to begin developing more robust training. this agreement with phillips alliance moved ultrasound equipment privileges from departments to the hospital, thus creating accessibility. with the equipment accessible to everyone in the hospital, continuous training could be provided to all residents, which quickly became a hospital priority. several adverse events in the hospital at the time highlighted the need for residents to be trained in pocus. the third author, who is an emergency medicine physician, was asked to create a system-wide gme training program around ultrasound-guided central line training in response to these adverse events. the program he created was designed as a gme wide quality improvement intervention that included both a didactic component with standardized ultrasound-guided vascular access training. additionally, a competency testing component was developed using a cadaveric model and a standardized grading rubric. blocks of time were set aside for residents to come to the center for ultrasound education and learn how to conduct pocus. initially, there were many different opinions concerning which exams and the type of training should be included in the curricula, but eventually a unified approach was constructed where all of the residencies would learn the same exam during each calendar month. the agreed upon curriculum for gme is outlined in table 3. this unified approach increased the visibility of pocus in the hospital, which continued to entice other residencies to adopt the technology. since then, central line associated blood stream infections (clabsi) associated with resident insertions was reduced from 3.75 infections per quarter to 0 in the last 6 quarters.9 additionally, major mechanical complications have been reduced from 4 infections per year in the preceding 12 months to 0 infections. the adoption of pocus in gme was the missing link for integration of pocus into the student clerkships. initially, clerkship directors struggled to articulate how to integrate it into the clinical years given mcg’s dispersed medical campus and clinical sites. it was not until the residency directors influenced the clerkship directors to implement pocus into m3 and m4 that they were able to creatively problem-solve and implement pocus into the clinical sites across the state. residency directors made the argument that if pocus was integrated throughout ume and gme, mcg would be better positioned to recruit higher-quality students and residents, thus increasing the public profile of its institution. therefore, the integration of pocus in residency laid the foundation for ultrasound integration into m3 & m4. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 5 original reports table 3. ultrasound training for residents undergraduate medical education (ume) – m3 & m4 the final stage of implementation occurred in mcg’s clerkships, which are distributed in clinical sites across the state of georgia. one of the difficulties in having a distributed campus model is that it makes it challenging to ensure standardized pocus experiences. to assess the feasibility of disseminating pocus into the clerkships, a pilot year was conducted within the emergency medicine clerkship. in 20162017, students were required to do one focused assessment with sonography in trauma (fast) exam and submit their images back to augusta’s emergency medicine clerkship director for feedback. fast exams are rapid bedside ultrasound exams typically performed by surgeons, emergency physicians and some paramedics as a screening test for internal bleeding. however, given that the equipment quality varied by site, students were asked to take pictures of their de-identified images using their smartphones and then upload the images to box, a cloud-based management, and file sharing service that mcg uses. by all accounts, the pilot was successful, and in 2017, a pocus requirement was added to two other clerkships, family medicine and ob/gyn. ob/gyn was chosen as one of the next clerkships because, in ways similar to emergency medicine, ultrasound technology is commonly used in each clinical site allowing the student to have access to ultrasound equipment in order to complete the assignment. the family medicine clerkship was chosen due to the strong state-wide network of clinical sites, being the longest established clinical clerkship with students at remote clinical sites. to support the family medicine clerkship rotations, philips lumify transducers and android-based tablets were used. beginning in 2018, the center for ultrasound education expanded pocus into two other clerkships, surgery and internal medicine using the model developed with the family medicine clerkship. the challenge at this phase, however, was that mcg’s 230 students were placed in 200 clinical sites across the state of georgia, in which only students in the emergency medicine and ob/gyn clerkships had access to pocus equipment. the other students in the 25 family medicine clerkships, did not have equipment, nor did they have access to someone to provide feedback on their images. again, it was the geographic distribution and placement of mcg’s students that made pocus implementation into the clinical years difficult, particularly given the need to standardize students’ learning experiences and the curriculum. complicating the issue was that many of the family medicine preceptors had not been exposed to pocus and were hesitant in having students use it on their patients or in their clinics where they had no ability to supervise or assist students with making sense of the images. additionally, community preceptors experienced a reduction in patient flow as students scanned patients, which many family medicine preceptors found frustrating. to solve these problems, an additional sonographer was hired at mcg’s center for ultrasound education to assist with reading and providing feedback on students’ pocus images. students in all three clerkships were required to scan five patients, then upload their de-identified images to mcg’s learning management system (desire2learn; d2l) where they were assessed by the trained sonographer. when students completed their five scans, the sonographer provided each student and their clerkship director with feedback on student performance. additionally, the center for ultrasound education secured 20 lumify transducers and distributed them to each of the 20 different family medicine clinical sites for students to use during their rotation. rather than giving each student their own equipment, it continues to be shared across students at each site. in clinics where community preceptors are concerned about students scanning patients, patients sign an electronic consent form indicating that the patient knows that the ultrasound exam is for non-diagnostic, educational purposes and the information will not be included in the patient’s medical record. in some cases, students were allowed to scan their family members and friends, rather than patients, which is primarily the case in centers for primary care, where liability concerns are the highest. conclusion innovation dissemination always has its challenges, however when issues of standardization must be met across regional campuses, medical educators are faced with an extra layer of complexity. as we reflect on aspects that made our effort successful, we recognize that mcg’s leadership was doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 5 original reports helpful in identifying curricular openings and convincing faculty members to be flexible with the curriculum. we also had the advantage of an expert in ultrasound technology who could teach ultrasound in m1 and m2 years. in addition to ensuring the right personnel, we also have several suggestions for other institutions interested in implementing pocus into their own medical education curricula. we would suggest that ultrasound not be taught as a separate and distinct skill, but rather a tool for teaching medical students at the ume level. the value of pocus is in the ability to integrate it into procedures, which helps to solidify knowledge and ensure ultrasound will be used in the clinic. we suggest finding ways to integrate into the current curriculum and assist students to see its value within both the pre-clinical and clinical environment. we also suggest working backward by starting the implementation process with where there is ultrasound experience and then moving into specialties where ultrasound is fairly new. our efforts suggest beginning the adoption process in this order: emergency medicine, ob/gyn, surgery, internal medicine, family medicine, and pediatrics because we have had remarkable success in the uptake of ultrasound by appealing first to those specialties who already have exposure and experience with the technology. and finally, we suggest that instead of beginning with ultrasound implementation in ume, as we did, start by convincing the residency directors of its value and then move to clerkship directors. working in this direction helps sell the residency to potential applicants and recruit better residents, all the while working to create an institutional climate that supports the use of ultrasound in the clinic. references 1. tarique u, tang b, singh m, kulasegaram k, ailon j. ultrasound curricula in undergraduate medical education: a scoping review. journal of ultrasound in medicine. 2018;37:69-82. 2. bahner d, adkins e, hughes d, barrie m, boulger c, royall n. integrated medical school ultrasound: development of an ultrasound vertical curriculum. critical ultrasound journal. 2013;5(1):6. 3. fox j, schlang j, maldonado g, lotfipour s, clayman r. proactive medicine: the "icu 30," and ultrasoundbased clinical initiative from the university of california, irvine. academic medicine. 2014;89(7):984-989. 4. hoppmann r, rao v, poston m, et al. an integrated ultrasound curriculum (iusc) for medical students: 4year experience. critical ultrasound journal. 2011;3(1):1-12. 5. hoppmann r, rao v, bell f. the evolution of an integrated ultrasound curriculum (iusc) for medical students: 9-year experience. critical ultrasound journal. 2015;7(1):18. 6. rogers e. diffusion of innovations. new york: the free press; 1995. 7. durlak j, dupre e. implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation. american journal of community psychology. 2008;41(3-4):327-350. 8. sanson-fisher r. diffusion of innovation theory for clinical change. medical journal of australia. 2004;180:s55-s56. 9. lyon m, holsten s, coston a, bao-ling a, gordon r, gibson r. the impact of an ultrasound guided central venous access training course on clabsi rate. american college of emergency physicians (acep); 2018; san diego, ca. microsoft word reapingthefruitsarticle.docx published by university of minnesota libraries publishing reaping the fruits of our labor and our relationship with the grmc paula m. termuhlen, md z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc paula m. termuhlen, md; regional campus dean university of minnesota medical school, duluth campus all work in jrmc is licensed under cc by-nc volume 2, issue 3 (2019) journal of regional medical campuses abstrtact reaping the fruits of our labor and our relationship with the grmc by paula m. termuhlen, md editor-in-chief, journal of regional medical campuses this issue of the jrmc highlights the important relationship that we share with the association of american medical colleges, group on regional medical campuses. we are excited to provide, for the first time, extended abstracts of presentations given at the 2019 group on regional medical campuses spring meeting held april 15-17, 2019 in spokane, wa. presenters were invited to submit their peer-reviewed abstracts to the jrmc, updated with questions that were considered by the audience and including important take home points. the grmc spring meeting is the premier venue for sharing the work that originates on regional medical campuses in north america and networking with colleagues that work on our campuses. the jrmc is honored to be able to capture a snapshot of the content of importance to our readers. the jrmc editorial board would like to thank our partners at the aamc in educational affairs who support our grmc and who have been instrumental in helping us foster a close working relationship with our regional campus stakeholders-katherine mcowen, stephen mckenzie, ethan kendrick and sarah brown. their support and encouragement have helped the jrmc expand it readership and to increase its submissions. enjoy this issue and please let us know your thoughts of what we can do to improve it! microsoft word 2clinical setting differences article.docx published by university of minnesota libraries publishing clinical setting differences in third-year medical student perceptions of “patient ownership” elena wood, md, phd; tasha r. wyatt, phd; sarah egan, ms doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 1, issue 5 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc elena wood, md, phd, academic affairs, medical college of georgia at augusta university, orcid id: 0000-0003-1231-8473 tasha r. wyatt, phd, educational innovation institute, medical college of georgia at augusta university, orcid id: 0000-0002-00715298 sarah egan, ms, educational innovation institute, medical college of georgia, at augusta university orcid id: 0000-0003-3549-4576 corresponding author: tasha r. wyatt, phd; 1120 15th street, gb 3351 augusta, ga 30912 tawyatt@augusta.edu (706) 721-7816 all work in jrmc is licensed under cc by-nc volume 1, issue 5 (2019) journal of regional medical campuses original reports clinical setting differences in third-year medical student perceptions of “patient ownership” elena wood, md, phd; tasha r. wyatt, phd; sarah egan, ms abstract patient ownership in clinical settings is a construct that may be described as feelings of responsibility and accountability towards a patient, which has potential implications for patient safety and clinical care. researchers were interested in examining differences in student perceptions of patient ownership across main and regional campuses. the purpose of this study is to assess third-year student perceptions of "patient ownership" during their clerkship rotations in different clinical settings. items from a validated instrument on psychological ownership were adopted to suit a clinical environment. scores on each of the sub-scales of: a) territoriality, b) accountability, c) self-efficacy, d) belongingness, and e) self-identification were calculated. the survey was administered to third-year medical students multiple times throughout the academic year. responses from regional campus and community practice settings were compared to responses associated with the main campus setting. a mann-whitney u test was performed on each sub-scales along with individual questions/items on students' psychological ownership scores. surveys were distributed at the end of each of seven clerkships resulting in 265 total responses, and response rate of 41%. there were no statistically significant differences between campuses for territoriality scores when examining this sub-scale. on selfefficacy, accountability, self-identification and belongingness scales, community practice and regional campuses group had significantly higher scores on 1-5 likert scale (1-strongly disagree, 5strongly agree) than main campus (p<0.05). an analysis performed for all scales by individual questions/items resulted in statistically significant differences in 2 out of 4 items/questions for territoriality, 2 out of 5 on accountability, 2 out of 6 on self-efficacy, 5 out of 5 on belongingness, and 7 out of 7 for selfidentification. surveys were distributed at the end of each of seven clerkships resulting in 265 total responses, and response rate of 41%. there were no statistically significant differences between campuses for territoriality scores when examining this sub-scale. on selfefficacy, accountability, self-identification and belongingness scales, community practice and regional campuses group had significantly higher scores on 1-5 likert scale (1-strongly disagree, 5strongly agree) than main campus (p<0.05). an analysis performed for all scales by individual questions/items resulted in statistically significant differences in 2 out of 4 items/questions for territoriality, 2 out of 5 on accountability, 2 out of 6 on self-efficacy, 5 out of 5 on belongingness, and 7 out of 7 for selfidentification. none of the authors has a conflict of interest. this study was approved by our institution’s institutional review board. introduction “ownership” of patient care is an important area of study in that it encompasses issues around professionalism, patient safety and the humanities in medical education1, 2, 3. the term is fairly amorphous and used ambiguously, in part because it has both cognitive and affective components that have only recently been defined in healthcare4. to measure students’ ability to take ownership of their patients5, the concept has been related to the construct of psychological ownership, which has a long history of measuring individual’s sense of responsibility for a target (i.e. objects, tasks, or processes)6. in the case of medical education, patients are considered the target that physicians and physicians in training should “own.” although the term might not be familiar to some physicians, it is often used interchangeably with others such as responsibility, commitment, accountability, and advocacy7, 8, all of which are important to develop within students’ clinical experiences9. further, ownership promotes leadership development in healthcare, a current area of much interest and investment in healthcare settings10. clearly, learning to take ownership of patients is a critical skill that should be mastered in residency4, but it should also be developed in medical school as students begin to frame their identity and what it means to be a physician11, 12. this study builds on the growing body of work at our institution, on the doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. x, issue x original reports development of patient ownership in medical students during their clerkships5, 13, 14. at our main and regional medical campuses (rmc), our institution offers various clinical settings, including an academic medical center, rural/community hospitals, and community practices. these clinical settings differ in practice patterns, physician to student ratios, and patient populations, thus having the potential to influence students’ ability to learn how to take ownership of a patient. this study investigates students’ perception of whether they take ownership of their patients across these different clinical settings. this is a critical question to explore as our institution continues to expand and utilize a variety of sites for students’ clerkship opportunities. methods the setting for this study is medical college of georgia (mcg), which partners with community providers across the state to address a limited number of clerkship rotations on our main campus. with approximately 230 students in each class, mcg has expanded to include three regional campuses which are responsible for two years of clinical training, and one campus that trains students for all four years. one of our two-year rmc uses longitudinal curriculum while the other four use traditional curriculum. all students, even those with longitudinal curriculum, receive same academic content lead by clerkship directors on the main campus with difference in when and how this content delivered. all students have assigned carrier adviser when they declare preferred specialty. mcg makes use of physician practices across the state for students’ clerkship placements, utilizing nearly 2500 physicians from various specialties15. these clinical sites expose students to a variety of rural and urban communities, and provide students with diverse clinical experiences and practice models. to assess the differences between third-year students’ perceptions of their ability to take ownership of their patients, items from a validated instrument on psychological ownership6 were adopted to suit a medical education clinical environment. the instrument was altered with permission of the publisher and was necessary because the psychological ownership instrument was originally developed using literature from organizational psychology16 and focused on employee’s perceptions of work-based ownership within their organization. in the original development of the instrument6, researchers were interested in an instrument that managers could use to assess individuals’ level of organizational commitment. therefore, to ensure the adopted instrument was appropriate for a medical student population, subtle revisions in the item’s language were made and sent to clerkship directors for feedback. these revisions were then incorporated into the final survey distributed to students. the instrument is comprised of five sub-scales: a) territoriality, b) accountability, c) self-efficacy, d) belongingness, and e) self-identification. each of these subscales is briefly described to provide a general sense of the areas assessed. territoriality occurs when individuals feel they must mark their place or objects, believing they have exclusive rights to them. a feeling of territoriality is often accompanied by feelings of anticipation of infringement and threat from others17. items in this sub-scale include questions if medical students feel been able to protect information about their patients, (notes, slides, records, ideas) from other team members. accountability is the expectation that one may be asked to justify one’s beliefs, feelings and actions18, and supports the idea that individuals have expected rights about holding others accountable and a sense of responsibility for one’s self. items in this sub-scale include questions if medical students feel been able to access patient data/information, advocate and hold other accountable for their patients. self-efficacy is related to the idea that people’s beliefs facilitate or constrain success as they attempt to implement action or complete a specific task. if an individual feels they can accomplish a task, they will feel more responsibility for achieving it19. items in this sub-scale include questions if medical students feel been able to make plan, participate in decision-making regarding patient care. belongingness is the psychological need individuals have for feeling they have a home or place. a sense of belongingness can be met by providing individuals with both the social and socio-emotional needs they have within a particular job, a work team, work unit, division, organization or professional field16. items in this sub-scale include questions if medical students feel been able to be included, belong to the team on a clerkship. self-identity is met when individuals internalize the organizational identity as an extension for the definition of self. this extension of self helps to develop a sense of meaningfulness and connectedness20. items in this sub-scale include questions if medical students feel member of healthcare team specifically and as profession in general. scores on each of the sub-scales were calculated by averaging the items belonging to each sub-scale, giving a possible range from 1 to 5 on a likert scale from “strongly disagree” to “strongly agree”. for the analysis, items negatively worded were reversed. in addition, data were analyzed by items within the sub-scales. the survey was administered to 233 third-year medical students multiple times throughout the academic year. due to small numbers of students at multiple regional campuses and community-based practices, those data were combined for the analysis. patient ownership data were compared between main campus (academic medical center) and regional medical campus/community practices (rmc/cp). to examine differences between these two clinical settings in students' psychological ownership scores, a mannwhitney u test was performed. this test was determined since the data was found to be not normally distributed. all statistical analysis was performed using spss statistics 25 and doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. x, issue x original reports statistical significance was assessed using an alpha level of 0.05. data was presented as a median as well as interquartile range for each sub-scale. descriptive statistics across learning settings (main campus, rmc/cp) for each of the psychological ownership sub-scales and individual items (territoriality, accountability, self-efficacy, belongingness, and self-identification) were determined. this study was approved by our institution’s institutional review board. results in total, 95 third year medical students completed the survey out of 233 third-year students (response rate 41%). surveys were distributed at the end of each of seven clerkships, resulting in 265 total responses. responses from participating students were divided into two clinical settings: main campus (n = 155, 58.5%) and rmc/cp (n = 110, 41.5%). there were no statistically significant differences between settings for the territoriality sub-scale combined (table 1). students completing clerkship rotations in a rmc/cp setting scored significantly higher compared to the main campus setting on accountability, self-efficacy, belongingness, and self-identification scores. rmc/cp students self-efficacy, belongingness and self-identification scores were highest (p<0.05). table 1: descriptive statistics and mann-whitney u test results for differences in psychological ownership scores * p≤0.05 the researchers examined the individual items for the five different sub-scales and found statistically significant results for 2 out of 4 items/questions for territoriality, 2 out of 5 on accountability, 2 out of 6 on self-efficacy, 5 out of 5 on belongingness, and 7 out of 7 for self-identification. given the copyright agreement on the psychological ownership instrument, the full instrument, original or altered cannot be published. however, sample items from each subscale are provided below (table 2). table 2: descriptive statistics and mann-whitney u test results for individual significant items in psychological ownership scale * p≤0.05 r – reversed questions discussion the results of this study indicate students’ education in the rmc/cp model benefits their professional development in that it provides a clinical environment where students can begin to experience and develop an ability to “own" patient care. the medical students in this study rated accountability, self-efficacy, belongingness, and self-identification sub-scales higher after participating in a clerkship in a rmc/cp setting compared to students completing their rotation on the main campus that utilizes an academic medical center as the clinical setting. rmc/cp settings provide more one-one time with a preceptor, direct interactions with patients, and higher autonomy in making clinical decisions, which could contribute to these significant results. additionally, we were interested in exploring the impact of clinical setting among the different individual items of the modified psychological ownership instrument. a sense of belongingness on the team seems to be one of the biggest differences between clinical settings, evidenced by the fact that all five items were significant. this finding that there are differences between clinical settings and that these differences influence students’ perceptions of patient ownership should be added to the growing literature on the benefits of educating students in community settings21, 22, 23. reasons for the identified differences was not a focus of this study, but we anticipate that it was most likely because the main campus utilizes residents who work with medical students, whereas in rmc settings, especially those that make use of community providers, there is more direct interaction between medical students and clinical faculty. such interactions may contribute to deeper interpersonal relationships between students and faculty, which is an important contribution to high-quality clinical rotations24. furthermore, smaller clinical settings facilitate team building and a team-based approach to care21, as well as an opportunity to provide students with hands-on experience. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. x, issue x original reports although we found significant differences between these settings, this study was conducted at a single institution as a pilot for understanding how patient ownership differs across clinical settings. future research could examine differences in patient ownership across other institutions that use a regional campus model. this will help tease out whether these findings are unique for mcg students or if clinical experiences with community providers is an important piece in building patient ownership. additionally, due to the low sampling of participants who identified as either rmc or cp, we combined the groups to represent clinical experiences that differ from the main academic campus. researchers who are interested in exploring patient ownership across settings further could categorize setting by examining number of students in a rotation, the physician-to-student ratio, medical resident involvement, type of clerkship curriculum25, and type of healthcare facility. conclusion patient ownership is considered an important aspect of patient care, patient safety, and professional identity formation, yet researchers have not examined how clinical settings may impact the development of patient ownership in medical students. this study is the first of its kind to explore how differences in clinical experiences may influence students’ ability to take ownership of their patients. references 1. saba g, villela t, chen e, hammer h, bodenheimer t. the myth of the lone physician: toward a collaborative alternative. annals of family medicine. 2012;10:169-173. doi: 10.1370/afm.1353 2. greenzang k, kesselhelm j. responsibility for patient care in graduate medical education: yours, mine or ours? jama pediatrics. 2015;169:987-988. doi: 10.1001/jamapediatrics.2015.1825 3. van eaton e, horvath k, pellegrini c. professionalism and the shift mentality: how to reconcile patient ownership with limited work hours. archives of surgery. 2005;140(3):230-235. doi: 10.1001/archsurg.140.3.230 4. mclaren, lord, j., murray, s., levey, m., ciechanowski, p., markman, j., ratzliff, a., grodesky, m., cowley, d. (2013). ownership of patient care: a behavioral definition and stepwise approach to diagnosing problems in trainees. perspectives on medical education, 2, p. 72-86. 5. wyatt tr, egan s, wood e. assessing patient ownership in clerkships: an exploratory study of student and clerkship directors’ perceptions. journal of contemporary medical education. 2018. doi: 10.5455/jcme.20180613062630 6. avey j, avolio b, crossley c, luthans f. psychological ownership: theoretical extensions, measurement, and relation to work outcomes. journal of organizational behavior. 2009;30:173-191. doi: 10.1002/job.583 7. walshe c, caress a, chew-graham c, todd c. nurses' feelings of 'ownership' of palliative care patients: findings from a qualitative case study. progress in palliative care. 2010;18(6):346-351. doi: 10.1179/096992610x12775428637060 8. park j, woodrow s, reznick r, beales j, macrae h. patient care is a collective responsibility: perceptions of professional responsibility in surgery. surgery. 2007;142(111-118). doi: 10.1016/j.surg.2007.02.008 9. laskowski r. a piece of my mind. the power of "my". jama. 2016;315(12):1235. doi: 10.1001/jama.2015.17153 10. mohanna, k. (2017). values based practice: a framework for thinking with. education for primary care. 28(4), p. 192-196. 11. cruess r, cruess s, boudreau j, snell l, steinert y. reframing medical education to support professional identity formation. academic medicine. 2014;89(11):1446-1451. doi: 10.1097/acm.0000000000000427 12. cruess r, cruess s, steinert y. medicine as a community of practice: implications for medical education. academic medicine. 2017. doi: 10.1097/acm.0000000000001826 13. wyatt t, bowen j, mann k, regehr g, cianciolo a. coming in from the cold – pysician professional development as deepening participation in the healthcare community. teaching and learning in medicine: an international journal. 2016;28(4):1-4. 14. wyatt t. teaching ownership in the 3rd year: the development & implementation of a video intervention: https://www.youtube.com/watch?v=zrovkn0x9uq. poster presented at the american association for medical colleges (aamc); 2017; boston, ma. 15. medical college of georgia. medical college of georgia fact sheet. 2018; https://www.augusta.edu/mcg/documents/mcgfacts .pdf. accessed august 30, 2018. 16. pierce j, kostova t, dirks k. towards a theory of psychological ownership in organizations. academy of management review. 2001;26:298-310. doi: 10.2307/259124 17. brown g, lawrence t, robinson s. territorality in organizations. academy of management review. 2005;30:577-594. doi: 10.4236/jss.2014.212006 18. lerner j, tetlock p. accounting for the effects of accountability. psychological bulletin. 1999;125:255275. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. x, issue x original reports 19. bandura a. self-efficacy: the exercise of control. new york: freeman; 1997. 20. albert s, ashforth b, dutton j. organizational identity and identfication: charting new waters and building new bridges. academy of management review. 2000;25:13-17. 21. kandiah d. perception of educaitnoal value in clinical rotations by medical students. advances in medical education and practice. 2017;8:149-162. doi:10.2147/amep.s129183 22. mlambo m, dreyer a, dube r, mapukata n, couper i, cooke r. transformation of medical education through decentralised training platforms: a scoping review. rural remote health [online]. 2018;18(1). doi: 10.22605/rrh4337 23. de villiers m, van schalkwyk s, blitz j, et al. decentralised training for medical students: a scoping review. mbmc medical education. 2017;17(196):1-13. doi: 10.4102/phcfm.v9i1.1449 24. sheehan d, wilkinson t. maximising the clinical learning of junior doctors: applying educatinonal theory to practice. medical teacher. 2007;29:827829. doi: 10.1080/01421590701551730 25. o’brien b, hirsh d, krupat e, et al. (2016) learners, performers, caregivers, and team players: descriptions of the ideal medical student in longitudinal integrated and block clerkships. medical teacher. 2016;38:3, 297-305, doi:10.3109/0142159x.2015.1033390 microsoft word attending physician perceptions article.docx published by university of minnesota libraries publishing attending physician perceptions of the benefits and disadvantages of teaching medical students on clinical clerkships at a regional medical campus catherine adams, bs; william cathcart-rake, m.d. journal of regional medical campuses, vol. 1, issue 2 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc catherine adams, bs, kansas university school of medicine-salina (3rd year medical student) william cathcart-rake, m.d., campus dean and clinical professor of medicine, kansas university school of medicine-salina corresponding author: william cathcart-rake, m.d., kansas university school of medicine-salina, 400 south santa fe, salina, ks 67401; email; wcathcart-rake@kumc.edu; fax: 785-822-0450 all work in jrmc is licensed under cc by-nc volume 1, issue 2 (2018) journal of regional medical campuses original report attending physician perceptions of the benefits and disadvantages of teaching medical students on clinical clerkships at a regional medical campus catherine adams, bs; william cathcart-rake, m.d. abstract background: north american medical schools are now creating regional medical campuses (rmcs) to train more physicians to meet the healthcare needs of rural and underserved populations. part-time and volunteer faculty must be recruited and retained to teach medical students engaged in clinical experiences at these rmcs. physician educators report being positively motivated by the presence of medical students but also report increased time constraints. there is a paucity of information regarding the impact on attending physicians of teaching medical students at rmcs. the aim of this study was to investigate the benefits and disadvantages for attending physicians at a rural regional medical campus on having medical students on their services during clinical rotations. methods: an online questionnaire was sent to 62 kansas university school of medicine-salina (kusm-s) clinical faculty members that supervised third and/or fourth year medical students in clinics and/or the hospital. physicians were queried as to the benefits and disadvantages of supervising medical students. results: thirty-six physicians completed the survey, yielding a response rate of 58%. the majority of respondents felt positively about having medical students on their service: 92% of respondents enjoyed having medical students in clinic/hospital, 81% agreed that having a medical student working with them was personally beneficial, and 72% agreed that the presence of medical students increased their job satisfaction. fifty-six percent of respondents reported that having medical students with them in the clinic/hospital decreased the number of patients they were able to see and that additional incentive would encourage them to remain a teaching faculty member. conclusions: attending physicians at kusm-s report that they enjoy having medical students on their service and that it increases job satisfaction; however, teaching medical students is time consuming and may decrease productivity. adequate financial compensation for physician teachers at rmcs may be necessary to ensure successful delivery of the educational product. key words: attending physician satisfaction, regional medical campus, teaching medical students acknowledgments: the authors wish to thank tony paolo, ph.d., assistant dean for assessment and evaluation, kansas university school of medicine, kansas city, ks for his assistance with preparation of manuscript. journal of regional medical campuses, vol. 1, issue 2 original report medical school enrollment has burgeoned since 2006 when the association of american medical colleges (aamc) called for a 30% increase in enrollment at liaison committee on medical education (lcme)-accredited medical schools from the 2002 level by the year 2016.1 in reality, this increase will not be reached until 2019.2 the increase in enrollment has been accomplished by increasing matriculation at existing medical schools, including creation of regional medical campuses (rmcs), and creation of new medical schools. concordant with the increase in medical students is a required increase in the number of physicians to teach the students. hemmen et al3 conducted a national survey of internal medicine clerkship directors on the impact of increasing medical school class size. respondents agreed that increasing class size necessitated recruiting more clinical teachers to avoid adversely affecting medical education. to recruit and retain faculty, administration must convince faculty that the benefits of teaching outweigh the disadvantages. if teaching is not a rewarding endeavor, medical schools, especially rmcs that depend in large part on part-time and volunteer faculty, may not be able to attract the medical educators they need. decreased productivity and lack of reimbursement for time spent teaching may negatively impact physicians who assume a role as a medical student educator, especially rmc physician educators dependent upon practice income for their livelihood. in 2004 a review of the literature regarding the impact of medical students on rural general practitioner preceptors was conducted by walters, et al.4 they reported that satisfaction with teaching was a positive driver, while the single most negative aspect of teaching was time management. in contrast, a study conducted at the university of kentucky college of medicine in 1993 compared the productivity of fifteen family practice faculty and third year residents with and without medical students and found no significant difference in the number of patients each of these groups saw.5 compensation for time spent teaching may also contribute to a physician’s satisfaction as a medical student educator. shea et al6 studied the compensation of faculty members of the department of medicine at columbia-presbyterian medical center in new york city and determined that faculty members spent many hours teaching medical students and house staff but felt they were insufficiently reimbursed for their time. they concluded that compensation issues may jeopardize the teaching activities of the faculty, and compensation issues may be particularly acute on rmcs. the aim of this study was to investigate the benefits and disadvantages of having medical students on their services perceived by the clinical faculty at kusm-s. if the prevalence for discontent with teaching at kusm-s was high and the predictors for this discontent were identified, corrective measures could be explored. as noted by lowenstein et al,7 failure of medical schools to pay attention to sources of faculty discontent could result in a significant percentage of faculty members leaving academic careers. methods kansas university school of medicine-salina (kusm-s) is a rural, four-year rmc located in a community of approximately 48,000 in northcentral kansas. kusm-s was created in response to the undersupply and poor distribution of physicians in kansas.8, 9 the salina rmc was opened in 2011 with a first class of eight students, making it the smallest four-year medical school in north america.10 foundational science lectures during the first and second years of medical school are delivered to salina students by live interactive television and are also available by podcast. laboratory and small group discussion sessions during these years are facilitated by local faculty. journal of regional medical campuses, vol. 1, issue 2 original report required and elective third and fourth year clinical experiences are also provided in salina. at the time of the study, 112 of the approximately 125 members of the active medical staff in salina had kusm-s clinical faculty appointments, and approximately one-half of all salina faculty members actively participated in teaching medical students on clinical rotations. twenty-seven clinical faculty members received small salaries ($3,00014,000/year) for administrative duties and teaching. the remainder of the clinical faculty received no remuneration for teaching medical students. the twenty-seven paid faculty supervised students on third and fourth year clinical rotations two to four months per year. the strictly volunteer faculty supervised students less than two months but typically more than two weeks per year. all sixty-two kusm-salina clinical faculty members involved in teaching third and/or fourth year medical students on required and elective clinical rotations during the 2016 calendar year were invited to complete an online questionnaire. the survey consisted of fourteen questions on a 5-point likert scale, two open-ended questions regarding the advantages and disadvantages of teaching medical students, and one final section for any additional comments. the survey questions were developed by the student author (c.a.) based on physician comments she and other students heard during clerkships and on issues raised by other authors studying this issue.4-7, 11 the fourteen likert scale questions are listed in table 1. the kansas university medical center institutional review board reviewed and approved the study protocol (irb#00140503). descriptive statistics were used to analyze results of quantitative survey items. a preliminary email was sent to the physicians explaining the nature of the questionnaire and when it would be delivered. several days later, the physicians were notified that the survey was open. reminders to complete the survey were sent one week and ten days after the survey was opened. the survey closed two weeks after opening. participation in the study was strictly voluntary and no incentives were given. respondents recorded neither compensation status (paid versus volunteer) nor their specialties, as several physicians were the sole practitioner in a specific discipline and could easily be identified. physicians invited to respond represented a wide range of specialties, including family medicine, general internal medicine, internal medicine subspecialties, general surgery, orthopedics, urology, neurosurgery, neurology, psychiatry, pediatrics, emergency medicine, critical care medicine, and obstetrics and gynecology. results thirty-six physicians completed the questionnaire (58% response rate). all respondents answered the fourteen likert scale questions. only two respondents did not enter free-text comments regarding the advantages and disadvantages of having medical students on their services. seven respondents provided additional comments. compensation status, physician specialty, and time spent teaching medical students were not reported on the survey. results of the survey are shown in table 1. instead of listing responses to questions in five columns, according to the five-point likert scale, strongly agree and agree responses were combined in one column, neutral was left as a second column, and disagree and strongly disagree responses were combined in a third column. an overwhelming majority of respondents felt positively about having medical students in the hospital and/or clinic. thirty-three (92%) physicians agreed/strongly agreed that having medical students in clinic/hospital was enjoyable, twenty-nine (81%) agreed/strongly agreed that having medical students working with them in clinic/hospital was beneficial to themselves, and twenty-six (72%) agreed/strongly agreed that having medical students in clinic/hospital increased their job satisfaction. additionally, thirty-two (89%) respondents agreed/strongly agreed that having medical students in clinic/hospital prompted them journal of regional medical campuses, vol. 1, issue 2 original report to be a more educated physician, and thirty-three (92%) agreed/strongly agreed that having medical students increased their aptitude to relearn disease processes. twenty-eight (78%) of responding physicians agreed that medical students were adequately prepared for clinical rotations, and thirty-four (94%) agreed that students displayed mature and professional behavior during their tenure on the clerkship. thirty-four (94%) respondents felt valued by the medical students on their service, and twenty-nine (81%) also felt valued by kusm-s administration. many of the clinical faculty at kusm-salina receive no financial incentive or only a small salary to serve as a medical student educator. although survey respondents did not identify whether they received financial compensation for teaching, twenty (56%) physicians agreed/strongly agreed that additional incentive would encourage them to remain a teaching faculty member, and seventeen (47%) respondents agreed/strongly agreed that additional incentive would be necessary for them to accept more medical students. twelve (33%) physicians agreed/strongly agreed that medical students increased their patient satisfaction rating, seventeen (47%) physicians were neutral regarding medical students in clinic increasing their patient satisfaction rating, and seven (19%) disagreed/strongly disagreed. slightly more than one-half of respondents (56%) felt that supervising medical students decreased the number of patients they were able to see. discussion this study may be limited by less than 100% participation by clinical faculty, and may not be generalizable to other rmcs that differ in size, mission or geographic location. additionally, since respondents did not disclose their specialty focus, compensation status, or amount of time spent teaching medical students, correlation of these identifiers with question answers could not be determined. nevertheless, the survey provided a strong sense of physician sentiments regarding their roles as medical student educators on a rural rmc. several major themes emerged from review of the survey results: (1) most physicians enjoyed supervising medical students; (2) supervising medical students increased job satisfaction; (3) medical students on the service prompted physicians to become better educated or relearn disease processes; (4) financial compensation for teaching is a significant issue; and (5) supervising medical students decreases productivity. our findings confirmed previous reports that physicians feel positively challenged and motivated by the presence of medical students.4, 11 overwhelmingly, physicians at kusm-s valued having medical students on their service. physicians felt energized by the presence of medical students, noted an overall increase in job satisfaction, enjoyed passing on their knowledge and being part of the education of the next generation of physicians, and felt valued by both students and the rmc administration. additionally, student preparation and professionalism issues were not barriers to teaching. a minority of physicians believed that medical students increased their patient satisfaction rating. despite the majority of clinical faculty members embracing their role as teachers at the rmc, not all faculty members were entirely positive about their experiences with students. the majority of respondents felt that time management issues, productivity, and efficiency were negatively influenced by the presence of medical students on their clinical services. nearly one-quarter of respondents felt that they saw fewer patients and spent longer hours at work due to having medical students on their service. several physicians commented that students were not always prepared. additionally, several physicians noted that not all of their patients were comfortable with journal of regional medical campuses, vol. 1, issue 2 original report having a medical student in the exam room with them. the clinical faculty at kusm-s are asked to devote valuable time to teaching medical students, yet are given only small or no salaries for their teaching duties. many physicians reported that additional incentive would encourage them to continue their role as medical student educators and that additional incentives would be necessary to take on more students per year. incentive was not defined in this study, but financial compensation may be the most compelling incentive. increasing salaries for those physicians already receiving compensation for teaching and adding physicians to the paid-teacher ranks on our rmc must be considered. in addition to providing salaries for those clinicians assuming a major role in clinical teaching, kusm-s has developed other rewards for all physician teachers, including: (1) providing cme credits, necessary for state licensure, (2) medical library access, (3) academic promotion opportunities, (4) financial support of research initiatives or other scholarly activities, and (5) public recognition for excellence in teaching. conclusions this study brings into focus the benefits and disadvantages of having medical students in clinic and/or hospital at a rural rmc. although physicians report that having medical students is timeconsuming, they also reported a variety of benefits from teaching medical students. nevertheless, rmcs must remain cognizant of the demands medical students may place on part-time and volunteer faculty and make efforts to reward them for their educational endeavors, or face the possibility of losing their services to competing interests. osteopathic and off-shore medical students, as well as mid-level trainees, are also seeking clinical experiences in the same communities hosting rmcs, and at times are willing to offer more compensation to clinicians than tendered by the rmc. rmcs educate an increasing number of medical students in north america and recruiting and retaining a talented physician educator workforce is paramount to their success. whether salina physician satisfaction results are comparable to other rmcs is unknown, nor do we believe we have an educational template that can be adopted by other rmcs. however, we are pleased that the majority of our clinical faculty are enthusiastic about teaching. it is important that kusm-s and other rmcs continually monitor their physicians’ satisfaction to having medical students on their services. references 1. association of american medical colleges. results of the 2013 medical school enrollment survey. [accessed 2017 april 7]. available from: https://members.aamc.org/eweb/upload/1 3239%20enrollment%20survey%20201310.p df. 2. association of american medical colleges. 2017 update the complexities of physician supply and demand: projections from 2015 to 2030. [accessed 2017 april 4]. available from: https://aamcblack.global.ssl.fastly.net/.../aamc_projecti ons_update_2017.pdf. 3. hemmer pa, ibrahim t, durning sj. the impact of increasing medical school class size on clinical clerkships: a national survey of internal medicine clerkship directors. acad. med. 2008; 83:432-437. 4. walters ls, worley ps, prideaux d, rolfe h, keaney c. the impact of medical students on rural general practitioner preceptors. rural and remote health 2005; 5:403. 5. kearl gw, mainous ag. physicians’ productivity and teaching responsibilities. academic medicine 1993; 68(2):166-7. 6. shea s, nickerson kg, tenenbaum j, morris tq, rabinowitz d, o’donnell k, perez e, weisfeldt ml. compensation to a journal of regional medical campuses, vol. 1, issue 2 original report department of medicine and its faculty members for the teaching of medical students and house staff. n engl j med 1996; 334:162-7. 7. lowenstein sr, fernandez g, crane la. medical school faculty discontent: prevalence and predictors of intent to leave academic careers. bmc medical education 2007; 7:37. doi:10.1186/14726920-7-37. 8. greiner ka, paolo a, kennedy m, cook d, cox cg, nazir n, epp a. a kansas physician workforce report. the university of kansas medical center and the department of health and environment office of local and rural health. kansas workforce advisory board, topeka and kansas city, ks; march 12, 2007. 9. phillips rl, dodoo ms, petterson s, xierali i, bazemore a, teevan b, et al. medical student and resident choices? the robert graham center: policy studies in family medicine and primary care, washington, dc, 2009. 10. cathcart-rake wf, robinson m, owings cs, kennedy m, paolo a, chumley h. the birth of a rural medical school—the university of kansas school of medicine-salina experience. med. sci. educ. 2012; 22(4): 250-258. 11. pichlhofer o, tonies h, spiegel w, wilhelmmitteracker a, maier m. patient and preceptor attitudes towards teaching medical students in general practice. bmc medical education. 2013. [accessed 2017 april 4]. available at: http://www.biomedcentral.com/14726920/13/83.. table 1 survey questions agree/strongly agree neutral disagree/strongly disagree 1. i enjoy having medical students working with me in clinic. 91.7% (33) 2.8% (1) 5.6% (2) 2. having a medical student working with me in clinic/hospital is beneficial to myself 80.6% (29) 8.3% (3) 11.1% (4) 3. having a medical student working with me in clinic/hospital is beneficial to my patients 72.2% (26) 19.4% (7) 8.3% (3) 4. having medical students in clinic/hospital increases my aptitude to relearn disease processes 91.7% (33) 8.3% (3) 0% (0) 5. having medical students in clinic/hospital makes me a more educated physician. 88.9% (32) 11.1% (4) 0% (0) 6. having medical students in clinic/hospital increases my job satisfaction. 72.2% (26) 22.2% (8) 5.6% (2) 7. having a medical student in clinic increases my patient satisfaction rating. 33.3% (12) 47.2% (17) 19.4% (7) journal of regional medical campuses, vol. 1, issue 2 original report 8. having medical students in clinic/hospital decreases the number of patients i am able to see. 55.6% (20) 16.7% (6) 27.8% (10) 9. additional incentive would encourage me to remain teaching faculty. 55.6% (20) 13.9% (5) 30.6% (11) 10. additional incentive would be necessary to take on more medical students. 47.2% (17) 19.4% (7) 33.3% (12) 11. medical students are adequately prepared for clinical rotations. 77.8 % (28) 16.7% (6) 5.6% (2) 12. medical students display mature, professional behaviors in clinic/hospital. 94.4% (34) 0% (0) 5.6% (2) 13. i feel valued by the kusom-salina administration. 80.6% (29) 8.3% (3) 11.1% (4) 14. i feel valued by medical students on my service. 94.4% (34) 0% (0) 5.6% (2) microsoft word abriefexercisearticle.docx published by university of minnesota libraries publishing a brief exercise in narrative medicine for preclinical medical and premedical students: my story allison b. engelbrecht, b.s.; rebecca e. higdon; hannah m. marshall; sarah r. parker, b.s.; dimond a. shelton; william j. crump, m.d. doi: https://doi.org/10.24926/jrmc.v2i5.2272 journal of regional medical campuses, vol. 2, issue 5 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc allison b. engelbrecht, b.s.; m-2 medical student, ulsom trover campus. rebecca e. higdon; college rural scholar, ulsom trover campus hannah m. marshall;college rural scholar, ulsom trover campus sarah r. parker, b.s.; m-2 medical student, ulsom trover campus. dimond a. shelton; college rural scholar, ulsom trover campus william j. crump, m.d.; associate dean, university of louisville school of medicine trover campus at baptist health madisonville. all work in jrmc is licensed under cc by-nc volume 2, issue 5 (2019) journal of regional medical campuses perspective a brief exercise in narrative medicine for preclinical medical and premedical students: my story allison b. engelbrecht, b.s.; rebecca e. higdon; hannah m. marshall; sarah r. parker, b.s.; dimond a. shelton; william j. crump, m.d. abstract as part of a 3-week summer regional medical school campus rural immersion experience, preclinical medical and pre-medical students accompanied a rural family medicine residency inpatient team on bedside rounds. one theme of the summer program is the value of empathy and the importance of truly understanding what it is like to “walk a mile in the patient’s shoes.” a previously established brief narrative exercise was modified so that the learner spent an hour facilitating a hospitalized patient’s recall of their life and then produced a short summary that was edited by the patient and then provided to the team. the senior resident chose the patient for the exercise and introduced the student, who remained when the team left the bedside. the response from the patients was uniformly positive, and in an anonymous written evaluation, eight of 11 students completing the project rated it as positive, with 3 neutral, and none negative. four gave it the highest rating possible in terms of meeting the goals of the program. introduction in july each year for almost 20 years, the university of louisville trover campus has hosted a group of pre-clinical and pre-medical students who spend three weeks in the host town of madisonville, population 20,000, which also is home to the oldest family medicine residency in kentucky.1-3 the students work in small groups to step through a clinical case in twiceweekly sessions facilitated by the regional dean to learn clinical reasoning. they also work together to provide free school and sports physicals to 12 year olds in adjoining underserved counties, supervised by a volunteer family physician. the college students receive some academic tutorials, and both groups shadow rural physicians. in the 2019 session, we provided an opportunity for each student to go along on bedside hospital rounds with the family medicine residency inpatient team, and we used a narrative medicine exercise to provide structure for these relatively inexperienced learners to connect with patients. as an introduction to compassion training and the importance of empathy, the group heard a presentation covering the professional identity curriculum used at the trover campus.4,5 the focus of the narrative exercise was provided by a quote: but often (third year histories) were not as good as first-year students in gaining an accurate and comprehensive view of what bothered the patient, or what living with the illness was like… the disparate behavior of firstand third-year medical students was the result of education. first-year students listened to the story of illness. third-year medical students strove to write a story of disease. for them the disease was the thing: classification, or merging the current patient with preceding patients, was their objective.6 methods when preparing for the summer program, trover campus staff became aware of the “my life, my story” effort in the veteran’s administration (va) system.7 the authors contacted that group and adapted the my life, my story interviewer guide and script for consent for use with non-va patients, along with prompt questions for the students (see table 1). during program orientation, we described the narrative project as an opportunity to interview the patient in-depth without the time constraints that characterize everyday medical practice. while the va project assumed that an “anchor identity” for all their patients would be the former service in the military, the students were encouraged to find the anchor identity for their “my story” patients. students were introduced to semi-structured interviewing techniques in their initial program orientation. they interviewed the patient assigned to them after being introduced by the senior resident caring for the patient during bedside hospital rounds. the student told the patient they would write up a 1,000-word story and bring it back to them to read and make changes. once the patient was satisfied with it, it would be given to the patient’s doctor and the patient would receive a copy. patients were free to journal of regional medical campuses, vol. 2, issue 5 perspective decline participation as well as to make any edits to their story they wished. the student interviewer also provided brief written feedback on their perspectives of the experience at the end of the program. results what follows are brief anonymized excerpts from some “my story” pieces written by the students, followed by their comments on the process. a country girl with a calling mrs. m is former nurse and mother of four. she has three daughters and one son; her son, who she admits wanted her to go to the doctor sooner than she did, is currently living with her at her home. she says that she never knows just how sick she is; she always tells herself that she’s going to be alright, even when she isn’t feeling her best. she found out a few months ago that she has lung cancer, but it was actually pneumonia and a high fever that brought her into the hospital this time. mrs. m started smoking at the age of 36 and has continued until her most recent admission to the hospital, at the age of 71. she smoked around a pack a day at first, and then cut back to about half a pack a day. she was married to her first husband at the age of 15. her second husband died a few years ago from an aneurysm, although he had also been diagnosed with lung cancer before he died. she worked for both general electric and a plastic factory, but her favorite job was at a local “rest home” where she worked as a nursing assistant. mrs. m recalls her days as a nurse very fondly. she loved the group of people that she got to work with and remembers giving out many hugs during her time there. her favorite part of her job was helping the residents get ready to leave by cleaning them and “getting them prettied up.” she loved helping them feel more confident about themselves, whether this involved their outward appearance or personality. her career as a nurse was cut short when she was injured while on the job. as she was attempting to help a resident move around, mrs. m made an awkward movement and seriously injured her back. she had to leave work immediately and ended up having a thirteen-and-a-half-hour surgery. after the surgery, she “laid in bed” for 3 months. she had a hard time walking again, saying that “my legs didn’t want to go,” but she had a house full of kids, so she had to keep going. mrs. m has devoted her life to her kids and she’s been with them through thick and thin. they all live close to her, yet she sadly admits that after her husband died, her three daughters seemed to pull away from her. she feels like after years of her caring for them, giving them everything she could, they didn’t take it well when the roles were reversed, with her needing them more than they needed her. luckily, her son remains by her side, being the one to bring her to and from the hospital when she becomes sick. mrs. m is a country girl with a positive personality; she has a huge heart and a true passion for making others feel special. a mother with pain in her way i’m a madisonville native, born and raised; my family has lived in the area for years and i’m proud to call it home. i moved to nashville for a while to pursue a degree in business administration before returning home, where i now manage accounts for local government. while this may be what i do, it is only a small part of who i am. i am a wife and mother to six beautiful children who are my pride and joy. they range in age from thirteen to twenty, four girls and two boys. my husband and i have joked that they seemed to pair off along the way, each pair being inseparable, almost more like having three sets of twins than six individual children. as they get older, it is exciting to see who they are becoming as individuals. the second oldest will be moving away to start college this fall, and it’s starting to hit home that they will all be making their own way in the world soon. journal of regional medical campuses, vol. 2, issue 5 perspective we like to spend time as a family enjoying the outdoors. you’ll find us fishing and kayaking near clarksville, tennessee. it’s beautiful out there, and if you ever get the chance to visit, i highly recommend it. i enjoy spending time with my children. they are strong willed and independent and they are my driving force. they keep me going and push me to stay healthy and be positive, even in situations like mine where it seems like the answers are never quite clear. my first hospitalization was a few years ago. i felt severe pain in my stomach and when it didn’t go away, i decided it was time to see a doctor. they said i had polycystic ovary syndrome and severe endometriosis. between the two, i had to undergo numerous surgeries to remove cysts and suffered from many infections that frequently put me back in the hospital. it was then that i decided to undergo a hysterectomy and oophorectomy. it seemed like more of a means to an end, a necessary procedure that would end the need for surgeries and allow me to stay out of the hospital, return to work, and not keep me away from my family so often. since then the pain has returned on several occasions. i have met with specialists, been through numerous imaging studies and a few more hospital stays, but the answer as to why this keeps happening isn’t clear. the financial burden of these repeated stays is growing, and at times, it feels like i may never get an answer. it’s during these times that i think about my family and keep pushing. the doctors here have been very kind and have listened to my concerns. i just hope to be able to return to my family and get back to enjoying the outdoors soon. second-generation coal miner and competitive athlete mr. g was born and raised in madisonville, kentucky, and has continued to stay and raise his children in the area. he is the only child of a coal miner father and a mother who was a proficient seamstress. he was just nine years old when the united states entered world war ii, and his father was granted an exemption from the draft because he was a coal miner. mr. g has memories of his family gathering coal that had fallen off the trains in order to heat their home before madisonville had natural gas. growing up in the era before television, everyone played outside and participated in sports. he remembers his neighbor from down the street, a legendary basketball player who made his way to the hall of fame after playing for the boston celtics. mr. g vividly recalls that star’s father hanging up lights in the backyard so they could shoot hoops late into the night together. mr. g himself was an athlete who earned 13 varsity letters among basketball, football, and baseball. the first time he laid hands on the leather of a football during a game, he scored a touchdown. in one game of baseball, he hit two homeruns. during a single basketball game, he racked up 25 points for his team. after high school, he went to a regional university to play basketball for the coach for whom the arena was eventually named. after playing basketball for a year, he transferred to another college to continue his sports career on a football scholarship. mr. g later pursued a career in the mining industry and sold underground mining equipment to coal mines all over the nation. he recounted not only mining underground coal, but also the mining of salt in 16 different states. he has traveled the country and firmly believes that the united states of america is the greatest country on earth and is the land of opportunity. he has two sons and a daughter. he boasted that all of his children graduated as high school valedictorians of their respective classes. his children have a wide range of talents that carried over into their careers: from playing multiple instruments to engineering mining equipment. mr. g has four granddaughters, one grandson, and one great grandson. his family is a large part of his life, and he is a proud father, grandfather, and great grandfather. he enjoys trivia in his free time. a frequent participant in the local restaurant’s weekly trivia night, he excels in all topics of trivia. his general knowledge across all areas exceeds most competitors, he says. proud of his willpower, he says as a former tobacco and alcohol user, he put down both of these habits, cold turkey, about 20 years ago. mr. g was admitted for cellulitis, which has cleared up and healed well. he tries to remain as active as possible with his age. when asked about the care he has received, he had nothing but praise. the nurses and medical assistants were caring and would openly engage in conversations with him. his doctors were never afraid to reach out and shake his hand or touch his shoulder when discussing his future care options. instead of having medical advice thrown at him and the doctors making all the decisions regarding his care, mr. g felt he was included in these discussions and played a very active role in determining the care that best suited him and his needs. he insisted that our local hospital is ahead of the competitors when providing quality medical care. a lucky girl suzy r is now on a regular nursing unit after first being admitted to the icu for severe shortness of breath from her known copd. she describes herself as a healthy person until a few years ago when several bouts of pneumonia resulted in several hospital admissions. she sees everything now in the light of her last big hospital scare when a wisdom tooth extraction caused her to develop jaw osteomyelitis. that journal of regional medical campuses, vol. 2, issue 5 perspective hospitalization left her depressed and intermittently suicidal. she was very embarrassed and ashamed of her facial deformities at first and felt as though she had nothing to live for. however, it was for her two children that she turned her attitude around in spite of the long recovery road ahead of her. she now calls her facial deformities her “lucky scars” and she feels as though she became stronger because of this process, discovering what and who was really important to her. suzy spent most of our conversation proudly bragging on her two children and describing the effect they have on her emotional wellbeing. her daughter is going back to college with intentions to graduate. she was very proud that her daughter decided to continue her education. also with pride, mrs. r recounted that since that last scare, she permanently stopped smoking. she also appreciates the chance to share her experience with students and doctors so they can better recognize and treat jaw osteomyelitis. her eyes lit up when she discussed her love of the outdoors and told of many happy hours spent fishing with her children. she carries her oxygen tank with her and strives to be as active and involved in life as she possibly can be. she then spoke sadly about her physical inability to work in her former role as a manager of a general store. she also worries about paying her share of costs of medicines and doctor’s visits. the smile returned when she talked about how lucky she is to have been adopted by her grandparents, and how fortunate she is to have survived all her close calls to continue to be in her children’s lives. she also expressed how pleased she is with her hospital care and feels comfortable returning here if needed. the favorite aunt mrs. r is a 51-year-old african american woman who has just been diagnosed with diabetes after an episode of diabetic ketoacidosis for which she was hospitalized. one morning she woke up, walked outside, and noticed that everything was so blurry that she couldn’t recognize any of her family members. she stayed at home for two days and was incredibly fatigued and thirsty the entire time. she does not have any children, but her family is extremely important to her. her young niece stayed with her the entire time and would not let her go to sleep, for fear that she would not wake up. she refers to her as “my little angel.” after two days at home, mrs. r’s mother told her she would take her to get food and instead she sneakily took a “wrong turn” and made her get out at the er. as a child, mrs. r played center for the women’s high school basketball team. she likes watching baseball and tennis, playing ps4, and going out with her girlfriends to applebee’s and other places around town. her mother works for the water department and her father, who is deceased, was a coal miner. mrs. r has lived alone for the past year in a house across the street from her mother. she was born and has lived her whole life in a town of 1700 in western kentucky. she is the oldest child of four with three younger brothers. some of her younger brother’s daughters live with mrs. r’s mother across the street and they frequently spend time with her. the greatest joy in her life is spending time with her family—listening and comforting them is what she enjoys the most. she has no children herself and suffered a miscarriage a few years ago fathered by a man who is no longer in her life. she broke up with her last boyfriend a few months ago but keeps in close contact with him still. currently, she has no job but has worked in the food service industry at a large number of restaurants around town. after a few months on the job, she often gets bored or finds some of the other staff hard to deal with, so she quits and moves on to something else. she would like to get a factory job in the future and someday have enough money to get her teeth fixed cosmetically. faith is important to mrs. r and she considers herself a christian baptist. she likes to “float” around to different churches and try them out. she is currently a member of a local baptist church. in her opinion, a good church will send someone to check on you if you aren’t at the service on sundays. as for her rating of the hospital, she says that “everything gets a 10.” she has no complaints about her or any of her family member’s treatment. comments from students as a medical student, it is very easy to get caught up in the diagnosis and treatment portions of medicine. my story allows you the opportunity to step away from the “what” and connect with the “who.” these interactions can help guide shared decision-making plans for treatment and can aid in building a better patient-physician relationship. as a college student, i thoroughly enjoyed talking to the patient about his life and what brought him to seek care at the hospital. i think it’s especially helpful for the patient more than we realize because it demonstrates that someone has interest in their background. as a college student, i gained a new perspective when it comes to treating patients. when interviewing my assigned patient, i realized the effects a diagnosis can have on a patient beyond their physical health. as physicians, we feel relieved when we finally, after months of back and forth, narrow down the cause of our patient’s symptoms. we often don’t realize that when we place the diagnosis on a patient, their acceptance and understanding is just beginning while ours is just ending. we close the book, and move on to journal of regional medical campuses, vol. 2, issue 5 perspective another patient with more handfuls of complicated problems. i understand now how important it is to get to know your patients. this experience will change the way i practice medicine in the future, and i hope to be a better physician because of it. from my perspective as a college student, this exercise showed me what it is like to see a patient as more than just a patientto see the whole person. i think anyone planning on going into healthcare should do a similar exercise. for me, it added fuel to my passion for helping people and gave me a new perspective on the patient. in the first two years of medical school, we learn about the intricate complexity of bodies we will take care of, but we rarely get to hear about the souls attached. in the 45 minutes i spent with my “my story” patient, i learned about their past, the forces that move them every day, and how i could serve them best as a physician one day. these stories continue to drive me on my medical journey. evaluation the response from the patients was uniformly positive, and in an anonymous written evaluation, eight of 11 students completing the project rated it positively, with three neutral, and none negative. four gave it the highest rating possible in terms of meeting the goals of the program. discussion we found the “my story” narrative exercise to meet the needs of this rural summer program that included relatively inexperienced interviewers. the structure is easily learned, and patients accepted it well. it seemed that careful communication with the senior resident and faculty on the residency inpatient service was important in our success. the inpatient setting provides a less time-stressed environment than an office experience would, and has the additional benefit of allowing these preclinical learners to see confident family medicine role models on the acute hospital service. feedback from the students was that this exercise was effective in providing an opportunity for reflection on the value of empathy, and we consider it as a first step of a compassion training effort. references 1. crump wj, fricker rs, ziegler ch, wiegman dl. increasing the rural physician workforce: a potential role for small rural medical school campuses. the journal of rural health. 2016; 32(3):254-259. 2. crump wj, fisher sm, fricker rs. community service as learning laboratory: a report of six years of a rural community-academic partnership. journal of the kentucky medical association. 2014; 122: 131-136. 3. whittington cp, crump wj, fricker, rs. an invitation to walk a mile in their shoes: a rural immersion experience for college pre-medical students. journal of regional medical school campuses. 2019;1(5). doi:10.24926/jrmc.v1i5.1565. 4. crump, b. professional identity curriculum at the university of louisville trover campus: reflection and meaning in medical education. the journal of the kentucky academy of family physicians. winter 2017;88:18. 5. crump wj, ziegler ch, fricker rs. a residency professional identity curriculum and a longitudinal measure of empathy in a community-based program. journal of regional medical campuses. 2018:1(4). doi: https://doi.org/10.24926/jrmc.v1i2.1292. 6. reiser sj. science, pedagogy, and empathy. in spiro h, curnen mg, peschel e, and st. james d (ed). empathy and the practice of medicine. yale university press. new haven and london. 1993. p129. 7. ringler t, ahearn ep, wise m, lee er, krahn d. using life stories to connect veterans and providers. federal practitioner. june 2015: 8-14. microsoft word perception of social determinants article.docx published by university of minnesota libraries publishing perceptions of social determinants of health in a student-led free clinic: do students see things differently from their patients? sarah r. parker, bs; william j. crump, md doi: https://doi.org/10.24926/jrmc.v5i1.4384 journal of regional medical campuses, vol. 5, issue 1 (2022) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc sarah r. parker, bs, trover rural track medical student, university of louisville school of medicine trover campus at baptist health deaconess madisonville, madisonville, kentucky william j. crump, md, associate dean, university of louisville school of medicine trover campus at baptist health deaconess madisonville, madisonville, kentucky corresponding author: william j. crump, m.d. associate dean, university of louisville trover campus at baptist health madisonville 200 clinic drive, third north madisonville, ky 42071 p. 270.824.3515 f. 270.824.3590 e. bill.crump@bhsi.com all work in jrmc is licensed under cc by-nc volume 5, issue 1 (2022) journal of regional medical campuses original reports perceptions of social determinants of health in a student-led free clinic: do students see things differently from their patients? sarah r. parker, bs; william j. crump, md abstract understanding a patient’s social determinants of health (sdoh) needs is an important component of medical care. to better understand how well future physicians are aware of these needs, student primary care providers (pcps) at a student-led free clinic in the upper southeastern united states surveyed 15 patients via telemedicine between october 2020 and january 2021 concerning their sdoh needs. they addressed 17 sdoh items using a 10-point likert scale. prior to administering the survey to patients, student pcps were asked to complete the survey to predict each individual patient’s responses. the average difference between student and patient responses ranged from 1.3 to 3.8 for each sdoh item, and patients expressed a higher need than the student pcps did for health services navigation, health insurance limitations, and education options and affordability. we conclude that even this group of motivated medical students providing continuity care could benefit from a more formal curriculum addressing sdoh. introduction there is mounting evidence that supports the need to screen and manage so-called social diagnoses in primary care.1 patients who struggle to address social determinants of health (sdoh) needs (eg, financial, food, or housing insecurity; lack of transportation; interpersonal violence) have worse health outcomes, including higher rates of developing chronic diseases such as diabetes and hypertension.2,3 one solution to overcome these barriers is the use of patient navigators. a patient navigator is a member of the health care team whose purpose is to make social diagnoses and connect patients to appropriate resources to meet their needs. the use of patient navigators first grew out of the need for timely care and follow-up for cancer patients, and patient navigators have since been used to manage chronic diseases. patient navigation programs are effective in increasing rates of preventative screening and completions of scheduled medical care.4,5 though medical students are trained to assess the impact of medical diseases on patients’ lives, little is taught about how to uncover and act on sdoh needs. there is little evidence available about how well doctors know their patients’ social situations, and much of the evidence that is available shows that doctors are not very good at predicting many aspects of a patient’s social needs.6 this study focused on how well medical students can predict their free clinic patients’ sdoh needs, with the goal of providing the background for a program for students to act as patient navigators themselves. the research question here is the following: despite previous typical medical visits with students in the pcp role, are the students’ perceptions of patients’ sdoh needs different from the needs expressed by the patients in a survey? if so, in which topic areas are the perceptions farthest apart? since so little is known about this topic, this can be considered a descriptive, or hypothesisgenerating, study. methods the community’s free clinic is directed and staffed by third-year medical students and supervised by the dean at a regional rural medical school campus in the upper southeastern united states.7,8 established in journal of regional medical campuses, vol. 5, issue 1 original reports 2004, the clinic serves the local county population of approximately 45,000 (with a host town population of 20,000) and provides free care for patients who are uninsured or underinsured. due to the covid-19 pandemic, all clinic services transitioned to telemedicine in september 2020, and each student was assigned a cohort of patients to care for throughout the school year as the patients’ primary care provider (pcp). all 7 third-year medical students participating in patient care for that academic year agreed to participate. the patient–student doctor relationships provided an excellent opportunity to assess patients for sdoh needs. a 10-point likert-scale survey was developed for 17 different areas of sdoh need and interactions with the medical system. this research came out of a community improvement project with the american academy of family physicians (aafp); one goal of this project was to better understand how medical students could act as patient navigators. rather than use previously validated but narrow instruments, we developed a broader instrument that included issues such as interactions with the medical system, the free clinic’s role within this system, and an understanding of a patient’s insurance history.9-11 an initial small field study showed that the survey accomplished its goals. a 10-point likert scale was used because the answers tended to be clustered at one end of a narrower scale on the small field test. we included questions regarding how these patients ended up at the free clinic: what interactions in the medical world led them to the clinic, and how were they doing under the clinic’s care? how had insurance costs or costs accrued due to not having insurance affected them previously? we included questions related to the affordability of medications and access to phone and internet services to understand how patients rated the clinic’s ability to find affordable medications for them and reach them remotely during the pandemic via telephone or webcam. because there is a local community college, we also wanted to understand how patients understood their options for furthering their education and if finances played a role in their decision. finally, given the increased amount of political polarization across the united states and the effect on medical mistrust— which has been increasingly more apparent throughout the covid-19 pandemic and due to racial doi: https://doi.org/10.24926/jrmc.v5i1.4384 unrest—we wanted to understand how our patients perceive local government and law enforcement. each student had at least 2 interactions with their patient population prior to surveying, with the initial “new patient” interactions taking place in person in late july through august 2020. surveying occurred in october through december 2020. the clinic is entirely student run, so it is likely most students had multiple other interactions with patients via telephone or video call, such as scheduling appointments, communicating lab results, ensuring that prescriptions could be filled, and discussing any paperwork needs to fulfill requirements for prescription drug–sponsored payment assistance programs. in reviewing the literature about how well physicians understand their patients’ sdoh needs, the few studies we found made it clear that there are often gaps in physicians’ understanding, which we wanted to investigate.12-15 furthermore, we thought it would be an educational experience for understanding the needs of our own patient group in a formal manner. from october 2020 through january 2021, student pcps completed the surveys, which asked them to answer the questions as if they were one of their assigned patients. next, each student administered the same survey to each of their assigned patients via a telephone call or video visit. comments were allowed for each item. the 15 patients were surveyed by 7 students, with an average of 2 patient responses per student; each student had at least 1 patient response, with a maximum of 4 patient responses per student. the students were 85% white. one student was from south asia, 71% of students were female, the average student age was 26, and all of the students had attended high schools in the same state as the campus where the study took place. data from the patient and student survey responses were de-identified, matched as individuals, and ranked in areas of sdoh needed most by patients and perceived by students. the difference between patients’ responses and the students’ perceived needs for each individual patient was calculated for each patient-student response and averaged overall for each sdoh topic. no statistical testing was done, as this was a descriptive study. the project was approved by the host hospital institutional review board as exempt. journal of regional medical campuses, vol. 5, issue 1 original reports results patient responses individual patient responses varied widely. table 1 shows the numbers and percentages of patients in each age range and with specific chronic diseases. figure 1 shows patients’ responses to sdoh needs, with statements with the highest need scored as a likert score of 10 and those with the least need assigned a score of 1. based on overall averages, we found the following areas to be the ones with the most need: 1. navigation, in response to the statement “i worry about finding my way around the health system outside of hccc (eg, other doctor appointments, dentist offices, health insurance coverage, the hospital).” 2. health insurance, in response to the statement “the health insurance i have (or lack of health insurance) prevents me from getting affordable medical care.” 3. education options and affordability, in response to the statement “i feel that i have affordable options to continue my education if i want (for myself and my family).” common themes in comments many patients feared the surprise medical bills they might get if they needed urgent or emergent care. some were upset that needed subspecialist visits were not covered by their insurance. several did not regularly get dental care or preventative services outside the clinic (eg, colonoscopy, mammogram, pap smear), even if free sources of these services were intermittently available. patients were also concerned about out-of-pocket costs. many had no insurance; some had insurance, but deductibles were so large that the insurance was of little value to them (eg, 1 patient had a deductible of $5,000). some patients reported that they would see subspecialists if they had insurance coverage. most were not interested in continuing their education, and at least 3 felt that continuing their education would be too expensive. overall, there was at least 1 individual patient who identified each of the categories of food insecurity, financial stress, job security, or housing as significant stresses, even though community resources were available. doi: https://doi.org/10.24926/jrmc.v5i1.4384 student responses as shown in figure 2, the areas of need perceived to be the greatest were the following: 1. education options, in response to the statement “i feel that [my patients] have affordable options to continue [their] education if [they] want.” 2. phone/internet access, in response to the statement “[my patients] have trouble with phone service and/or internet services.” 3. insurance limitations, in response to the statement “the health insurance [my patients] have (or lack of health insurance) prevents [them] from getting affordable medical care.” there was also wide variability among the students’ perceptions of their patients’ needs. common themes in student comments most student pcps expressed that continuing education was not a manageable option for most of their patients due to disinterest, inability to afford to pursue an education, or feasibility within work schedule. comments pertaining to phone and internet access noted that while most patients had access to a cell phone (though not all), some had no internet service or the internet connection was often poor during telemedicine visits that took place during the covid-19 year. students reported that not all patients had smartphones with the capability to have video connections. most student pcps expressed that a lack of insurance or, if they had insurance, high deductibles kept their patients from getting affordable care outside of the capabilities of the clinic, such as screening colonoscopies and mammograms. other student pcps reported that because their patients had no insurance, the community clinic was the only option in terms of medical care. overall, students expressed that the clinic was not enough to meet patients’ full medical needs. patient-student response difference as shown in table 2, the areas of greatest difference between student pcps’ perceptions’ of needs and patients’ reported needs concerned food access, activity options, and insurance limitations. as this was a descriptive study, no statistical testing was done. students were more concerned than their patients about patients’ access to affordable food and physical journal of regional medical campuses, vol. 5, issue 1 original reports activity. patients felt that insurance limitations were a more restricting factor than did their student pcps. discussion the goal of this project was to understand how well medical students understand the sdoh needs of their free clinic patients. our findings show that the student pcps’ perceptions of patient needs often do not match the patients’ perceptions. in our case, prior to this study, students at the rural health campus learned about sdoh through student-led community cardiovascular screenings. each class of medical students was tasked with designing and implementing these screenings as an attempt to uncover populations within the community in need of chronic disease management. in addition, as part of the case-based medical teaching, students were often directed to think about how medical costs and lifestyle factors play a role in medical management. in most standard medical student curriculum and clinical experiences, students are evaluated on their ability to express empathy and understanding of a patient’s social limitations. on almost all standardized patient exams, students are expected to ask something along the lines of, “how does your illness affect your life?” although students are expected to include a “review of systems” in all patient encounters, this provides a limited view of a patient’s social well-being. by teaching students a systematic approach to asking about social determinants, medical schools can ensure student physicians are better prepared to build stronger doctor-patient relationships in the future. if they can lay the framework for discussing social issues, students may be more prepared to identify and potentially build resource networks for their patients. understanding what community resources can address individual patient needs is an evolving process, and by incorporating an sdoh interview format into patient interactions, students can become more knowledgeable about the context of the medical care they provide. as a result of this project, we attempted to incorporate the “student as patient navigator” role at the local family medicine residency clinic. students would screen patients who frequently missed appointments, as identified by the clinic’s licensed clinical social worker. logistically, this approach was not feasible because of communication barriers with doi: https://doi.org/10.24926/jrmc.v5i1.4384 these patients. as a second attempt at incorporating a patient navigator, the students have incorporated the sdoh screening into the cardiovascular screening at a local salvation army shelter. through this process, students will learn sdoh experientially while managing patients who may have insurance and even a pcp but cannot access care because they are homeless. in the future, after this experiential learning, a similar study could be done to evaluate if students’ awareness of their patients’ sdoh needs has changed. limitations and strengths as with any small study, generalizability must be limited to similar students, patients, and environments. by necessity, our surveys were not conducted in person, and we did not use a patientwritten survey. in addition, for matching patient and student answers, our surveys had to be nonanonymous. for the sake of reproducibility and clinical use, it would be easier to use a validated survey such as the aafp social needs screening tool, but for the purposes of education in survey creation and patient-physician relationship building, we wanted to include a more extensive list of issues. although student pcps were encouraged to frame the questions with language that was unassuming about patient needs, our patients may have given more socially acceptable answers. our study was also limited to third-year medical students, and it is possible that those with more clinical experience would better predict their patients’ sdoh responses. given the small sample size of students, we did not try to find whether any student groups predicted patients’ responses more closely than others. a key strength of our study was the complete matching of student pcp and patient responses. we did not find another published study with that design. conclusion most medical students choose their career with the goal of relieving the burden of disease. the complex reality of coordinating medical care is that often the most difficult problems are those that stem from social determinants of health issues. coordination with a team of health professionals is required to take care of one patient, and a rich system of services outside the office is needed to care for a whole doi: https://doi.org/10.24926/jrmc.v5i1.4384 journal of regional medical campuses, vol. 5, issue 1 original reports community. our study shows that without a structured experience, even motivated medical students providing continuity care are unlikely to predict what is most important to their patients. as innovations in medical education are planned, acting as a patient navigator for patients seen in continuity could be a valuable addition to a medical student’s education. acknowledgments we appreciate the active participation of the entire student sdoh working group: matthew barber, toni s. carter, vd clark, allison b. engelbrecht, talitha h. jones, and sravya veligandla. we also thank kendall denny and steve fricker for data management. this project was completed as a part of the american academy of family physicians family medicine leads emerging leader institute. table 1. study population (n = 15) the proportion of patients with hypertension, diabetes mellitus, and hyperlipidemia is included to describe the population. it is clear from the literature that high sdoh need is associated with increases in population prevalence of chronic diseases.1-2 the box-and-whisker plot represents the degree of patient-reported sdoh needs on a likert scale of 1 to 10 on the y-axis. each numbered sdoh statement is shown on the x-axis and written in full below the plot. for example, statement 2 is represented by the boxand-whisker plot with an average likert scale response of 6.9 (indicated by the x), a median of 7.5, a minimum of 1, and a maximum of 10. doi: https://doi.org/10.24926/jrmc.v5i1.4384 journal of regional medical campuses, vol. 5, issue 1 original reports the box-and-whisker plot represents the degrees of student-predicted sdoh needs of their patients on a likert scale of 1 to 10 on the y-axis. each numbered sdoh statement is shown on the x-axis and written in full below the plot. for example, statement 2 is represented by the box-and-whisker plot with an average likert-scale response of 7 (indicated by the x), a median of 6.9, a minimum of 2, and a maximum of 10. table 2. average difference between student and patient responses references 1. brown p, lyson m, jenkins t. from diagnosis to social diagnosis. soc sci med. 2011;73(6):939-943. doi:10.1016/j.socscimed.2011.05.031 2. braveman p, gottlieb l. the social determinants of health: it’s time to consider the causes of the causes. public health rep. 2014;129(suppl 2):19-31. doi:10.1177/00333549141291s206 3. marmot m, friel s, bell r, houweling taj, taylor s, commission on social determinants of health. closing the gap in a generation: health equity through action on the social determinants of health. lancet. 2008;372(9650):1661-1669. doi:10.1016/s0140-6736(08)616904. crighton e. nhs greater glasgow and clyde public health directorate out-turn report 20152016. nhs greater glasgow and clyde; 2016. https://www.nhsggc.org.uk/media/239714/nh sggc_ph_directorate_outturn_report_-20152016.pdf 5. jacob v, chattopadhyay sk, hopkins dp, et al. economics of community health workers for chronic disease: findings from community guide systematic reviews. am j prev med. doi: https://doi.org/10.24926/jrmc.v5i1.4384 journal of regional medical campuses, vol. 5, issue 1 original reports 2019;56(3):e95-e106. doi:10.1016/j.amepre.2018.10.009 6. iezzoni li, barreto ea, wint aj, hong cs, donelan k. development and preliminary testing of the health in community survey. j health care poor underserved. 2015;26(1):134153. doi:10.1353/hpu.2015.0023 7. crump wj, fricker rs, ziegler ch, wiegman dl. increasing the rural physician workforce: a potential role for small rural medical school campuses. j rural health. 2016;32(3):254-259. doi:10.1111/jrh.12156 8. crump wj, fricker rs, crump am, james te. outcomes and cost savings of free clinic care. j ky med assoc. 2006;104(8):340-343. 9. american academy of family physicians. the everyone project: social needs screening tool. american academy of family physicians; 2018. 10. hager e, quigg a, black m, et al. development and validity of a 2-item screen to identify families at risk for food insecurity. pediatrics. 2010;126(1):26-32. doi: 10.1542/peds.2009314 11. north carolina department of health and human services. sdoh screening tool paper. north carolina department of health and human services; 2018. 12. verlinde e, de laender n, de maesschalck s, deveugele m, willems s. the social gradient in doctor-patient communication. int j equity health. 2012;11(12):12. https://doi.org/10.1186/1475-9276-11-12 13. kovach k, reid k, grandmont j, jones d, wood j, schoof b. how engaged are family physicians in addressing the social determinants of health? a survey supporting the american academy of family physician’s health equity environmental scan. health equity. 2019;3(1):449-457. 10.1089/heq.2019.0022 14. naz a, rosenberg e, andersson n, labonté r, andermann a, clear collaboration. health workers who ask about social determinants of health are more likely to report helping patients: mixed-methods study. can fam physician. 2016;62(11):e684-e693. 15. street r, haidet p. how well do doctors know their patients? factors affecting physician understanding of patients’ health beliefs. j gen intern med. 2010; 26(1):21-27. doi: 10.1007/s11606-010-1453-3 microsoft word promoting regional campus excellence article.docx published by university of minnesota libraries publishing promoting regional campus excellence: the scholarly concentrations program at indiana university school of medicine paul m. wallach, md; deborah r. birnbaum, mba; bradley l. allen, md, phd; daniel r. corson-knowles, md; elizabeth r. ryan, edd; jay l. hess, md, phd, mhsa. doi: https://doi.org/10.24926/jrmc.v4i1.3541 journal of regional medical campuses, vol. 4, issue 1 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc paul m. wallach, md, professor of medicine, dolores and john read senior professorship in medical education. executive associate dean, medical education and institutional improvement, indiana university school of medicine. orcid: https://orcid.org/00000002-7444-5374 deborah r. birnbaum, mba, scholarly concentrations program manager, project manager for executive associate dean, medical education and institutional improvement, indiana university school of medicine. orcid: https://orcid.org/0000-0002-4344-6630 bradley l. allen, md, phd, senior associate dean for medical student education, associate professor of clinical medicine, indiana university school of medicine. orcid: https://orcid.org/0000-0002-8846-9342 daniel r. corson-knowles, md, director of clinical distinctions, phase 3 curriculum, assistant professor of clinical emergency medicine, department of emergency medicine, indiana university school of medicine. orcid: https://orcid.org/0000-0002-00365486 elizabeth r. ryan, edd, associate dean and director, iusm-northwest-gary, professor of clinical family medicine, department of family medicine, indiana university school of medicine. orcid: https://orcid.org/0000-0001-8680-3741 jay l. hess, md, phd, mhsa, dean, school of medicine, walter j. daly professor, professor of pathology & laboratory medicine, professor of medicine, indiana university school of medicine. orcid: https://orcid.org/0000-0002-5968-4326 corresponding author: deborah r. birnbaum debbirnb@iu.edu 340 w. 10th st., indianapolis, in 46202 (317) 278-3044 all work in jrmc is licensed under cc by-nc volume 4, issue 1 (2021) journal of regional medical campuses original reports promoting regional campus excellence: the scholarly concentrations program at indiana university school of medicine paul m. wallach, md; deborah r. birnbaum, mba; bradley l. allen, md, phd; daniel r. corson-knowles, md; elizabeth r. ryan, edd; jay l. hess, md, phd, mhsa. abstract while indiana university school of medicine has had multiple regional campuses delivering the pre-clerkship phase of the education for 50 years, since 2008 all 4 years of medical education, including clinical, have also been available at the 8 regional campuses statewide. while 67% of admitted students designate a preference for the indianapolis main campus, 60% of students are assigned to a regional campus for pre-clerkship education. of those, 32% chose to be at their assigned campus. students are often not able to identify a compelling reason to choose a regional campus. despite data to the contrary, including our own, a majority of students continue to believe the path to success is through the main campus in indianapolis, and as a result, transfer to the main campus for clerkships. in 2019, the school launched a scholarly concentrations program as a key strategy to address this problem. the program leverages the unique expertise and resources at its diverse campuses and shines a spotlight on them to attract and retain students at regional campuses through educational enhancement and engaged community scholarship. while still in pilot phase, significant progress has been realized. with faculty statewide, 11 concentrations launched in less than one year, and 17 in 2 years. about 220 students are enrolled in concentrations statewide; about half at regional campuses. a special program through the admissions process resulted in 9% of the class of 2024, with an average gpa of 3.8 and 512 mcat, choosing to enroll at a regional campus and its associated scholarly concentration. immediate plans revolve around supporting concentration growth, building systems and processes to support a sustainable program, and monitoring results of the 3 pilot phases to inform future development and implementation. in addition, students are being recruited to regional campuses through an early decision program. problem indiana university school of medicine (iusm) is the nation’s largest medical school with 9 campuses statewide. over the school’s 110-year history, the majority of students have spent all 4 years of their medical education in indianapolis. for 50 years, regional campuses have played a significant role in preclerkship student enrollment, and in 2008, all 8 regional campuses began offering all 4 years of the md curriculum. during the past 5 years, an average of 173, or 67%, of students who submitted their campus preference upon admission to the school chose the indianapolis campus as their first choice. sixty percent of students are assigned to a regional campus for pre-clerkship education. of those, 32% chose to be at their assigned campus. journal of regional medical campuses, vol. 4, issue 1 original reports despite achieving comparably excellent student outcomes across all 9 campuses, many students and some faculty believe that a “main campus” experience in indianapolis is necessary for a high-quality education and to be competitive in the residency match. two-thirds of students initially assigned to a regional campus choose to move to the main campus for clerkship education. in addition, the majority of research opportunities exist at the main campus. in the school’s student satisfaction surveys, students report regional campuses lack the resources and training opportunities for md candidates, and they must be in indianapolis to gain experience and cultivate relationships with clinical department chairs and others to secure residencies. however, regional campus student concerns about not placing into competitive residencies are not supported by iusm’s match data. according to school match data from 2011 to 2018, regional campus students match into highly competitive residencies at the same rate as students from the main campus. with a few exceptions, regional campuses have not provided students a compelling reason to choose their campus. one campus that has been successful in recruitment offers a rural health track, and 3 campuses are co-located with division i universities offering resources and social amenities students desire. all regional campuses see significant decreases in enrollment during the clinical years as shown in figure 1. figure 1: medical student enrollment by campus and class year previous literature around regional medical campuses has focused on increasing the number of physicians in underserved areas1 and most of the literature related to scholarly concentrations focuses on increasing student scholarship.2-4 we believe our program is unique in using scholarly concentrations as a viable way to increase student recruitment and satisfaction with medical education at regional medical campuses. we were unable to find any regional medical campus or scholarly concentrations literature regarding the use of scholarly concentrations programs to recruit students to regional campuses. the exception is rural track programs, which seek to recruit students to rural areas in order to increase the physician doi: https://doi.org/10.24926/jrmc.v4i1.3541 workforce in those areas.5,6 in this article, we will describe our novel experience using a scholarly concentrations program to recruit and retain medical students are regional medical campuses. approach these challenges of the regional medical campus model provide several opportunities for iusm and for other schools with a geographically dispersed model. iusm sees scholarly concentrations as a key component of a strategy to attract and retain students at regional campuses through educational enhancement, create a reputational focus and sustain enrollment growth at the regional campuses, increase student-faculty interactions and sense of community, increase satisfaction, and create new opportunities for faculty research, educational scholarship, and potentially philanthropy. the development of a scholarly concentrations program in iusm’s multi-campus regional model required a careful needs assessment, dedicated resources, and a clear vision. the needs assessment highlighted the challenges and opportunities facing the school: 1) to articulate areas of excellence for each campus, while supporting student research and collaboration. 2) resources were built on the strength of faculty and students with the support of an experienced project manager and dedicated faculty to lead the project along a carefully designed implementation plan. 3) a clear and consistent vision of the future of the program allowed rapid recruitment of program co-directors, project mentors, faculty and students. scholarly concentrations have become increasingly common in u.s. medical schools in the last decade (2007 to 2019). seventy-four percent of the u.s. medical schools that u.s. news & world report rank as top 25 for research or primary care (n=43 institutions) offer some form of a scholarly concentration program.7 some are required and part of their core medical education curriculum; others are optional and exist alongside the core medical education curriculum.3,7 all encourage students to study a topic of interest, develop additional expertise and engage in scholarly work. the iusm scholarly concentrations program (scp) leverages the unique expertise and resources at its diverse campuses and shines a spotlight on them (see figure 2). figure 2: iu school of medicine scholarly concentration themes are based on local expertise, strengths, interests, and needs. most concentrations (red) have partnered with a local organization or institution (black). journal of regional medical campuses, vol. 4, issue 1 original reports prior to launch in 2019, scholarly concentration themes, locations, and partners were carefully chosen in conjunction with regional campus leaders based on their local expertise, strengths, interests, and needs of both the school and their communities. we excluded fields that are the focus of a clerkship or residency and excluded topics that are well covered in the core medical education curriculum. concentrations are intended to be topics of broad interest that appeal to students to augment the medical curriculum and enhance their education. for example, the northwestgary campus, located in a diverse urban area with a history of deep community connections was a natural choice for urban medicine and health care disparities. ethics, equity, and justice was the choice at the south bend campus due to connections with scholars of ethics at the university of notre dame and expertise of iusm faculty. iusm expanded partnerships with purdue university’s weldon school of biomedical engineering, the indiana university kelley school of business, and fairbanks school of public health to develop concentrations. dual degrees in public health and business are already offered, and the scholarly concentrations provide students with additional opportunities along a continuum of learning. a new partnership with the world-renowned kinsey institute on the bloomington campus led to a concentration in human sexuality and health. the initial round of while the initial round of concentrations was proactively determined by program and campus leadership, as word of the program spread, in 2020, additional concentrations were proposed by faculty. the scp is a longitudinal extracurricular program designed to enhance the experiences of students through a parallel curriculum delivered through their 4 years of study at one campus, without incurring additional time or tuition. participation is optional. students complete topic-specific coursework, engage in scholarly pursuits, and benefit from mentorship to become better prepared leaders in their chosen field of interest. the scholarly project provides a focus for community-engaged scholarship. students make use of the summer between the first and second years of medical school, elective time, and other less busy times. students doi: https://doi.org/10.24926/jrmc.v4i1.3541 earn 2 non-clinical elective credits for completing the program, which provides 2 months during their fourth year to complete their concentration work. each concentration has a recommended pathway for students to integrate the scholarly concentration into their schedule (see example in figure 3). figure 3: recommended pathway for quality and innovation in health care *available mid-december to mid-february though still early in its 3-phase pilot, significant progress has been achieved. the idea of scholarly concentrations was introduced in the spring of 2018. meetings with regional campus deans, and the school’s curriculum council steering committee in july, set a trajectory to develop concentrations and launch a pilot in less than one year. during this time, campus deans and faculty members identified areas of expertise. faculty were recruited as co-directors to develop concentrations and to teach and mentor student scholarly work. a project manager directed program development and recruitment of the first cohort of current students. the pilot was launched in may 2019 with 11 concentrations representing all 9 campuses. six additional concentrations were subsequently approved to start in 2020 or 2021, expanding the program to 17 concentrations. to launch a pilot scholarly concentrations program expeditiously required strong leadership from the educational deans and faculty-led curriculum council steering committee, as well as the dedication of faculty and staff statewide. journal of regional medical campuses, vol. 4, issue 1 original reports role responsibilities executive associate dean vision and leadership; review and approve topics; develop partnerships curriculum council steering committee curricular leadership; review and approval of proposals scholarly concentrations program ad-hoc committee initial review and recommendation for approval to steering committee project manager/program manager program and systems development, implementation, ongoing direction scholarly concentration program faculty lead curricular review; evaluation, and assessment associate dean and director of regional campuses champion of campus expertise/topic, overall success of scp on campus scholarly concentration co-directors development of concentration, curriculum, scholarly projects. student success scholarly concentration project mentors guide students through scholarly project, manuscript, poster course directors development of course syllabus, course content, assessment liaison librarians provide support to scholarly concentrations students and educators through library resources and services creating a sustainable system with approximately 1 420 students in the md program, creating operational processes, systems, policies, and practices is an imperative. the program is led by a small team composed of a program manager, a faculty lead, and a program coordinator. each concentration is led by codirectors. the program team convenes a “co-director community” monthly to guide the program’s development and operations. early in development of the scp, a group of key personnel began to develop operations to support the launch and subsequently create systems to sustain the program. the group is composed of personnel from curricular operations, educational technology, information technology, registrar’s office, evaluation and assessment, concentration co-directors, and other creative stakeholders. mentors, librarians, an institutional review board representative, and doi: https://doi.org/10.24926/jrmc.v4i1.3541 other colleagues involved in scholarship and research are key collaborators. a variety of technology supports the pilot phase. a “plan – do – check – act” improvement cycle is used to evaluate operations and make adjustments. each concentration is typically composed of 2 or 3 topicspecific courses and scholarly work. the fundamentals of research and scholarship course, developed by iusm’s research department, is core to all concentrations. students complete a scholarly project leading to a manuscript submission or other appropriate product, and present at iusm education day. students completing the program’s requirements earn 2 non-clinical elective credits toward graduation and a scholarly concentrations designation. scholarly concentrations and campus recruitment for the initial pilot, the scp was promoted to all currently enrolled iusm students, regardless of year of study. a robust marketing and communications campaign launched with an announcement from iusm’s dean. a robust web site and md student news provided concentration details and reminders. a launch event was hosted via online video conference (zoom) with students gathered at campus locations. the executive associate dean of medical education and institutional improvement served as emcee and chief messenger. during the february 2019 application cycle, 139 students, primarily first-years, applied via online application. one-hundred twenty-three began in 11 concentrations in the initial pilot phase; 103 (84%) remain. in phase two, 121 students applied during fall 2019 recruitment, and 97 enrolled. currently, 92 (89%) remain enrolled. recruiting prospective students even though the inaugural recruitment was occurring well into the admissions cycle, the school emailed students admitted to the class of 2023 informing them about this new program and inviting them to preference a regional campus with a concentration of interest. following the recruitment of current students, phase 3 began with the implementation of the scholarly concentrations priority placement program to promote concentrations and regional campuses to applicants for the class of 2024. the main campus was not included in this program. available by invitation, the priority placement program provided admission notification earlier in the cycle in exchange for a non-binding commitment to spend 4 years on a regional campus studying and living in the community where students can enjoy deep experiences in the area of a scholarly concentration. the program received more than 600 applications; nearly 140 applicants were interviewed. priority placement interviews were combined with iusm’s applicant interviews to give applicants the opportunity to visit their preferred campus and meet campus leaders. questions about doi: https://doi.org/10.24926/jrmc.v4i1.3541 journal of regional medical campuses, vol. 4, issue 1 original reports interest and goals for participating in a scholarly concentration were added to the admissions interview rubric. while application required a minimum gpa of 3.5 and an mcat of 507 (science and overall), the applicant pool had a gpa average of 3.8 and mcat of 513. outcomes the scholarly concentrations program is still new, and current outcomes are as follows: • seventeen concentrations developed in 2 years; all are part of the multi-phase, multi-year implementation. o ten were developed to promote specific regional campuses. o three concentrations proposed by faculty as a result of the program have been implemented. o four concentrations are “statewide” to provide an array of options for medical students at every campus. • strong current and prospective student interest: o 123 students enrolled in the inaugural cohort and 103 (84%) remain enrolled; 97 enrolled in the second student cohort and 92 (89%) remain enrolled. o the priority placement program dramatically increased the number of students enrolled in the scholarly concentrations program at regional campuses. the invitation-only priority placement program resulted in nearly 140 interviews. sixty-seven prospective students were offered admission to a scholarly concentration on a regional campus for the class of 2024. thirty-four matriculated, with an average gpa of 3.8 and 512 mcat. this results in 9% of the class choosing a regional campus and its scholarly concentration. o the following figure 4 shows the number of students enrolled in regional campus concentrations based on recruitment campaigns conducted in winter 2019, fall 2019 and the results of the priority placement program, as well as students accepted during the fall 2020 recruitment cycle. these students will enroll in spring 2021. figure 4: student enrollment and acceptances in regional campus scholarly concentrations by graduating class as of dec. 1, 2020. *students accepted into scholarly concentrations fall 2020; will be enrolled spring 2021 **not available at time of priority placement recruitment • as a part of an assessment plan, end-of-course evaluations are completed for each course and results shared with course directors and scholarly concentration co-directors. a report is delivered annually to the curriculum council steering committee, iusm’s curricular governing body. evaluations for the inaugural 15 completed courses yielded at 48% response rate and 3.4 rating for overall quality on a 4-point likert scale with 4 being excellent. other questions asked about clarity of learning objectives, effectiveness of teaching modalities, and average number of hours per week. assessment plan like many other scholarly concentration programs, goals, and key outcomes include: a longitudinal educational experience; increasing student participation in scholarly work and submission of publications, as well as providing a credential to strengthen residency applications. goals unique to iusm are: • increasing student enrollment preference for regional campuses; • increasing 4-year regional student enrollment, with a target that third year enrollment is 50% of first year enrollment; and • increasing student satisfaction by campus. journal of regional medical campuses, vol. 4, issue 1 original reports in addition to end of course evaluations, data used to monitor program development include surveys from students who withdraw from the program and periodic progress reports that are being implemented. data used to track progress toward goals will include enrollment data, the school’s student satisfaction survey, match data, aamc graduation questionnaire, student publication rate, and focus groups. iusm will monitor implementation of the pilot and eventually all phases of its training program. where data can be stratified, comparisons will be made between scp students, attrition students and non-scp students based on common national and local benchmarks of academic success. where these data cannot be stratified by regional campus or scp participation, (e.g. gq), trends will be monitored over time. scholarly output will be cataloged and shared within the school community. iusm education day will provide a focal point to celebrate student successes. the scholarly concentrations program is committed to continuous quality improvement. a couple of courses have made adjustments based on feedback, and the program continues to experiment with its application process and marketing. best practices will continue to be shared to improve effectiveness. next steps incredible support and interest from faculty, students, and partner institutions has allowed this pilot to grow rapidly. immediate plans involve supporting concentration growth, building systems, and monitoring results of the 3 pilot phases to inform future development and implementation. during the 2020 recruitment cycle, prospective students for the class of 2025 were able to apply through an early decision program to a regional campus; scholarly concentrations were promoted as a part of this effort. we are evaluating recruitment strategies. in addition, scholarly concentration-based research is being promoted at the campuses through focused faculty recruitment and student engagement. previously, faculty were largely recruited based on basic science and clinical expertise. in partnership with the indiana clinical and translational sciences institute, a recruitment committee including regional campus and scp representatives was established to recruit faculty with concentration-specific expertise to regional campuses in order to further enhance opportunities for student scholarly work. students are engaged through topic-specific coursework; individualized scholarly projects, many of which are based in their communities; and by being part of a group of colleagues sharing a common interest in a scholarly concentration topic where they live, work and study. our experience suggests that other institutions would benefit from the needs assessment described in approach and other doi: https://doi.org/10.24926/jrmc.v4i1.3541 strategies described in this paper when seeking to implement a multi-campus scholarly concentrations program. references 1. fyfe t, akins r, gagne p, cheifetz c, petrocelly s, payne g. regional medical campuses in canada and the united states: a systematic review. jrmc. 2018;1(3). 2. dibiase rm, beach mc, carrese ja, haythornthwaite ja, wheelan sj, atkinson ma, et al. a medical student scholarly concentrations program: scholarly self-efficacy and impact on future research activities. med educ online. 2020;25(1):1786210. 3. wolfson rk, alberson k, mcginty m, schwanz k, dickins k, arora vm. the impact of a scholarly concentration program on student interest in career-long research: a longitudinal study. acad med. 2017;92(8):1196-203. 4. george p, green ep, park ys, gruppuso pa. a 5-year experience with an elective scholarly concentrations program. med educ online. 2015;20:29278. 5. eley d, baker p. does recruitment lead to retention? rural clinical school training experiences and subsequent intern choices. rural and remote health. 2006;6(1):511. 6. macqueen it, maggard-gibbons m, capra g, raaen l, ulloa jg, shekelle pg, et al. recruiting rural healthcare providers today: a systematic review of training program success and determinants of geographic choices. j gen intern med. 2018;33(2):191-9. 7. burk-rafel j, mullan pb, wagenschutz h, pulstkorenberg a, skye e, davis mm. scholarly c oncentration program development: a g eneralizable, data-driven approach. acad med. 2016;91(11 association of american medical colleges learn serve lead: proceedings of the 55th annual research in medical education sessions):s16s23. microsoft word novel methodology.docx published by university of minnesota libraries publishing novel methodology for recruitment of high school students to health professions lindsay buzzelli; michael flanagan, md; john gaspich iii; maryanne neal, rn, bsn; mark stephens, md doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 3, issue 2 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc lindsay buzzelli, bs, ms2; the pennsylvania state university college of medicine michael flanagan, md; the pennsylvania state university college of medicine john gaspich iii, bs, ms2; the pennsylvania state university college of medicine maryanne neal, rn, bsn, med; state college area high school mark stephens, md, ms; the pennsylvania state university college of medicine all work in jrmc is licensed under cc by-nc volume 3, issue 2 (2020) journal of regional medical campuses original reports novel methodology for recruitment of high school students to health professions john gaspich iii; lindsay buzzelli; maryanne neal, rn, bsn; mark stephens, md; michael flanagan, md abstract medical schools are creating programs to introduce careers in healthcare to students at earlier stages in their education. at the penn state college of medicine university park regional campus, we have created and implemented a novel improvisational, case-based, small-group learning curriculum for high school students to introduce integrative thinking in basic and clinical sciences and to cultivate an early interest in health profession careers. the program also includes elements of health systems science and humanities. a multidisciplinary team of educators with both secondary and post-secondary pedagogical expertise worked together to develop a longitudinal case-based curriculum suitable for high school students. this curriculum was administered to a group of 40 students in grades 9-12. at the start of each session, students were challenged to explore personal biases, reflect upon ethical dilemmas, and step outside of their comfort zones with “centering exercises.” through these activities, we strived to challenge the learners’ preconceptions about their colleagues, medicine, and role within it. students were then presented with a case as a large group. at critical junctures in the cases, students worked in small groups of 8-10 with 1-2 medical student facilitators to discuss questions and solve clinical dilemmas associated with the case. early feedback from students and faculty advisors has been overwhelmingly positive. the authors have no conflicts of interest. background the united states is experiencing a shortage of healthcare professionals. the association of american medical colleges (aamc) indicates a projected shortfall of nearly 105 000 physicians by 2030.3 this shortage is not isolated to physicians. the aging population of the united states is expected to create a concurrent demand for more than 446 000 home health aides, 98 000 medical and laboratory technicians, 95 000 nursing assistants, and 29 000 nurse practitioners by 2025.2 to address these shortages, medical schools have started to create programs for students in secondary schools to increase interest in health professions. various models of education and recruitment including minimedical schools, pipeline programs, and 3+3 integrated collegiate partnerships have been developed5,6 to identify and recruit students for medical school. rural communities have a particularly acute need for both physician and nonphysician healthcare providers.9 in recent years, medical education has become more studentcentered, interactive, and case-based. early clinical exposure, case-based learning, and near-peer student-directed education are strategies used to increase engagement, knowledge retention, and enhanced problem-solving skills.8 these strategies are designed to promote the growth of emotionally aware, resilient, and compassionate clinicians. one novel approach that has gained increased attention is the use of improvisational theater in medical education. healthcare workers regularly face complex decision-making dilemmas. employing techniques used in improvisational theater helps students to break down barriers, challenge preconceptions, and promote teamwork in the classroom with the hope that these skills may be applied in their future careers. improvisational learning has also previously been implemented successfully in medical curricula to enhance well-being.1 with this background in mind, we sought to design an innovative, case-based, improvisational curriculum to promote interest in health professions among high school students in our rural community. methods at the penn state college of medicine university park regional campus (uprc), medical students and physicianeducators are collaborators in a novel case-based curriculum with early clinical immersion. we specifically adapted this model to our pilot high school student curriculum. to do so, a multidisciplinary team of educators was assembled through a partnership between our regional medical campus and a local high school, state college area high school (scahs). this team, led by 2 medical students, also included a registered nurse secondary education teacher, and 2 physicianeducators. this team met regularly to develop a curriculum that would be feasible to implement in the high school environment. curriculum the curriculum that was developed by this interdisciplinary team consists of 10 case-based, problem-focused sessions. we termed the curriculum the university park-10 (up-10) (figure 1). case selection was informed by medical students’ doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports first year experiences during early clinical immersions. the up-10 was designed to provide high school students with an entree into clinical decision making and the types of cases commonly seen in a community-based primary care clinic (appendix). figure 1. up-10 curriculum topics. improvisation the up-10 curriculum was designed to deliberately leverage improvisational theater techniques that would inspire students to embrace uncertainty, uncomfortable situations, and difficult conversations. prior to each case, the group participated in an improvisational exercise that served as a paired discussion on personal development, compassion, ethics, shared decision making, and professional behavior. the exercises pushed students to think introspectively and challenged them to take on complex psychosocial situations in a manner that is similar to the daily challenges encountered by healthcare professionals in the workplace (figure 4). improvisational training requires individuals to take part in an activity previously unknown to them and adapt to the constraints of this activity. oftentimes these activities take the form of simple exercises that increase in complexity until the system has reached a critical maximum requiring the group to adapt or continue to brush against the limits of the proscribed constraints. by providing students with a space in which to fail safely, embrace the difficulty of problem solving, and communicate with their peers, we challenged them to embrace both a humanistic approach and failure as a requisite for change, adaptation, and success. figure 2. exemplar improvisational activities. improvisational activity teaching points a group of 8-10 students are organized to stand in a circle. a facilitator starts off by saying the name of an animal and then holding out their hand to gesture to a student in the circle. that student then names a different animal and gestures to another student in the circle. this continues until the final student says the name of an animal and gestures back to a facilitator. next, a small soft ball is added in and each person says the name of their animal and throws the ball to the person to whom they initially gestured. an outside facilitator then adds in more balls one at a time while those in the circle maintain the same pattern. students became increasingly willing to make mistakes at risk of embarrassment and social discomfort in front of peers and facilitators students learn to take verbal and non-verbal cues from others in the circle to anticipate their actions and respond in turn. students learn to remain calm in an increasingly demanding and chaotic setting. students were divided into 5 small groups, each paired with a facilitator. it was the students’ task to find 2 meaningful interests, experiences, etc. common to all members of the group within 5 minutes time. a student from each group was then chosen to present these findings to the large group. students gained increasing comfort with the process of posing questions to their peers and facilitator. students learned to find commonalities and connections with a seemingly dissimilar group of people. students learned to unite the concepts of other and self. design four cases from the up-10 curriculum were utilized as a proof-of-concept pilot. sessions were held in partnership with and hosted by a local high school health-professions club. these sessions were held biweekly for 8 weeks, and lasted an average of 1.25 hours. the cases were presented by medical students using discussion, flipped classroom, small-group, and socratic teaching methods. the medical students participating in the project also had prior teaching experience with high school and college students. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports sessions were open to any scahs student wishing to attend. recruitment and advertising were facilitated by the school’s chapter of the health occupations students of america (hosa). between 20 and 40 students attended each session. feedback was obtained from students via oral debrief in large-group format, and with individual students where possible. elements for each session were deliberately chosen and organized to be complementary and sequential. figure 3. breakdown of session elements. discussion this proof-of-concept curriculum was successfully delivered to 20-40 students for a total of 4 sessions. while participants were from a variety of backgrounds and cultures due to the demographics of our suburban partner school, they included a limited number of individuals recognized as being underrepresented in medicine. students actively participated in both largeand small-group activities and learned to evaluate clinical scenarios. while we did not build a standardized, irb-approved feedback mechanism into this pilot program, student feedback following each session was exclusively positive. many students expressed the realization that the content they had previously learned in science courses was applicable to medical situations. they reported increased confidence and pride in appropriately using scientific and medical vocabulary. several students stated that the cases helped them to explore an interest in fields of medicine they had not previously considered. others felt that the cases helped them more fully recognize the role of the physician and the many considerations that go into formulating a diagnosis and offering the appropriate treatment. the hosa faculty advisor noted increased attendance on days that up-10 cases were presented, as well as an increase in engagement and participation. both the students and their hosa advisor requested that we extend and expand the partnership into the future. there were several important lessons learned. first, we observed the need for near-peer mentorship of participating students. while many students were interested in the healthcare professions, several were unsure as to what specific path to take to meet their educational goals. studies in science education outreach have shown that mentorship is particularly effective when it occurs between a mentor who has recently passed through the stage of training where the mentee currently resides, as it allows mentees to see themselves in the position of the mentor.11 our program presents a unique opportunity to facilitate this relationship between medical students and high school students as they approach their post-secondary schooling. based on these observations and findings, we hope to grow a codified mentorship component within the program for future years by creating mentor-mentee groups/pairings and organizing mentorship events, such as open office hours and medical student panels. as a proof of concept, our pilot program has demonstrated initial success. the program was easy to implement, was wellreceived by educators, students, and administrators and capably augmented the secondary school health education curriculum without adversely impacting prerequisites or previously scheduled activities. it would be prudent to create a standard feedback mechanism and an irb approved protocol to better characterize the impact on students. while it is not possible to determine the long-term impact that this program had on student decision-making, or success with regard to entering a career in the health professions at this time, we plan to implement long-term follow-up mechanisms to determine how many participants subsequently pursue careers in the health professions. we plan to maintain our affiliation with this particular high school and expand to other high school students in future years. this program represents a curriculum that is easily scaled and translated to different demographic populations. our plan is to expand our relationships with both urban and rural students within the next academic year. to facilitate this, we have collaborated with the office of diversity, equity, and inclusion at the penn state college of medicine. we plan to deploy the up-10 curriculum through interactive webinars to reach students in the more rural recesses of our county. in addition, we are currently modifying our curriculum to fit a one-day “mini-med school” intensive immersion that will be delivered to students from groups that are often underrepresented in health professions. mini-med school concepts are not novel; however, we intend to integrate our innovative regional campus curriculum into this established approach. an initial session will be hosted at our regional medical campus in the fall of 2020. this will allow participants from more distant schools to participate in a health professions immersion that might otherwise be largely inaccessible. following this event, we plan to introduce our program to urban area students thus enhancing established pipeline programs that familiarize students with both our regional campus and penn state college of medicine as a whole. the potential is great for this pilot program to continue evolving, while eventually helping to increase medical career awareness among rural and underrepresented doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports students. ultimately, such programs may contribute toward meeting the nation’s recognized need for more healthcare professionals. references 1. bermant g. working with(out) a net: improvisational theater and enhanced well-being. front psychol. 2013;4:929. published 2013 dec 10. doi:10.3389/fpsyg.2013.00929 2. mercer. demand for healthcare workers will outpace supply by 2025. https://mercer.healthcare-workforce.us/. updated: 2018. accessed: june 22, 2019. 3. mitka m. looming shortage of physicians raises concerns about access to care. jama. 2007;297(10):1045–1046. doi:10.1001/jama.297.10.1045 4. dahl u, steinsbekk a, jenssen s, johnsen r. hospital discharge of elderly patients to primary health care, with and without an intermediate care hospital a qualitative study of health professionals' experiences. int j integr care. 2014;14:e011. published 2014 apr 30. doi:10.5334/ijic.1156 5. murray-garcía jl, garcía ja. from enrichment to equity: comments on diversifying the k-12 medical school pipeline. j natl med assoc. 2002;94(8):721–731. 6. valla jm, williams wm. increasing achievement and higher-education representation of under-represented groups in science, technology, engineering, and mathematics fields: a revier of current k-12 intervention programs. j women minor sci eng. 2012;18(1):21–53. doi:10.1615/jwomenminorscieneng.2012002908 7. hobson wl, hoffmann-longtin k, loue s, et al. active learning on center stage: theater as a tool for medical education. mededportal. 2019;15:10801. published 2019 jan 30. doi:10.15766/mep_2374-8265.10801 8. ramnanan cj, pound ld. advances in medical education and practice: student perceptions of the flipped classroom. adv med educ pract. 2017;8:63–73. published 2017 jan 13. doi:10.2147/amep.s109037 9. rosenblatt ra, hart lg. physicians and rural america. west j med. 2000;173(5):348–351. doi:10.1136/ewjm.173.5.348 10. yu y, arnold a, keegan da. the calgary guide: teaching disease pathophysiology more effectively. medical education. 2016;50:580-581.figure 3. exemplar case discussion from the up-10. 11. pluth, m. d., boettcher, s. w., nazin, g. v., greenaway, a. l., & hartle, m. d. (2015). collaboration and near-peer mentoring as a platform for sustainable science education outreach. journal of chemical education, 92(4), 625–630. appendix objectives and case summary: key points: objectives: students will be able to differentiate between a virus and a bacterial illness based on key signs/symptoms, appropriate treatments, and basic features of the microbes themselves. students will be able to theorize a connection between natural selection, overprescription of antibiotics, and antibiotic resistance. case summary: cc: headache, cough, rhinorrhea, nausea, vomiting, and diarrhea hpi: ms. x is 42-year-old female with a 2-day history of headache, cough, rhinorrhea, nausea, vomiting, and diarrhea. two days ago, she came home from work feeling more tired than usual and went straight to bed. she slept soundly for about 4 hours, but then woke up to use the bathroom where she had an episode of watery diarrhea and vomited twice. at that time, she said her head felt ‘heavy’ and ‘filled with mucus.’ the pain in what: bacteria – domain of unicellular prokaryotes that have cell walls containing peptidoglycan; produce an infection that is often associated with high fever, longer course, and white exudate. virus – particle made up of nucleic acid, protein, and often lipids that can replicate only by infecting living cells; produces an infection that is associated with a shorter course. antibiotics – compound that blocks the growth and reproduction of bacteria. natural selection – process by which individuals that are better suited to their environment survive and reproduce most successfully. resistance – an ability of a microorganism to withstand the impact of a medication that previously neutralized it. opqrst – a mnemonic that can be used to remember the important questions to ask when taking a pain history: onset, provocation/palliation, quality, radiation, severity, and time. differential diagnosis – process of differentiation a doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports her head was a 4 out of 10 and she took ibuprofen and went back to bed, both of which helped her feel better. she called off of work sick the following day and is out again today. she continues to have nausea, but has not vomited again since that time 2 days ago. she has continued to have diarrhea about 3 times each day and describes it as watery and brown in nature. she woke up with a cough today that she says comes and goes about every ten minutes, feels like a tickle in her throat and is partially relieved by cough drops and water. she does not endorse anorexia, night sweats, chills, blood in the stool, or sore throat. pmhx: hypothyroidism (levothyroxine) pshx: none fhx: father – dmii maternal grandmother – mi (age 87) shx: ms. x is a preschool teacher. she lives with her husband in state college, pa. she traveled to puerto rico about 2 months ago but does not endorse any other travel. she is insured through her school. disease from others that are clinically similar. how: students will be presented with a chief concern. they will then have to take a history from a mock patient, suggest physical exam skills, lab/imaging tests and adjust their mental models and differential diagnoses as they are presented with new information. why: flu-like symptoms are a common concern that medical students see in their family medicine clinics on a nearly daily basis. it is important to be familiar with a basic differential diagnosis and framework to approach this problem as a healthcare professional. presenting this information as a case and having information slowly revealed allows students to engage in the process of taking a history, thinking about physical exam, and clinical decision making, something that they will be doing each day as future healthcare providers. a discussion around antibiotic resistance satisfies a review of evolution and natural selection but also offers an entrée into medical stewardship and effective and responsible use of resources. she drinks 1 glass of wine every evening and does not endorse smoking or recreational drug use. ros: none vitals: bp: 124/84; hr: 80; rr: 16 (and regular); spo2: 98%; temp: 99.1 f physical exam: heent: some pain upon palpation of frontal sinuses; ears nonerythematous and nonedematous, tympanic membranes visualized bilaterally; mucus and erythema and edema visualized in nostrils bilaterally; throat appears erythematous, no exudate appreciated. pulm: – lungs clear bilaterally to auscultation. no rales, rhonchi, or wheezes heard. cardio: regular rate and rhythm with s1 and s2 present. no rubs, gallops, or murmurs. relevant data: negative rapid strep test chief concern, history taking, and physical exam findings medical student facilitators: present chief concern to students. ask what the students would like to know about this patient (one medical student acts as mock students: formulate questions within the provided framework. have the opportunity to raise their hands and ask the mock patient questions about doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 original reports patient using information above). present the opqrst framework as well as the key categories involved in a patient history (history of present illness, medical/surgical history, family history, social history, and review of systems). her medical history and physical findings. differential diagnosis introduce the concept of a differential diagnosis. note a focus on most likely, unlikely but possible, and cannot miss diagnoses. cold call students and serve as scribe. challenge students to think about what makes each diagnosis more or less likely. turn and talk to partner about which conditions fall into these categories and come up with a three-item differential diagnosis. share differential and reasoning with the group. bacterial vs. viruses activate prior knowledge by asking students what they know about bacteria, viruses, their differences, and their similarities. call on students to share their insights. mentally review concepts learned in biology about microbes (cellularity, nucleic acids, illnesses caused, etc.) share thoughts aloud with group. testing challenge students to think about what tests they would run based on the history they obtained, provide examples of possible tests that would be helpful, quickly research possible how the test would change their clinical course, and the costs associated with each test. reveal a negative strep test. ask students to revise their differential diagnosis with the information they now have. costs, and share information with the group. defend to group why test would be helpful. come to the board and reorder the differential based on new information. treatment ask students to come up with a treatment plan with a partner. ask students to explain what they know about natural selection. challenge students to make a connection between natural selection and antibiotic resistance. turn and talk with a partner about what treatments may be effective for a virus and why. think back to what they know about natural selection, identify selection pressures on bacteria, which bacteria survive and what the implications are. stop and jot thoughts in provided notebook. figure 4. exemplar case discussion from the up-10. microsoft word acustomizedapproacharticle.docx published by university of minnesota libraries publishing a customized approach to interprofessional education on a regional campus angel holland, pt, dpt, edd; audra butler, ba; pearl mcelfish, phd, mba; jonell hudson, pharmd, bcps, cde; leslie jordan; scott warmack, pharmd doi: https://doi.org/10.24926/jrmc.v2i4.2145 journal of regional medical campuses, vol. 2, issue 4 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc angel holland*, pt, dpt, edd; director of clinical education, associate program director, assistant professor, department of physical therapy; associate director ipe – nw campus, university of arkansas for medical sciences, northwest campus, fayetteville, arkansas. audra butler, ba; community health coordinator, university of arkansas for medical sciences, northwest campus, fayetteville, arkansas. pearl mcelfish, phd, mba; vice chancellor northwest arkansas region, university of arkansas for medical sciences, northwest campus, fayetteville, arkansas. jonell hudson, pharmd, bcps, cde; associate professor, college of pharmacy, co-director, north street clinic, university of arkansas for medical sciences, northwest campus, fayetteville, arkansas; pharmacy practice, uams family medical centerspringdale, arkansas. leslie jordan, director of students services, university of arkansas for medical sciences, northwest campus, fayetteville, arkansas. scott warmack, pharmd; associates dean, associate professor of pharmacy practice, university of arkansas for medical sciences, northwest campus, fayetteville, arkansas. corresponding author: angel holland, pt, dpt, edd department of physical therapy uams northwest campus 1125 n college avenue fayetteville, ar 72703 tel: 1-479-713-8603 fax: 1-479-713-8606 email: amholland@uams.edu all work in jrmc is licensed under cc by-nc volume 2, issue 4 (2019) journal of regional medical campuses perspectives a customized approach to interprofessional education on a regional campus angel holland, pt, dpt, edd; audra butler, ba; pearl mcelfish, phd, mba; jonell hudson, pharmd, bcps, cde; leslie jordan; scott warmack, pharmd introduction addressing complex health issues and unmet health needs within current and future healthcare systems requires a collaborative-practice ready workforce. the world health organization (who) defines a collaborative-practice ready workforce as “healthcare workers who have received effective training in interprofessional education (ipe).”1 ipe is the educational practice in which students from different professions or disciplines “learn about, from, and with each other” with the expressed goal of engendering collaborative efforts and improving health outcomes.1-2 ipe empowers students and healthcare providers to work collaboratively through an understanding of team dynamics, leadership, and patient centered management that promotes better health services and improved health outcomes. in 1972, the institute of medicine (iom) called for academic health centers to “recognize an obligation to engage in interdisciplinary education and patient care” and to “relate interdisciplinary education to the practical requirements of health care.”4 following this report, some medical schools across the us voluntarily implemented ipe opportunities within their curriculum. interest in interdisciplinary teams within healthcare spiked in the mid-1990s following rapid increases in healthcare spending.3,5 in addition to efforts to decrease national spending on healthcare, iom identified ipe and collaboration as a means to address patient safety concerns.6-8 in 2010, who described interprofessional collaboration in education and practice as an essential strategy in addressing current and future crisis in global health care.1 in 2011, the interprofessional education collaborative (ipec) identified core competencies that prepared healthcare students to enter the workforce ready to work as effective members of interprofessional teams.9 following the call for increased interprofessional collaboration within medical school curricula, numerous health profession accreditation organizations introduced and adopted accreditation standards for interprofessional education and collaboration.10-16 in recognition of the importance of ipe and to meet standards by multiple accrediting organizations, the university of arkansas for medical sciences (uams) created the office of ipe17 with a dual focus on meeting the triple aim (defined below) and expanding ipe infrastructure. the only academic health center in arkansas, uams offers 73 degree and certificate programs through classes offered at the main campus in little rock, arkansas. the uams northwest regional campus was established in 2007 in fayetteville, arkansas and is located more than 200 miles from the main campus. the regional campus has undergraduate radiological imaging sciences students (ris), graduate level genetic counseling students, doctorate level physical therapy students, masters and doctoral level nursing students, third and fourth year medical students, and third and fourth year pharmacy students (see table 1). in addition to current program offerings, a doctorate level occupational therapy program is in development. approximately 300 students are trained on the uams northwest regional campus each year. there are hundreds of regional medical campuses through the us and canada.18 regional campuses are required to meet the same accreditation standards as main campuses, but often struggle to offer all opportunities to students. however, regional campuses also present opportunities to provide regional campus students with unique and rewarding ipe experiences. on the main campus the student population presents several degree programs, which provides multiple combinations of healthcare students within interprofessional doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 perspectives education experiences. the regional campus must work to include the small amount of healthcare disciplines to ensure the learning experiences are meaningful to all students. in addition to the decreased student census, the amount of available faculty to facilitate ipe learning experiences on a regional campus is also a challenge. in this paper we discuss the development and implementation of an ipe curriculum on a regional medical campus. ipe program model19 the uams office of ipe supports ipe and collaboration on campus through a 5-pillar approach that includes curriculum, collaborative practice, development, faculty development, and research/scholarship. for the purpose of this paper, we will focus on curriculum and the impact on the regional campus student experience. the student curriculum includes approximately 25 contact hours of ipe coursework required for graduation for all degree seeking students at uams on both the main campus and regional campus. each learning experience has a different time devoted to the activity based on the objectives of each phase. the curriculum was designed to address the triple aim, a framework developed by the institute for healthcare improvement, that offers a 3 dimensional approach to improving overall health system performance through improving the patient experience, improving population health, and reducing the overall cost of health care.20 the uams student curriculum includes a 3phase triple aim framework (see figure 1) that provides instruction and collaborative activity for students at the novice, intermediate, and advanced levels.21 the uams ipe curriculum works in 3 phases of educational development: exposure, immersion, and competence. regional campus approach developing innovative ipe opportunities for regional campus students by may 2015, all 5 uams colleges and the graduate school approved the ipe triple aim framework, requiring students who entered uams programs in fall 2015 or later to participate in ipe activities. may 2019 graduates were the first cohort required to fulfill all ipe core activities as a requirement for graduation. regional campus students complete the same 3-phase framework and 7 core activities as shown in figure 1. some students complete their first 2 years of didactic coursework on the main campus (medicine and pharmacy); these students complete the first phase of the ipe framework on main campus, with the remaining requirements fulfilled on the regional campus. the development and implementation process for ipe on the uams northwest regional campus has differed significantly from that on the uams main campus. prior to the approval of the overarching uams ipe curriculum in 2015, an interprofessional team began plans for a student led free clinic (slfc) on the northwest campus in 2013.23-24 following an extensive series of community needs assessments, the north street clinic was established as a slfc focused on chronic disease management within the marshallese population in northwest arkansas. patient care doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 perspectives and clinic administration are provided by interprofessional healthcare teams.24 the north street clinic was approved by the uams office of ipe to fulfill ipe requirements in the competency phase as it incorporates all dimensions of the triple aim into student education, clinic administration, patient care, and research. on the uams main campus, ipe events that fulfill each of the 7 core activities are facilitated at least once per month during the spring and fall academic semesters. students self-select and enroll in these activities through online registration. due to the smaller faculty staff and student population unique to the northwest campus, these methods of scheduling and enrollment are not used on the regional campus. scheduling of the ipe events on the northwest campus are confirmed by an interprofessional committee to ensure that all students’ schedules can accommodate the ipe learning experiences. because of the small student census, students are enrolled by the administration of their academic program or college and assigned event dates and times. the number and types of events are also reduced on the northwest campus to support the needs of the regional campus students and maximize resources of faculty and staff. regional campus events ipe student events on the northwest campus are designed to fulfill the requirements of the triple aim framework while also meeting the unique needs of the regional campus. due to smaller student census and limited faculty size of the northwest campus, many of the following activities are offered a maximum of once per fall and spring academic semester. student learning experiences have been developed to provide regional campus students with unique and rewarding ipe experiences (see table 2). • cultural training: the cultural training workshop fulfills the transition bridge activity component of the triple aim framework. during this 2-hour workshop, students on the northwest campus are exposed to key concepts of working with individuals from different cultural backgrounds. • triple aim team projects: the triple aim team projects require students to work in interprofessional teams of 4-6 to address a quality improvement topic submitted by uams faculty, staff, or community partners. this 4hour workshop event has student teams work with a faculty/staff advisor to develop a proposal to address the goals and objectives of the triple aim for their chosen topic. at the conclusion of the event, students give a final presentation of the team proposal to a panel of judges. the interprofessional teams included students from all programs on the northwest campus. • medical error disclosure simulation: students are required to participate in one, 2-hour interprofessional simulation event to fulfill the simulation activity component of the triple aim framework. on the northwest campus, students from all programs complete a medical error disclosure simulation in interprofessional teams of 4-6. the simulation is facilitated by faculty and staff and the uams simulation center. the simulation case was written specifically to include roles for each healthcare discipline represented on the northwest campus. students work together to formulate and execute a plan for disclosing medical errors to a patient family member played by a trained, professional actor. teams are monitored by ipe facilitators who debrief with the teams on their performances following the simulation. • emotional intelligence competency workshop: the emotional intelligence competency workshop fulfills the 2.5 hour competence workshop component of the triple aim framework. students attend an interprofessional workshop facilitated by faculty in which they learn about components of emotional intelligence and team dynamics. students are assigned to interprofessional teams and participate in team building and plan of care development activities with a focus on patient care. • culinary medicine competence workshop: the culinary medicine workshop is an optional event that fulfills the 2.5 hour competence workshop component of the triple aim framework. uams northwest partnered with northwest arkansas community college (nwacc) brightwater: a center for the study of food to develop a student event that incorporates culinary medicine into the triple doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 perspectives aim framework. students learn the importance of healthy food choices and potential substitutions to improve patient health within an ipe team environment. • medical humanities competence workshop: the medical humanities workshop is an optional event that fulfills the 2.5 hour competence workshop component of the triple aim framework. uams northwest partnered with crystal bridges museum of american art to develop and facilitate a medical humanities workshop that incorporates concepts of empathy, emotional intelligence art, and the humanities into the triple aim curriculum. utilizing discussion, personal reflection, artful thinking routines, and inquiry-based pedagogy, museum educators at crystal bridges engage healthcare students through facilitated experiences and encourage deeper connections with works of art among diverse clinicians and students. • north street clinic practice activity: participation in the north street clinic fulfills the 3-4 hour practice activity component of the triple aim framework. interprofessional teams include students from medicine, pharmacy, physical therapy, and nursing. students collaborate to complete patient intake, examination, treatment, counseling, and followup care. following patient care, student teams work together to determine the best treatment plan for the patient. interprofessional collaborative practice is modeled in the clinic when the student teams then present the case to an interprofessional group of faculty preceptors who review and approve the care plan. • community health screening: participation in community health screenings fulfills the 3-4 hour practice activity component of the triple aim framework. students work on interprofessional teams facilitated by faculty and staff to provide health screenings to underserved populations in the community. health screenings are organized by ipe faculty and staff in conjunction with uams office of community health and research and college of pharmacy. students who have completed at least one health screening opportunity and return to train other students in completing screenings can receive credit for the student educator component of the triple aim framework. • north street clinic student board of directors: the board of directors is an interprofessional student group that provides insight into the form and function of the north street clinic. medical, pharmacy, and physical therapy students submit an application to serve on the board. the current board of directors votes on the new members for each academic year. members serve on the board for a term of 1-2 academic years, before graduation. as part of his or her role as a board member, each member serves as director-on-duty (dod) for the north street clinic on a rotating basis. in their role as dod, students receive credit for the student educator component of the triple aim framework. challenges and solutions although the characteristics of a regional campus offer unique benefits for the development and implementation of an ipe program, regional campuses also have some unique challenges. successful implementation of an ipe program requires transparent communication, flexibility, buy-in, and support across the regional campus. ipe on the uams northwest regional campus falls under the authority of the office of ipe, located on the uams main campus. each ipe office is supported financially by the respective campus budget. at the onset of ipe development and the creation of the office of ipe on the main campus, there was not an ipe office or dedicated ipe staff or faculty member on the uams northwest regional campus. regional campus students were connected to events via video technology or had to attend events on the main campus 3 hours away. events were not designed to meet the unique needs of students on the regional campus. the additional burden and confusion created by the trans-campus model resulted in a lack of student and faculty buy-in to the ipe curriculum on the regional campus. the lack of a specified ipe leadership position on the northwest regional campus created confusion, duplicated efforts, and limited open and transparent communication between the 2 campuses in regard to ipe requirements and effort. in response to these challenges, an ipe leadership team was developed that included the academic heads on the northwest regional campus, the director of student services, and representatives from the office of community health and research and the north street clinic. in addition to the leadership team, academic leaders on the campus requested the development of an ipe leadership position for the northwest campus to improve communication with the main campus and to develop an ipe program specific to the regional campus students. the position of associate director for ipe on the northwest campus was created and filled by an existing faculty member in spring 2017. the addition of the ipe leadership position on the northwest campus created a partnership between the main campus ipe office and the doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 perspectives regional campus ipe office. the following year, an ipe coordinator was added to the northwest regional campus staff to support the associate director of ipe for the regional campus and to coordinate learning events and tracking. this position ensures the students on the regional campus meet all ipe requirements to successfully graduate from uams. conclusion ipe is important in training the next generation of health care professionals. regional medical campus often have reduced ipe activities due to limited resources and their distance from their main campuses. however, regional campuses can also provide opportunities for innovative solutions to provide ipe learning experiences. uams northwest has created a thriving ipe program by creating innovative learning experiences to meet the needs of all healthcare students on the regional campus. references 1. world health organization: framework for action on interprofessional education and collaborative practice. geneva, who, 2010. available at: http://www.who.int/hrh/resources/framework_action/e n/. 2. center for the advancement of interprofessional education. (1997) interprofessional education: what, how, & when? file:///c:/users/butleraudra/downloads/caipe-bulletinno-13-1997.pdf 3. baldwin, d.c. jr., (1996). some historical notes on interdisciplinary and interprofessional education and practice in health care in the usa. journal of interprofessional care, 1996; 10(2): 173-187 4. institute of medicine. educating for the health team 5. catlin, ac, cowan, ca. (2015) history of health spending in the united states, 1960-2013. https://www.cms.gov/research-statistics-data-andsystems/statistics-trends-andreports/nationalhealthexpenddata/downloads/historic alnhepaper.pdf 6. davis, b. teaching the teachers: faculty development in inter-professional education 7. institute of medicine (us) committee on quality of health care in america; kohn lt, corrigan jm, donaldson ms, editors. to err is human: building a safer health system. washington (dc): national academies press (us); 2000. available from: https://www.ncbi.nlm.nih.gov/books/nbk225182/ doi: 10.17226/ 8. institute of medicine (us) crossing the quality chasm: a new health system for the 21st century. washington (dc): national academies press (us); 2001. 9. interprofessional education collaborative expert panel. core competencies for interprofessional collaborative practice: report of an expert panel. washington, d.c. https://www.aacom.org/docs/defaultsource/insideome/ccrpt05-10-11.pdf?sfvrsn=77937f97_2 10. alexandraki i, hernandez ca, torre dm, chretien kc. interprofessional education in the internal medicine clerkship post-lcme standard issuance: results of a national survey. j gen intern med. 2017;32(8):871–876. doi:10.1007/s11606-017-4004-3 11. liaison committee on medical education. functions and structure of a medical school: standards for accreditation of medical education programs leading to the m.d. degree. washington, dc: liaison committee on medical education; 2015. available at http://lcme.org/wpcontent/uploads/filebase/standards/2016-17_functionsand-structure_2016-09-20.docx. 12. commission on collegiate nursing education. standards for accreditation of baccalaureate and graduate nursing programs. washington, dc: commission on collegiate nursing education; 2013. available at http://www.aacn.nche.edu/ccneaccreditation/standards-amended-2013.pdf. 13. accreditation council for pharmacy education. accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. chicago, il: accreditation council for pharmacy education; 2015. available at https://www.acpeaccredit.org/pdf/standards2016final.pdf. 14. commission on accreditation in physical therapy education. standards and required elements for accreditation of physical therapist education programs. alexandria, va: american physical therapy association; 2015. available at http://www.capteonline.org/uploadedfiles/capteorg/abo ut_capte/resources/accreditation_handbook/capte_ptst andardsevidence.pdf 15. accreditation council for genetic counseling. standards of accreditation for graduate programs in genetic counseling. mclean, va: accreditation council for genetic counseling; 2013. available at https://www.gceducation.org/wpontent/uploads/2018/12/standards-final-approved-feb2013.pdf 16. accreditation council for genetic counseling. practicebased competencies for genetic couselors. mclean, va: accreditation council for genetic counseling; 2015. available at https://www.gceducation.org/wpcontent/uploads/2019/02/acgc-core-competenciesbrochure_15_web.pdf 17. association of american medical colleges. about the aamc. https://www.aamc.org/about. accessed may 6, 2019. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 perspectives 18. neil k and ward w. structure and implementation of a longitudinal triple aim-focused interprofessional curriculum. 19. ward, w, zagoloff a, reick, c, robiner, w. interprofessional education: opportunities and challenges for psychology. journal of clinical psychology in medical settings, 2018; 25:250–266. https://doi.org/10.1007/s10880-017-9538-3 20. institute for healthcare improvement (ihi). (2010). ihi triple aim initiative: better care for individuals, better health for populations, and lower per capita costs retrieved from http://www.ihi.org/engag e/initiative s/triple aim/pages /default.aspx. 21. interprofessional education-curriculum framework. uams office of ipe website. https://ipe.uams.edu/student-curriculum/ 22. ris standards 23. mcelfish pa, kohler p, smith c, et al. community-driven research agenda to reduce health disparities. clin transl sci. 2015;8(6):690–695. doi:10.1111/cts.12350 24. mcelfish, p. a., hudson, j., schulz, t., warmack, t., moore, r., purvis, r., dalke, m., & buron, b. (2017). developing an interprofessional student-led clinic to address health disparities in a pacific islander migrant community. journal of student-run clinics, 3(1). retrieved from https://journalsrc.org/index.php/jsrc/article/view/41 microsoft word attendingaregionalmedicalcampusarticle.docx published by university of minnesota libraries publishing does attending a regional medical campus influence the training outcomes of family medicine residents? komal kochhar, laurie m. fancher, james j. brokaw, peter m. nalin doi: https://doi.org/10.24926/jrmc.v2i1.1997 journal of regional medical campuses, vol. 2, issue 2 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc komal kochhar; office of research in medical education, dean’s office for educational affairs, indiana university school of medicine, indianapolis, indiana laurie m. fancher; office of research in medical education, dean’s office for educational affairs, indiana university school of medicine, indianapolis, indiana james j. brokaw; department of anatomy and cell biology, indiana university school of medicine, indianapolis, indiana peter m. nalin; medical sciences program, indiana university school of medicine, bloomington, indiana all work in jrmc is licensed under cc by-nc volume 1, issue 6 (2019) journal of regional medical campuses original reports does attending a regional medical campus influence the training outcomes of family medicine residents? komal kochhar, laurie m. fancher, james j. brokaw, peter m. nalin abstract introduction: indiana university school of medicine (iusm) is the largest medical school in the nation, with its main campus located in indianapolis and 8 regional medical campuses (rmc) distributed across the state. in this study, we compared the survey responses of family medicine residents who had attended medical school at the main campus in indianapolis versus an rmc to see if there were any noticeable differences in their residency training outcomes. methods: from 2012 to 2017, in the spring of each year, a cross-sectional survey was administered to all final-year family medicine residents graduating from the 11 family medicine residency programs in indiana. a total of 519 out of 520 residents completed the survey. of whom, 132 respondents indicated they had graduated from iusm; 45 reported they had attended the indianapolis campus and 87 had attended one of the rmcs in the state. our dataset for this study was comprised of these 132 respondents. chisquare test or fisher’s exact test were used to compare responses between groups. p-values ≤ 0.05 were considered statistically significant. results: in the acgme competency areas, the residents who attended an rmc versus the indianapolis campus were significantly more likely to report being fully competent in medical knowledge (90% vs. 76%, p = 0.032) and systems-based practice (83% vs. 64%, p = 0.019). additionally, the residents who attended an rmc compared to their indianapolis counterparts reported significantly higher rates of being trained to serve rural populations (73% vs. 52%, p = 0.017) as well as being fully competent to serve rural populations (69% vs. 42%, p = 0.003). however, the residents who attended an rmc were not more likely to establish a practice in a rural area than were the residents who attended indianapolis (18% vs. 17%, p = 0.845). conclusions: based on these self-reported data, the family medicine residents who attended an rmc may perceive themselves to be better-prepared in a few core competency areas and in serving rural populations, compared to those who attended the indianapolis campus. these findings suggest that iusm’s complex statewide system of medical education may offer some unique advantages in preparing students for residency, especially in family medicine. introduction the indiana university school of medicine (iusm) employs a large geographically distributed system of medical education, with approximately 1450 students enrolled across 8 regional medical campuses (rmcs) and the main medical campus at indianapolis. iusm currently admits 364 students per year and the majority (62%) are assigned to rmcs located at bloomington, evansville, fort wayne, gary, muncie, south bend, terre haute, and west lafayette (fig. 1). the remainder of the class matriculates at indianapolis. the rmc students complete their basic science years one and two onsite. they may also complete all or some of their third and fourth-year clinical rotations at the rmc, or they may opt to complete their clinical rotations at indianapolis. by virtue of their locations, the rmcs produce graduates who are wellattuned to the local health care needs of the community. in fact, these graduates often return to the rmc region to practice medicine.1 previous studies of iusm’s statewide system have assessed the influence of rmcs with regard to specialty choice and practice location.1-3 however, it is during residency that medical school graduates hone their professional skills to become independent practitioners of their chosen specialty.4 yet, the residency training outcomes of iusm graduates have never been fully evaluated in the context of our statewide system. the particular educational experiences these graduates had as medical students, and the kinds of patients they encountered, will undoubtedly impact their preparation for residency and early career plans. previous studies have shown that graduates who attended an rmc are disproportionately influenced to pursue primary care careers in local communities similar to their hometowns.1-2 this suggests that many rmc graduates enter residency training already predisposed in some ways that are fundamentally different from their indianapolis counterparts, and this predisposition may manifest itself in the training outcomes at the end of residency. thus, given the rmc’s doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports orientation to primary care and community-based practice, we conducted an exploratory study to determine whether residents who attended an rmc have noticeably different training outcomes compared to those who attended the indianapolis campus. to address this question, we evaluated the responses obtained from a statewide exit survey of all finalyear family medicine residents who completed residency training in indiana from 2012 to 2017. after excluding the non-iusm graduates, we compared the responses of the iusm graduates who attended an rmc versus indianapolis and noted a few key differences in residency training outcomes that may be related to differences in the campus environments. methods the indiana family medicine residencies exit survey© is a cross-sectional survey administered in the spring of each year to all final-year family medicine residents graduating from the 11 family medicine residency programs in indiana (fig. 1). residents are asked to provide their demographic information, educational debt, an assessment of their residency training program, and their plans after graduation. for those planning to enter clinical practice directly after graduation, information is requested about the practice setting, its specific location, the main reason why it was chosen, and the residents’ expectations for first-year income. in addition, residents are asked to self-report their perceived competence in each of the six accreditation council for graduate medical education (acgme) core competencies5 and their perceived competence in providing care for underserved and rural populations (rating scale: fully – partially – not at all). in the period from 2012 to 2017, the exit survey was administered to a total of 520 residents graduating from the 11 family medicine residency programs across the state. all but one resident (519) completed the survey, yielding a response rate of nearly 100%. this high response rate was achieved by administering the paper-and-pencil survey in group settings at each residency site during pre-arranged visits scheduled with the local program coordinators. residents who were absent during the group-administered session were contacted and given the opportunity to complete the survey and return it by mail. of the 519 respondents, 132 were graduates of iusm, as determined by a survey question asking them to identify their medical school location. following which, the iusm graduates were asked to indicate their campus assignment. of the 132 respondents, 45 had been assigned to the indianapolis campus and 87 had been assigned to one of the rmcs. this constituted the dataset for our analysis. in those instances where respondents provided an address for their practice location, we noted whether it fell within a primary care health professional shortage area (hpsa), a medically underserved area (mua), or a rural area. the health resources and services administration defines hpsas as geographic areas and populations with health care provider shortages in primary care, dental care, or mental health; and muas are defined as geographic areas with inadequate access to primary care services.6 although several eligibility criteria are used in defining hpsas and muas, the population to provider ratio is especially important in both designations. there are currently 30 geographic primary care hpsas and 45 muas in indiana.6 the federal office of rural health policy defines rural areas to include non-metro counties and rural census tracks.7 according to the 2010 census, approximately 38% of indiana’s population live in counties designated as either rural or a rural/urban mix.8 data analysis was performed using statistical software, ibm spss statistics v24. mapping software, arcgis 10.5, was used to measure distances from residency sites to practice locations. the chi-square test or fisher’s exact test were used to compare responses between groups. p-values ≤ 0.05 were considered statistically significant. effect size measures of cramer’s v or phi were reported for all significant findings. the number of cases in each statistical analysis varied slightly because of missing data elements for certain questions. this study was granted exempt approval from the indiana university institutional review board. results table 1 displays the demographic characteristics of the 132 iusm graduates who responded to the survey. residents who attended an rmc were somewhat younger (p = 0.012, cramer’s v = 0.260) and more likely to be white (p = 0.028, phi = 0.192) than those who attended the indianapolis doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports campus, but the proportion of males and females in the two groups was nearly identical. over 90% of the residents in both groups were native to indiana. educational debt was similar across both groups, with about half of all residents owing at least $200k. the proportion of residents who planned to enter clinical practice immediately after residency was similar for both groups (80.5% for those who attended an rmc and 75.0% for those who attended indianapolis, p = 0.768). as shown in table 2, the residents who attended an rmc had somewhat different perceptions of clinical competence compared to their indianapolis counterparts. with regard to the acgme core competencies, the proportion of residents who reported being fully competent in medical knowledge was significantly greater for those who attended an rmc than for those who attended indianapolis (89.7% versus 75.6%, p = 0.032, phi = -0.186). similarly, residents who attended an rmc reported being fully competent in systems-based practice at a higher rate than those who attended indianapolis (82.8% versus 64.4%, p = 0.019, phi = -0.205). no significant differences were noted for the other core competencies. with regard to patient care for special populations, 100% of residents in both groups reported that they received training to care for underserved populations, and both groups reported being fully competent to care for underserved populations by similar proportions (93.1% for those who attended an rmc and 86.7% for those who attended indianapolis, p = 0.337). however, significant differences were noted between the two groups regarding rural populations. compared to their indianapolis counterparts, the residents who attended an rmc reported significantly higher rates of being trained to serve rural populations (73.3% versus 52.3%, p = 0.017, phi = 0.210) as well as being fully competent to serve rural populations (69.0% versus 42.2%, p = 0.003, phi = 0.292). table 3 shows the intended practice outcomes of the 103 residents who planned to enter clinical practice directly after completing residency. about two-thirds of these residents chose hospital-based settings in indiana for their first practice location, unaffected by whether they attended an rmc or indianapolis (69.8% versus 60%, p = 0.497). the proportion of residents practicing in areas designated as either underserved (hpsa or mua) or rural was unaffected by what campus they attended. about two-thirds (67.8%) of all residents chose practice locations within 50 miles of where they completed residency. although salary was an important consideration in selecting their first practice location (it was rated fourth), the residents appeared to give priority to interpersonal and family relationships in making their decision. for example, “liked the people” was the reason selected by 75.7% of the residents who attended an rmc and by 72.7% of those who attended indianapolis (p = 0.745). expected income in the first-year was similar across both groups, with over half of all residents expecting to earn $200k or more. discussion this study explored the question of whether attending an rmc during medical school influences the training outcomes of family medicine residents. by examining the responses obtained from a statewide exit survey of all final-year family medicine residents in indiana, we found that the residents who attended an rmc reported significantly higher rates of doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports being “fully competent” in certain acgme core competencies and in their ability to care for rural patients compared to the residents who attended the indianapolis campus. in all other aspects, the training outcomes of the two groups were comparable. these findings suggest that iusm’s complex statewide system of medical education may confer some unique advantages in preparing students for residency, particularly in family medicine. according to iusm’s match data and recent trends, about 11% of each graduating class will match into family medicine. we chose to examine family medicine residents, as opposed to residents in other specialties, primarily because the family medicine exit survey collected information about the campus assignment of iusm graduates, which enabled us to distinguish the responses of those who had attended an rmc from those who had attended indianapolis. the survey solicits information specifically relevant to family medicine, so our findings cannot be extrapolated beyond this primary care specialty. it still remains an open question whether rmc attendance has any impact on the residency training outcomes of iusm graduates pursuing other specialties. iusm responded to the perceived physician shortage of the late 1960s by establishing 8 rmcs at strategic locations around the state in the hope that they would serve as incubators for primary care physicians who would eventually return to those communities to practice medicine. there is some evidence that this strategy was effective. by analyzing a large dataset of iusm graduates from the classes of 19881997, researchers found that students who attended the rmcs were statistically more likely to practice primary care medicine in local communities compared to students who attended the indianapolis campus.1,2 however, in the ensuing 20-30 years since these graduates completed residency and settled into practice, the rmcs have evolved considerably and are no longer limited to pre-clinical education as they now offer third and fourth year clerkships as well. a more recent study of iusm graduates from the classes of 2011 to 2017 found that rmc students entered primary care fields in about the same proportions as indianapolis students, suggesting that the training environments of the rmcs and indianapolis are sufficiently alike to engender similar career paths for the students.3 the one exception is the terre haute rmc, which produces proportionally more family physicians than any other iusm campus, but that is largely due to its special rural medical education program, which emphasizes primary care.3 nevertheless, it remains fair to say that students attending the rmcs are probably exposed to more primary care medicine than students attending the indianapolis campus, which is an academic medical center emphasizing specialty care. the residents in this study graduated from iusm between 2009 and 2014 and then entered one of the 11 family medicine residency programs in indiana. as might be expected, the demographic characteristics of the residents who attended an rmc versus indianapolis were for the most part similar. the observed difference in the racial/ethnic composition of the two groups is probably a consequence of the campus assignment process at iusm which, for a variety of reasons, tends to favor the placement of underrepresented minority students at the indianapolis campus.1 however, there is no obvious explanation for the apparent age difference between the two groups. perhaps the residents who attended indianapolis were somewhat older when they started their residency compared to those who attended an rmc. the reason this should be so is not clear. it is possible that indianapolis has more dual-degree students (e.g., md-mba) who would require a longer time to graduate. the level of educational debt reported by the residents in this study is fairly consistent with previous research. in a recent cross-sectional survey of 6,229 family medicine residents seeking american board of family medicine certification, 60.1% of the respondents had more than $150 000 of debt and 28.5% had more than $250 000 of debt.9 the most interesting observations in this study relate to residents’ perceptions of their own clinical competence. compared to the residents who attended indianapolis, those who attended an rmc appear to rate themselves more highly in two of the acgme core competencies, medical knowledge and system-based practice. according to the acgme common program requirements10, medical knowledge is defined as “knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care” and systemsbased practice is defined as “awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.” it is important to point out that the residents reported their perceived competence in these two domains, which is not the same as an objective measure of their actual competence. however, as noted by lurie et al.11, objectively measuring the acgme core competencies independently of one another is exceedingly difficult. we have only the residents’ subjective self-assessments of their clinical competence, which are likely to be inaccurate.12 nevertheless, our data suggest that something in the collective educational experiences of the residents who attended an rmc may have promoted a stronger sense of competence in medical knowledge and systems-based practice compared to those who attended indianapolis. the formal curriculum is unlikely to be responsible because it is essentially the same at all iusm campuses. perhaps the residents who attended an rmc were nurtured to be less self-critical than their indianapolis counterparts, who were immersed in the more competitive environment of an academic medical center. further studies with a larger sample are needed to confirm these preliminary results and identify the specific factors responsible. the observed difference in the residents’ perceived competence to care for rural patients may be more easily doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports explained. each rmc has its own unique training environment, characterized in part by its network of connections with the local clinical community and patient population. given the rmcs’ placement in smaller communities, it is reasonable to assume that, on average, the rmc students would be more likely to encounter rural patients compared to the indianapolis students who would be more likely to see patients from the surrounding metro area. these early clinical experiences may shape the residents’ perceived competence in serving rural patients throughout their residency training. this is consistent with previous research showing positive associations between rural training experiences during medical school and a variety of outcome measures, including high student satisfaction, improved clinical skills, and choice of rural practice locations.13 however, despite their greater perceived competence in serving rural patients, the residents who attended an rmc are no more likely to actually practice in a rural area than are the residents who attended indianapolis, nor are they any more likely to practice in an underserved community more broadly (i.e., hpsa or mua). this finding is an agreement with an earlier study of iusm graduates showing that the rmcs and indianapolis produce graduates practicing in underserved areas in about the same proportions.3 in fact, all of the residents’ practice outcomes are remarkably similar, regardless of which campus they attended. after completing residency, the ‘typical’ family physician will remain in indiana to practice in a hospital-based setting located within 50 miles of the residency site, which conforms to the well-established observation that first practice locations are often found in close proximity to the residency sites.14 the practice location will be chosen primarily on the basis of interpersonal and family relationships with an expected income of at least $150k in their first year of practice. limitations the relatively small sample size of 132 family medicine residents necessarily limits the study’s statistical rigor and obscures trends that might otherwise be apparent with a larger study population. for example, the contribution of individual rmcs to the overall study results cannot be properly evaluated due to the small number of residents from each rmc. however, with a larger sample, the survey responses of residents from individual rmcs could be statistically compared to determine whether some rmcs are more influential than others. moreover, the residency training itself could be confounding our results. over the three-year training program, residents will experience a variety of clinical encounters that will shape their skills as physicians, apart from whatever influence rmc attendance may have. perhaps the observed differences in perceived clinical competence have less to do with rmc attendance and more to do with differences in the training at the various residency sites. with a larger sample, a multivariate study could be devised to control for this potential confounding effect. another limitation stems from the fact that the study population is restricted to family medicine residents, which excludes all of the iusm graduates who matched into other specialties. to what extent these residents are representative of iusm graduates completing residency programs in other specialties is not known. this represents a significant selection bias, which must temper any broader conclusions about the role of rmcs in residency preparation. the findings of this study are not generalizable to all residents, as they only have applicability to family medicine residency. lastly, as with all surveys, the data collected is selfreported and subject to recall bias. missing or inaccurate data elements are inevitable. as mentioned earlier, the clinical competence of residents is reported as a subjective selfassessment, not an objective measure of actual competence. conclusions residents who attended an rmc for medical school are at least as well-prepared for family medicine residency as are those who attended the indianapolis campus, and there is some evidence to suggest they may be more self-confident in certain areas of clinical competence, including the care of rural patients. however, attending an rmc appears to have little impact on the residents’ choice of practice location after residency. references 1. brokaw jj, mandzuk ca, wade me, deal dw, johnson mt, white gw, wilson js, zollinger tw. the influence of regional basic science campuses on medical students’ choice of specialty and practice location: a historical cohort study. bmc medical education 2009; 9:29. (https://doi.org/10.1186/1472-6920-9-29). 2. wade me, brokaw jj, zollinger tw, wilson js, springer jr, deal dw, white gw, barclay jc, holloway am. influence of hometown on family physicians’ choice to practice in rural settings. family medicine 2007; 39(4):248-254. 3. kochhar k, fancher lm, brokaw jj, wilson js, nalin pm. tracking medical students and graduates from hometown to practice using geographic information systems, 2011-2017. journal of regional medical campuses 2018; 1:3. (https://doi.org/10.24926/jrmc.v1i3.1136). 4. cooke m, irby dm, o’brien bc. the resident’s experience: graduate medical education. in: cooke m, irby dm, o’brien bc. educating physicians: a call doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports for reform of medical school and residency. san francisco, ca: jossey-bass; 2010. 5. new england journal of medicine knowledge plus team. exploring the acgme core competencies (part 1 of 7). (https://knowledgeplus.nejm.org/blog/exploringacgme-core-competencies/). published june 2, 2016. accessed january 21, 2019. 6. health resources and services administration. find shortage areas. (https://data.hrsa.gov/tools/shortage-area). accessed march 4, 2019. 7. health resources and services administration. federal office of rural health policy data files. (https://www.hrsa.gov/rural-health/aboutus/definition/datafiles.html). accessed march 4, 2019. 8. ayres j, waldorf b, mckendree m. defining rural indiana—the first step. (http://www.extension.purdue.edu/extmedia/ec/ec -766-w.pdf). published january, 2013. accessed march 4, 2019. 9. phillips jp, peterson le, fang b, kovar-gough i, phillips rl jr. debt and the emerging physician workforce: the relationship between educational debt and family medicine residents’ practice and fellowship intentions. academic medicine 2019; 94(2):267-273. doi:10.1097/acm.0000000000002468. 10. accreditation council for graduate medical education. common program requirements. (https://www.acgme.org/what-wedo/accreditation/common-program-requirements). revised february, 2017. accessed march 9, 2019. 11. lurie sj, mooney cj, lyness jm. measurement of the general competencies of the accreditation council for graduate medical education: a systematic review. academic medicine 2009; 84(3):301-309. doi:10.1097/acm.0b013e3181971f08. 12. davis da, mazmanian pe, fordis m, harrison rv, thorpe ke, perrier l. accuracy of physician selfassessment compared with observed measures of competence: a systematic review. journal of the american medical association 2006; 296(9):10941102. doi:10.1001/jama.296.9.1094 13. barrett fa, lipsky ms, lutfiyya mn. the impact of rural training experiences on medical students: a critical review. academic medicine 2011; 86(2):259263. doi:10.1097/acm.0b013e3182046387. 14. dorner fh, burr rm, tucker sl. the geographic relationships between physicians’ residency sites and the locations of their first practices. academic medicine 1991; 66(9):540-544. microsoft word integratingpointofcarearticle.docx published by university of minnesota libraries publishing integrating point of care ultrasound into medical clerkships in a statewide distributed campus model ann marie kuchinski doi: https://doi.org/10.24926/jrmc.v2i5.2190 journal of regional medical campuses, vol. 2, issue 5 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc ann marie kuchinski all work in jrmc is licensed under cc by-nc volume 2, issue 5 (2019) journal of regional medical campuses original reports integrating point of care ultrasound into medical clerkships in a statewide distributed campus model ann marie kuchinski abstract introduction: integration of point of care ultrasound (pocus) into clinical clerkships in a statewide campus is challenging. the objective of this paper was to describe the implementation and evaluation of a pocus curriculum that was added to emergency medicine (em) and obstetrics and gynecology (ob/gyn) core clinical rotations in a distributed campus undergraduate medical education (ume) model. the authors declared no conflicts of interest. the study was reviewed by the institutional irb and determined to be exempt. methods: this was a descriptive study of the implementation and evaluation of pocus into 2 clinical clerkships. in this paper, we describe the development of a grading rubric, educational design, and image transfer process used to evaluate student performance. results: implementation occurred in step-wise fashion. in the em clerkship between 2016 and 2018, 395 students participated with a 100% completion rate. in the 2017-2018 ob/gyn clerkship, 186 students completed the clerkship with all but one successfully completing the assignment. conclusion: this pilot project demonstrated the successful implementation of a pocus curriculum in 2 clinical clerkships in an ume distributed campus model. introduction point of care ultrasound, or pocus, is the use of ultrasound by a clinician to answer a specific clinical question at the patient’s bedside. this powerful tool aids clinicians in rapidly diagnosing emergency conditions, narrowing differential diagnosis, facilitating resuscitation, and guiding procedures.1,2 over the past decade, the use of pocus in clinical practice has increased dramatically and is now the standard of care in many instances including guidance of central venous access and assessment of free intraabdominal fluid in trauma patients with the focused assessment with sonography in trauma (fast) exam.2,3 the use of ultrasound as an educational tool in undergraduate medical education (ume) is also rapidly growing.4 many schools have integrated ultrasound into the pre-clinical years as an educational tool for teaching anatomy, physiology, and the physical exam.5,6,7 however, fewer medical schools have successfully included ultrasound training into the clinical years.8,9 the association of american medical colleges (aamc) curriculum inventory data shows that in 2015-2016, 101 medical schools offered an integrated ultrasound curriculum; however, the majority of these institutions only offered “relevant content in the first 2 academic years”.10 integrating ultrasound into the clinical years of ume is important for the long-term integration of ultrasound skills into clinical practice. skills that are learned in the first 2 years of medical education wane when not used regularly.2 further, integration of pocus exams into clinical rotations teaches students how to integrate diagnostic imaging skills with patient treatment and management plans. while developing proficiency with any new skill requires sufficient opportunity to practice the procedure as well as quality instruction and feedback, certain scans can be learned successfully within a discreet time frame, increasing the feasibility of pocus training during a standard six-week clinical rotation.11,12 for example, kobal et al. demonstrated that after completing a brief training in cardiac ultrasound, medical students were able to correctly diagnose 75% of cardiac pathologies among 61 patients with known cardiac disease.11 krause et al. showed that after completing one hour of training on the fast exam, third-year medical students were able to increase the accuracy and speed in which they identified and interpreted image results.12 these results show that when provided training and access to practice clinical ultrasound, ume students can successfully learn and apply these skills to patient care. however, integrating ultrasound into the clinical years of ume is not without challenges. barriers to implementing an ultrasound curriculum into the clinical years of ume include: cost of equipment, lack of ultrasound-trained faculty, and limitations on ultrasound use by non-radiology faculty.9, 13 these challenges are magnified for medical schools that have large classes distributed across multiple campuses that use hospitals and clinical sites over a wide geographic area for clinical rotations (a distributed campus model).14, 15 larger institutions, specifically, face the unique challenge of implementing an equivalent educational experience (as required by the liaison committee on medical education or lcme) when there is large variation in ultrasound resources and faculty with ultrasound-expertise across clinical rotation sites. the objective of this paper was to describe the implementation and evaluation of integrating an ultrasound curriculum into emergency medicine (em) and obstetrics and gynecology (ob/gyn) core clinical rotations in a distributed campus ume model. journal of regional medical campuses, vol. 2, issue 5 original reports methods/implementation the medical school described in this paper has 240 ume students annually who train at 5 campuses and more than 200 clinical sites across the state (a distributed campus model). each campus has a dean who coordinates with regional hospitals, clinical practice sites, and physicians to establish clinical clerkship sites. a site director at each hospital, clinic, or physician office is responsible for providing students with adequate resources to provide a standardized educational experience equivalent to all other clinical sites. all sites within each clerkship specialty area share a common clerkship director and are guided by the same goals and objectives. in addition, all sites use a standardized format for each rotation including weekly quizzes, didactic sessions, and a comprehensive student evaluation process. didactic sessions are conducted by the clerkship director via teleconferencing, allowing all students to have a uniform educational experience. this research was determined exempt by the institution’s institutional review board (irb) under health and human services exempt category 1. as part of this project and of standard educational practice, students obtained consent from patients prior to obtaining and transmitting images. during the consenting process students inform patients that the exam is not for diagnosis, but is only being obtained for educational purposes. however, if concerning medical issues were found by a student, the physician in charge ensured that appropriate followup was scheduled for the patient. the integration of pocus into the initial clerkship clinical rotation started with a pilot year (figure 1) where the ultrasound-based objectives were not part of the students’ grades. this was to ensure that any issues with the program could be identified and corrected prior to their impact on students’ grades. at the start of the second year, when we were certain any issues had been resolved, the ultrasoundbased objectives became part of the students’ grade for the rotation. the students were instructed to complete the fast exam and the third trimester ultrasound exam for the em and ob/gyn clerkships respectively. students had previously received didactic training in both the fast exam and the third trimester us exam as part of the physical diagnosis modules during their first 2 years of ume. figure 1. implementation timeline. emergency medicine clerkship: during the 2016-2017 and 2017-2018 academic years, 14 hospitals were used as sites for ume student em clinical rotations. prior to implementation of pocus training in the emergency medicine clerkship (emc), we surveyed each hospital as to the availability and accessibility of ultrasound in their emergency department (ed). two of the 14 hospitals were found to lack an easily accessible ultrasound within the ed for student use. in order to provide parallel learning experiences for all students, the university loaned these 2 sites a siemens p10 hand held ultrasound system. each site reported having at least one clinical faculty member who had training in how to perform the fast exam. in the 2016-2017 academic year, the pilot year of ultrasoundbased curriculum in the emc, our focus was on the fast exam. students were instructed to obtain at least one fast exam on a patient evaluated during clinical duties. during weekly half-day (4 hour) videoconferences students were presented clinical vignettes with both normal and abnormal fast exams incorporated. students were encouraged to engage in group discussion about image interpretation and how findings could be integrated into patient care. prior to and during the pilot year, 70% of the student’s final grade was derived from their clinical duty, as assessed by faculty evaluations and feedback, 20% of their grade was derived from the national board of medical educators (nbme) end of clerkship test, 5% from weekly quizzes, and 5% from required online asynchronous assignments. after the pilot year, the ultrasound-based objectives were included in their grade, accounting for 5% of the overall emc grade and the clinical grade percentage was reduced from 70% to 65%. ob/gyn clerkship: based on the implementation in the emc, the ob/gyn clerkship integration began without a pilot year in the 2017-2018 academic year. there were 18 private practice sites used for the ob/gyn clerkship, all of which had adequate ultrasound equipment available for students to use. each site had at least one clinical faculty member who was trained in the third trimester pocus exam (defined in the objective of the rotation), which includes finding fetal heart tones, measuring fetal heart tones on m-mode, identifying fetal presentation (either cephalic or breech depending on orientation of the fetus), and identifying placental location. during weekly video conference, similar to the emc, students were presented ultrasound-based case scenarios to aid with the clinical integration and image interpretation component of the pocus curriculum. also, similar to the emc, the ultrasound-based objective was 5% of the overall grade for the clerkship while 50% came from clinical assessment, 35% from the nbme clerkship test, 6% from quizzes, and 5% from ob/gyn history and physicals (h &ps). ultrasound image evaluation: ultrasound images were transferred electronically to a learning management system by students and scored by a single sonographer, employed by the medical school, using a standardized rubric for each exam (see figure 2 and figure 3). prior to the end of the clerkship journal of regional medical campuses, vol. 2, issue 5 original reports students were provided both the score from the grading rubric along with written comments on performance and suggestions on improvement. students who did not complete the ultrasound component received an incomplete for the clerkship until the assignment was completed (including in the em pilot year). since there was no standardized method for electronically transferring the images, as a wide-variety of ultrasound equipment was used throughout the sites, students were encouraged to use smart phones to take a picture of the ultrasound with no patient identifiers included. students also had the option of extracting and transmitting de-identified jpeg images directly from the ultrasound machines. no patient identifiers or histories were included with the images. submitted images were evaluated based solely on image optimization and adequacy and not for pathology or diagnosis. if concerning medical issues were found by the student, the physician in charge ensured that appropriate followup was scheduled for the patient. all students received pocus performance feedback via several methods. students received direct feedback on image acquisition while performing the examinations on patients from faculty (physician, resident-physician, or sonographer) at each clinical site. the transmitted images were evaluated using a standardized grading rubric which was the same as that used during the physical diagnosis ultrasound assignments as part of the preclinical years of their medical education. this evaluation focused on image quality including appropriate labeling of organs, use of gain and depth, proper probe selection, and correct orientation (see grading rubrics figure 2 and figure 3). students were given written feedback to help improve their image acquisition skills. image interpretation and clinical integration were also evaluated during the weekly live videoconference. figure 2: phase 3 emed 5001 em clerkship fast ultrasound assessment rubric comments: figure 3: phase 3 obgn 5000 ob/gyn clerkship ob ultrasound assessment rubric comments: results during the 2 academic terms discussed in this paper (20162017 and 2017-2018) 581 students participated in the 2 clerkships. during the pilot year the exams were not graded and did not count toward the students’ grades. in the pilot year for the emc 139 students participated. despite many of the sites having preceptors that were unfamiliar with the fast exam and not accustomed to using it in clinical practice, students required to complete the fast exam had a 100% completion rate. starting in 2017-2018 images submitted by students were assessed according to a rubric specifically designed for each clerkship (figures 2 and 3). some of the students did not submit adequate images initially due to poor image acquisition, or failure to submit a complete exam. however, all successfully resubmitted adequate images prior to the end of their clerkships. the vast majority (all but 2) submitted their images via cell phone. the others submitted de-identified jpeg images directly from the ultrasound machine. during the 2017-2018 school year 256 students participated in the em clerkship. in total, 27 students did not complete the assignment. however, of these 27 students, 13 were on a 2week rotation and were not required to complete the assignment and 14 students dropped the course. of note, 4 students obtained images with the probe in the incorrect orientation and one student selected an inappropriate probe (linear probe) for the fast exam. therefore, 229 students turned in images to be assessed by the ultrasonographer. forty-one percent (95/229) students scored perfectly (100) on the assessment. fifteen percent (35/229) received an 87 on the assessment. of the remaining students, 25% (56/229) received an assessment score of between 60 and 79 while 19% (43/229) received a score of 50 or less. while image quality after transmission was an initial concern when developing the ultrasound curriculum, 100% of submitted journal of regional medical campuses, vol. 2, issue 5 original reports images were of adequate quality for grading purposes. no students were required to repeat the fast exam or re-submit images due to the inability to visualize the transmitted image. during the first year (2017-2018) of the ob/gyn ultrasound implementation, 186 students enrolled in the clerkship with all but one of these students ultimately completing the assignment successfully. students struggled more with ultrasound skills than with the process of turning in the assignment for grading. for example, 14 students did not label their images at all, 5 labeled their images incorrectly, 4 students did not include all relevant portions of the fetus in the image, and 2 did not provide all of the information for the assignment as per the instructions. none of the students were required to repeat the exam or resubmit images due to the inability to visualize the transmitted image. students in the ob/gyn clerkship were assessed based on a rubric designed for the ob pocus exam (figure 3). of the 186 students who submitted images for the ob/gyn clerkship, 73% (136/186) received a score of 100, 13% (25/186) received a score of 87, 4% (7/186) received a score of a 75, 3% (5/186) received a score of a 74, and the remaining 7% (13/186) students received a score of 50 or below. discussion many medical schools, both nationally and internationally, have begun to understand the value of incorporating pocus into students’ preclinical and clinical curricula; however, many continue to face barriers that limit its integration.16 prior publications such as the university of south carolina’s, the evolution of an integrated ultrasound curriculum (iusc) for medical students: 9-year experience, discuss the integration of ultrasound into medical student’s curricula.9 these examples, however, focus on the integration of ultrasound into a single campus system. many medical schools are comprised of multiple campuses and/or clinical sites, making a standard ultrasound curriculum difficult. moreover, multiple campuses and sites preclude the standardization of equipment and consistency in the pocusability and educational skills of clinical faculty. em and ob/gyn are ideal clerkships for the initial implementation of an integrated ultrasound curriculum because they inherently lack many of the barriers to ultrasound adoption in the clinical years of ume. first, most em physicians regardless of practice location are aware of pocus as it is part of the accreditation council for graduate medical education (acgme) curriculum for em residents. similarly, ultrasound is a critical component of antenatal health and documenting fetal development and plays a significant role in ob/gyn practice. therefore, em and ob/gyn faculty in both academic and community settings should have a working knowledge of how pocus can be used in clinical practice. second, many eds have ultrasound available for procedural guidance, particularly for central venous access.14 in addition, the necessity of ultrasound in the ob/gyn clinic guarantees accessibility for students and eases the burden of access for medical schools with a distributed campus. for the rare sites that do not have ultrasound equipment, medical schools can fill the void by providing small, portable ultrasound devices at a reasonable cost.17 for these reasons, em was chosen as the initial clerkship for ultrasound curriculum integration during the pilot year and, once feasibility was determined, was expanded to include the ob/gyn clerkship. while the barriers of faculty education and equipment can be overcome in most circumstances, the presence of an ultrasound education champion is optimal for success. enthusiasm for the program, from the clerkship director down through the clinical faculty, is also important. during the implementation of the ultrasound curriculum in the pilot year of the em clerkship several technical and educational barriers were encountered. first, many em sites did not use the fast exam as part of their clinical practice. in order to overcome this, we made available online didactic videos (transmitted via a learning management system) to provide background information to each student throughout the rotation. a fast module was also incorporated into the weekly educational half-day sessions where all students were connected to ultrasound faculty via teleconferencing video. ultrasound faculty are emergency medicine trained physicians credentialed to use pocus in clinical practice who have an interest in teaching ultrasound skills. these sessions included review of the important didactic components of the fast exam, of how to perform the exam, and of ultrasound videos with and without pathology. all students were able to complete a technically adequate fast exam at each location during their rotation during the initial project year. while we provided ultrasound-trained physicians for the didactic sessions and sonographers were available at the ob/gyn clinical sites, clinical site faculty often are not trained in pocus or in how to utilize ultrasound as a teaching tool. this is one of main barriers medical schools face when expanding ultrasound education from the pre-clinical years into the clinical years. clinical faculty participating in this project were provided online, recorded didactic training and were invited to participate in the academic half-day educational sessions. in addition, em and ob/gyn clerkships were selected specifically as the initial clerkships as their faculty, as a whole, have more experience with ultrasound. lastly, in this model, students are expected to perform pocus exams without direct faculty supervision. this is because students have been trained how to do these exams during the pre-clinical years. another barrier to implementation encountered in both em and ob/gyn was having a secure, standardized, method for transferring ultrasound images to the clerkship directors for evaluation and assessment. systems such as q-path can easily be used to electronically transfer images for review when students are at a single site or single campus, however, in a distributed campus model, this can be a problematic solution journal of regional medical campuses, vol. 2, issue 5 original reports to implement. each health system will have differing barriers such as the lack of wired or wireless connection, the need for licenses for using specific programming on the ultrasound machines, and other technical deficiencies. we found that the use of a learning management system, and cloud based storage ameliorated all transmission issues. in addition, students used their cell phones to capture and transmit anonymous images of the ultrasounds. there were no instances in which patient identifiers were accidentally included in these images. cost could be a barrier to integrating a new ultrasound curriculum into an ume curriculum because of the need to purchase technology and to upgrade to newer technology. two of the 14 sites used for the emc required a portable us be provided to them which did incur some (although arguably small) cost to the university. medical schools that house many sites without us equipment may find this to be a greater hardship; however, with the advent of new portable ultrasound technology, specifically the tablet-based ultrasound probes, this barrier will continue to decline. it is of note that none of the ob/gyn sites used for clerkships were found to lack an ultrasound machine, which eased much of the cost burden and logistical issues for implementing the ultrasound curriculum into this clerkship. conclusion as pocus continues to become a major part of clinical diagnosis it is important that training be extended to all phases of ume including clinical rotations. therefore, finding ways to effectively implement a pocus curriculum into the clinical years of ume is necessary. implementing an ultrasound curriculum into the pre-clinical years has been done in most medical schools. integration into clinical clerkships can be more difficult due to a variety of barriers that are even greater for schools with a distributed campus model. however, in this paper we have outlined and demonstrated the feasibility of integrating a pocus curriculum into 2 ume core clinical clerkships in a distributed campus model. as described above we encountered more barriers in one clerkship, em, than the other, ob/gyn, but the barriers were not insurmountable. minor difficulties such as lack of equipment, lack of standardization of equipment, and image transfer were overcome. this pilot project provides a starting point from which to implement a pocus curriculum over a ume distributed campus model. future efforts will include more qualitative data collection, such as assessments and student selfevaluations of ultrasound skills before and after their clerkships and student feedback specifically on the ultrasound component of the clerkships. this information may help improve the integration of pocus into future em and ob/gyn clerkships as well as be used to design and implement pocus into other clinical clerkships. references 1. moore cl, copel ja. (2011). point-of-care ultrasonography. n engl j med. 364: 749-757. doi: 10.1056/nejmra0909487. 2. abu-zidan fm. (2012). point-of-care ultrasound in critically ill patients: where do we stand? j emerg trauma shock. 5(1): 70-71. doi: 10.4103/09742700.93120. 3. sheng a, dalziel p, liteplo a, noble v. (2013). focused assessment with sonography in trauma and abdominal computer tomography utilization in adult trauma patients: trends over the last decade. emerg med int. 2013:678380. doi: 10.1155/2013/678380. 4. bahner dp, goldman e, way d, royall na, and liu yt. (2014). the state of ultrasound education in us medical schools: results of a national survey. acad med. 89(12): 1681-6. doi: 10.1097/acm.0000000000000414. 5. pawlina wojciech, and richard l drake. (2015). new (or not-so-new) tricks for old dogs: ultrasound imaging in anatomy laboratories. anat sci educ. 8(3):195-196. doi: 10.1002/ase.1533. 6. ivanusic j, cowie b, and barrington m. (2010). undergraduate student perceptions of the use of ultrasonography in the study of ‘living anatomy. anat sci educ. 3(6): 318-22. doi: 10.1002/ase.180. 7. rempell js, saldana f, disalvo d, kumar n, stone mb, chan w et al. (2016). pilot point-of-care ultrasound curriculum at harvard medical school: early experience. west j emerg med. 17(6):734-740. doi: 10.5811/westjem.2016.8.31387. 8. patel sg, benninger b, and mirjalili sa. (2017). integrating ultrasound into modern medical curricula. clin anat. 30(4): 452-460. doi: 10.1002/ca.22864. 9. hoppmann r, rao vv, bell f, poston mb, howe db, riffle s et al. (2015). the evolution of an integrated ultrasound curriculum (iusc) for medical students: 9year experience. crit ultrasound j. 7(1): 18. doi: 10.1186/s13089-015-0035-3. 10. suchard jeffrey r. ultrasound by academic level 2015-2016. aamc, mar. 2017, www.aamc.org/initiatives/cir/478058/ci10.html. 11. kobal s l, trento l, baharami s, tolstrup k, naqvi tz, cercek b et al. (2005). comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. am j cardiol. 96(6): 1002-1006. doi: 10.1016/j.amjcard.2005.05.060. 12. krause c, krause r, gomez n, jafry z, dinh va. (2017). effectiveness of a 1-hour extended focused assessment with sonography in trauma session in journal of regional medical campuses, vol. 2, issue 5 original reports the medical student surgery clerkship. j surg educ. 74(6): 968-974. doi:10.1016/j.jsurg.2017.03.007. 13. bahner dp and royall na. (2013). advanced ultrasound training for fourth-year medical students: a novel training program at the ohio state university college of medicine. acad med. 88(2): 206-213. doi: 10.1097/acm.0b013e31827c562d. 14. bahner dp, adkins ej, hughes d, barrie m, boulger ct and royall na. (2013). integrated medical school ultrasound: development of an ultrasound vertical curriculum. cri ultrasound j. 5(1):6. doi: 10.1186/2036-7902-5-6. 15. ray jj, meizoso jp, hart v, horkan d, behrens v, rao ka et al. (2017). effectiveness of a perioperative transthoracic ultrasound training program for students and residents. j surg educ. 74(5): 805-810. doi: 10.1016/j.jsurg.2017.02.005. 16. amini r, wyman mt, hernandez nc, guisto ja, adhikari s. (2017). use of emergency ultrasound in arizona community emergency departments. j ultrasound med. 36(5): 913-921. doi: 10.7863/ultra.16.05064. 17. rao s, van holsbeeck l, musial jl, parker a, bouffard ja, bridge p, jackson m, dulchavsky sa. (2008). a pilot study of comprehensive ultrasound education at the wayne state university school of medicine: a pioneer year review. j ultrasound med. 27(5): 745749. doi: 10.7863/jum.2008.27.5.745. microsoft word buildingarurallicarticle.docx published by university of minnesota libraries publishing building a rural lic in an accelerated curriculum: hubs, spokes, flat tires, and hovercraft jacob prunuske md, msph; heather roth; ellen m. schumann, md, ms; lisa dodson, md z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc jacob prunuske md, msph; assistant dean for clinical learning, associate professor of family & community medicine, medical college of wisconsin – central wisconsin; jprunuske@mcw.edu heather roth; education program manager, medical college of wisconsin – central wisconsin; hroth@mcw.edu ellen m. schumann, md, ms; central wisconsin integrated clerkship director, medical college of wisconsin – central wisconsin; eschumann@mcw.edu lisa dodson, md; campus dean, professor of family & community medicine, medical college of wisconsin – central wisconsin; ldodson@mcw.edu all work in jrmc is licensed under cc by-nc volume 2, issue 3 (2019) journal of regional medical campuses abstract building a rural lic in an accelerated curriculum: hubs, spokes, flat tires, and hovercraft jacob prunuske md, msph; heather roth; ellen m. schumann, md, ms; lisa dodson, md topic: across the country there are geographic maldistributions of physicians. many regional campuses have a mission to meet local workforce needs. regional campuses must balance comparability with the institution’s main campus curriculum with sufficient innovation to meet the regional campus mission. clinical training in a rural environment has many challenges, including limited access to specialty physicians, a greater proportion of health care delivered in the outpatient setting, lower patient volumes, fewer preceptors, increased travel time, and communication challenges for academic and administrative aspects of clinical experiences. the medical college of wisconsin – central wisconsin (mcw-cw) offers an accelerated curriculum that allows progression from matriculation to graduation in 3 years, includes a 4-year option, and has a distributed model for clinical training. in this session, we presented the challenges of development and implementation of a rural longitudinal integrated curriculum at an accelerated regional campus, described how these challenges are being addressed, and discussed future plans and implications for other institutions. short description: across the country there are geographic maldistributions of physicians. many regional campuses have a mission to meet local workforce needs. regional campuses must balance comparability with the institution’s main campus curriculum with sufficient innovation to meet the regional campus mission. clinical training in a rural environment has many challenges, including limited access to specialty physicians, a greater proportion of health care delivered in the outpatient setting, lower patient volumes, fewer preceptors, increased travel time, and communication challenges for academic and administrative aspects of clinical experiences. the medical college of wisconsin – central wisconsin (mcw-cw) offers an accelerated curriculum that allows progression from matriculation to graduation in 3 years, includes a 4-year option, and has a distributed model for clinical training. in this session, we presented the challenges of development and implementation of a rural longitudinal integrated curriculum at an accelerated regional campus, described how these challenges are being addressed, and discussed future plans and implications for other institutions. four questions that were posed to/considered by session participants: 1) what unique challenges are associated with an accelerated curriculum? 2) what are common challenges of clinical training in rural settings? 3) what are the advantages and disadvantages of a longitudinal integrated clerkship in an accelerated curriculum? 4) how might other institutions benefit from lessons learned in creating a rural longitudinal integrated clerkship in the context of an accelerated curriculum? three take home points from our session: 1) developing, nurturing, and sustaining relationships at all levels between campus and community partners, preceptors, institutions, and communities is essential. 2) each training site is unique, and schools should seek to identify and respond to local needs and take advantage of local strengths. 3) flexibility in scheduling and an emphasis on competency achievement, rather than time, helps ensure comparable educational experiences across sites microsoft word an invitation to walk a mile article.docx published by university of minnesota libraries publishing an invitation to walk a mile in their shoes: a rural immersion experience for college pre-medical students carli p. whittington, md. c.p., william j. crump, md., r. steve fricker, m.p.a. doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 1, issue 5 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc carli p. whittington, md. c.p., transitional year resident, kettering medical center and participated in the college rural scholar program from 2011-2013. william j. crump, md., associate dean. university of louisville school of medicine trover campus at baptist health madisonville. r. steve fricker, m.p.a., director of rural health/student affairs, university of louisville school of medicine trover campus at baptist health madisonville. corresponding author: william j. crump, md, university of louisville school of medicine trover campus at baptist health madisonville, 200 clinic drive, 3rd north, madisonville, ky 42431, v: 270.824.3515, e: bill.crump@bhsi.com all work in jrmc is licensed under cc by-nc volume 1, issue 5 (2019) journal of regional medical campuses original reports an invitation to walk a mile in their shoes: a rural immersion experience for college premedical students carli p. whittington, md. c.p., william j. crump, md., r. steve fricker, m.p.a. abstract purpose to report the outcomes of the first 15 years of an entirely rurally-based college-level program, based at a regional campus, designed to enhance rural students’ understanding of rural health and reinforce their potential affinity for rural practice. method choice of career, practice site, and evaluation results were collected from 80 program participants for the period 2003-2017. anonymous preand post-survey data were analyzed using the wilcoxon mann-whitney tests to compare survey results of students’ opinions of the importance of understanding traditional medical and social items when choosing a treatment option for very rural patients. results the authors found no statistically significant difference between preand postsurvey measures of opinions of traditional medical items. however, six of the nine social items showed a statistically significant increase (p <.05). the importance for a physician to understand social factors increased in post-test results for items of faith/spirituality, who prepares the patient’s meals, health beliefs held by the patient, the kind of work the patient does, how ready the patient is to make changes, and where the patient lives. evaluations were positive and comments supported that the goals were accomplished. of those completing each stage of training, 83% chose some health career, 58% chose medical school, 31% chose family medicine, and 66% chose primary care. of those establishing medical practice, 50% chose a rural site. conclusions rurally-based programs may reinforce college students’ rural affinity, promoting the likelihood of completion of medical school and subsequent rural practice choice. funding/support: none. human subjects: this study was determined exempt by the baptist health madisonville institutional review board. conflicts of interest: none the problem of unequal distribution of physicians in the united states continues to contribute to access issues for the 20% of americans who live in rural areas. after completing residency, the majority of physicians preferentially choose non-rural practice sites for a variety of reasons.1,2,3 even with recent increases in medical school class size, the disparity of urban versus rural physicians will only continue to widen unless a different approach is taken.2,4,5,6 doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 5 original reports introduction the rural affinity model supports that students who are from rural areas who remain connected to their rural background during training in non-urban settings are more likely to choose a rural practice site.3,5,7,8,9 there are a small number of successful college rural pipeline programs in the united states.10,11,12,13,14,15,16,17 these programs recruit undergraduate rural students who meet minimum academic requirements and then provide exposure to rural practice and some offer academic preparation to promote success in the classroom. while all provide some rural experience, they are usually based in the host university town which range in population from 100,000 to 200,000 and are focused on intermittent individual role modelling with a rural physician mentor and some field experiences. in this article, we report the outcomes of the first 15 years of the college rural scholar (crs) program, which takes place each summer on the university of louisville school of medicine trover campus. the 3-4 week clinical experience is in small towns of 600 to 3,000 population with about 40% time spent in team-based group assignments in madisonville (population 20,000), the host town of the rural trover campus in western kentucky. the students are housed together in madisonville with a shared commons area. program description the crs program is a 3-4 week program that includes college students nominated by their college pre-med advisors who must meet specific criteria: (a) be a graduate of a high school in a town with a population under 30,000 in a nonmetropolitan county, (b) show a substantial interest in a rural medical career, and (c) obtain at least a 24 score on the act and at least a 3.0 college gpa. applicants provide two letters of reference from college professors and submit an essay describing the role of the rural physician. there are typically about twice as many applicants as available positions, and preference is given to residents of western kentucky. beginning in 2003, the early years of the program had 3-4 students per year and then subsequently stabilized at 8-10 per year. the selection committee includes the members of the rural campus-based medical school admissions selection committee, the medical school associate dean of admissions and the director of admissions as well as the senior associate dean for undergraduate medical education. selected students who excel in the crs program are nominated for early assurance admission and subsequently interview at the urban campus as early as their sophomore year of college. students selected for early assurance must only meet minimum mcat and gpa criteria and complete all pre-medical course requirements to be assured of medical school admission after completing their senior year of college. this acceptance also assures them a position at the rural campus for their last two years of medical school. goals of program the crs program goals are shown in table 1. these goals are accomplished by immersing participants in activities focused on rural practice, all in a rural setting. didactics include rural health issues specific to the region such as coal mining, financing of rural hospitals and health departments, rural physicians’ practice models, rural interdisciplinary medical teams, and community health development. participants shadow local rural primary care physicians and assist with free school and sports physical examinations for kindergarten and sixth grade patients in very rural counties. their role is to develop a script of customizable anticipatory guidance to be used as they work with each individual screened as well as to find available teaching props that will provide hands on learning opportunities for the schoolchildren screened.18 crs meet with local residents described as key informants to discuss the current health resources available in their county. a final report is compiled by the students and presented at the end of the three to four weeks which summarizes the community information gleaned over the course of the program. table 1. university of louisville school of medicine trover campus college rural scholar program summary doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 5 original reports a case study of a patient who presents with fatigue and swelling is discussed using the iterative process of problem solving19 and the students work in small groups led by preclinical medical students to develop a diagnostic process where the history, physical, lab, and imaging results are progressively revealed during twice weekly sessions facilitated by the regional campus dean (wjc). in the concluding session, the large group of students formulates an individualized treatment plan for the patient in the case study. this same individual (wjc) facilitates a once weekly large group session called “friday morning reflections” that is focused on explaining choices made by the patients seen by the students from the previous week. the biopsychosocial model is used to promote the concept that a more thorough understanding of the details of the patients’ lives leads to choice of treatment options that are most likely to be successful in these patients from very rural environments. we report here data collected over 15 years from 80 college students who participated in the crs program. our focus was on outcomes measured by specialty and practice site choice and also a detailed view of the process of opinion change during this rural immersion. methods beginning in 2009, students completed an anonymous survey at the initial orientation session asking them to provide their opinions on how important some traditional medical items and some social issues are in choosing a treatment option. the initial survey items were developed by informal focus groups in the early years of the program by tabulating student responses to the invitation to report what they saw that surprised them in the week previous. as new themes emerged, they would be added to the list of questions on the survey in the following year. there was also an item asking their degree of agreement with a statement that they are comfortable planning and implementing a community health project. the same survey was administered on the closing day of the program. the social items were interspersed among the medical items, and the social issue questions changed across the years. complete pre-post data were not available for 2011 and 2013. also at the closing session, students completed an anonymous detailed evaluation where they rated how well each activity accomplished the program goals and separately indicated their enjoyment of each. we defined a rating of 7 and above as positive numerical feedback, using a 10 point scale from 1 = strongly disagree to 10 = strongly agree. the crs program coordinator tracked subsequent student career choice and residence through social media and digital communications. using this process, only one of the 80 students could not be located after training was completed. residence was coded as rural if the town was not in a metropolitan county and was population less than 30,000. survey results were entered into microsoft excel version 2010 (microsoft, redmond, wa) and then to spss version 25.0 (ibm corp, armonk, ny) for analysis. mann-whitney u was used to compare differences between preand post-test results. a p value < 0.05 was set for statistical significance. the baptist health madisonville institutional review board determined this study exempt. results there were no statistically significant differences on traditional medical items, with these items ranked as important both before and after the program (table 2). table 2. college rural scholars treatment survey, pre and post-test results, medical items a2009, 2010, 2012, 2014-2017 b2009, 2010, 2012, 2014 of the nine social items (table 3), six showed a significant change, all in the direction of more important. the item concerning prayer almost reached significance, and was one of the items that had a smaller sample size because it was added later in the process to try to understand the spirituality item better. health benefits and ethnic background did not show a significant change, and were also later-added items. table 3. college rural scholars treatment survey, pre and post-test results, social items doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 5 original reports a2009, 2010, 2012, 2014-2017 b2015-2017 c2014-2017 d2009, 2010, 2012, 2014 the students were significantly more in agreement with a higher comfort level with planning and implementing a community health project after the program as shown in table 4. table 4. college rural scholars survey, pre and post-test results, community planning a2014-2017 students reported that case studies was the most effective component in achieving the goals at 98.5% (131/133 responses), followed by free school physicals 97.2% (172/177 responses), shadowing physicians 93.9% (200/213 responses), and group discussion sessions 85.3% (424/497 responses). comparison of summed scores for each session/topic compared to previous years showed less than 5% variation from year to year. themes in student written comments are exemplified by those shown in table 5. table 5. college rural scholars summative evaluation, “what part of the program did you like the most?” to date, 64 participants in the crs program have completed college and 16 are currently in college. of the 64 crs students who have finished college, 53/64 (83%) have pursued a career in the health care field. this includes 37/64 students (58%) who chose medical school. of the 26 crs students who have completed medical school, 8/26 (31%) are in family medicine, 6/26 (23%) are in pediatrics/internal medicine/combined medicine-pediatrics, 3/26 (12%) are in obstetrics-gynecology, and 9/26 (35%) are in other specialties (emergency medicine, plastic surgery, dermatology, general surgery, neurology, radiology, psychiatry research). of the 26 crs medical school graduates, 14 have successfully completed their residency training and chosen a practice site and 7/14 (50%) chose a rural practice site. of crs who chose other health careers, 4/16 (25%) chose a rural location, and 3/11 (27%) of those choosing a non-health career chose a rural location. discussion strategies for addressing the maldistribution of physicians have included admissions efforts to include more rural students in medical school as well as rural tracks within medical school and residencies.5 others have reported positive results of brief rural immersion efforts of urbanbased medical students which comprise a much larger potential pool for future rural physicians.20 in most regions, without focused programs as early as high school, the pool of doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 5 original reports competitive rural students for admission to medical school is just too small to make a difference.21 the few established college programs in the u.s. have been successful, but the pipeline is very long. as in our report here, college programs occur 7 years before specialty choice and 10-15 years prior to first practice site choice. in addition to traditional didactic and individual mentoring efforts, our approach has been a bit broader, with a clear intent for these students to understand how rural patients make healthcare choices. it might seem that rural students would already understand this importance, but their opinions prior to the program supports that they had not considered this issue. perhaps already affected by the culture of their college town or broader popular culture, the non-scientific aspects that are part of everyday life did not seem important to understand when, as future doctors, they were to make treatment decisions. the comments on evaluations support that this realization came in the group discussions of their common experiences in the very small communities. although the “friday morning reflections” provided an organized forum for these discussions, it was clear that the students had already begun these discussions among themselves without a faculty facilitator. while our focus was on rural experiences, it seems likely that this repetitive process of immersion followed by group discussion would provide students a deeper understanding of any subculture. because the rural affinity model suggests that students from rural areas who remain connected to their rural roots throughout training will be more likely to choose a rural practice site, targeted college programs should help increase the number of physicians who choose a rural practice site. our initial proportion of 50% choosing rural sites is encouraging, and comparable to those of other similar programs. with time for more of our crs students to choose practice sites, it is possible that our broader rural immersion approach may even result in a higher proportion choosing a rural location. it is also interesting that the students who initially sought medical school but then moved to other careers chose a rural residence at only half the proportion (25% and 27%, respectively). we have previously shown in a subset of crs students that those who opted out of medicine were those who placed a higher priority on prestige and physician salaries when they made the initial decision to choose premed.4 it is possible that the crs program laid bare the practicalities of rural health and those who stayed with it embraced these challenges. survey limitations the responses to the postsurvey could have been skewed by a form of social acceptability bias, as the group facilitator and other faculty may have shown support for the importance of considering social issues in assessing patient adherence to treatment plans, but the anonymity of the survey should have minimized that effect. as these students began their identity development as future rural physicians, it would be natural for them to begin to agree with their role models, and thus their responses could be considered a lasting change rather than a transient survey bias. another possible limitation is that the individual student interpretation of the meaning of the words in the survey was something other than that intended. this was most apparent in the term “health benefits” which the authors intended to mean differences in out of pocket cost for medical care during the upheaval in the individual insurance market. since the cost to the patient for two options may differ, a caring physician might consider this when making recommendations between two roughly equally effective treatment options. however, in discussion with crs who had completed the post-survey, it became clear that some students interpreted this wording to mean that a patient who is underinsured might not be offered some options, and the experience of the program did not change their ambivalence about this. the other variation about meaning of the survey words was in the importance of understanding the ethnic background of the patient. some students agreed that this was an important nuance in choosing treatment options that the patient would embrace, but others in discussions after the post-survey saw this as a potential racial bias, potentially not offering all options to all ethnicities. future clarification of the survey wording could address these issues. program limitations the outcomes of the crs with regard to primary care residency and rural practice choice are very positive, in keeping with reports from other similar programs. however, another potential limitation is that it could be rural upbringing, and not the program itself, that is responsible for these outcomes. however, in a multiple logistic regression analysis in a population very similar to the crs, we found the value of our rural campus experience most significant. among 1120 graduates of both our urban and rural campuses, rural upbringing showed an odds ratio of 2.67 (1.58-4.52) of association with subsequent rural practice choice. family medicine residency choice showed an odds ratio of 5.08 (2.88-8.98) for rural practice choice, and training at our rural campus showed an odds ratio of 5.46 (2.61-11.42), all p<.001 when controlling for the other factors.9 to determine whether the brief crs rural immersion is as powerful as 2 years at our rural campus in affecting choice of subsequent rural practice will require further longitudinal study. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 5 original reports another potential limitation on the value of small, intensive programs like the crs is their ability to produce only a small number of future rural physicians. with this issue, small numbers matter, however. in our region of kentucky where almost two thirds of counties are classified as health professional shortage areas (more than 3500 population per primary care doctor), most of these counties would be removed from that classification if 1-2 primary care doctors located there.22 and retention is of the utmost importance, and students who make a practice choice based on good preparation are more likely to stay long term.23 conclusion the effectiveness of the crs program to broaden student opinions and the high percentage of crs graduates who choose rural practice could be cause to support development of more such rural programs, and continued support for those few in existence currently. the rural affinity model predicts that students coming from rural backgrounds are more likely to choose a rural practice site if they continue to maintain their rural connection throughout their training. if this rural connection is strengthened earlier in the academic pipeline during college, then the hope is that more students who complete programs like crs will choose to practice in non-urban settings and thus increase the number of rural physicians. references 1. geyman jp, hart gh, norris te, coombs jb, lishner dm. educating generalist physicians for rural practice: how are we doing? j rural health. 2000;16(1):56-80. 2. whitcomb me. the challenge of providing doctors for rural america. acad med. 2005;80:715-716. 3. brooks rg, walsh m, mardon re, lewis m, clawson a. the roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of the literature. acad med. 2002;77(8):790-798. 4. crump, wj, fricker, rs, crump am. just what are rural pre-medical students thinking?: a report of the first 6 years of a pathways program. journal of rural health. january 2010;26(1):97-99. doi: 10.1111/j.17480361.2009.00257.x. 5. rabinowitz hk, diamond jj, markham fw, wortman jr. medical school programs to increase the rural physician supply: a systematic review and projected impact of widespread replication. acad med. 2008;83:235-243. doi: 10.1097/acm.0b013e318163789b. 6. looney sw, blondell rd, gagel jr, pentecost mw. which medical school applicants will become generalists or rural-based physicians? j ky med assoc. 1998;96(5):189193. 7. crandall la, dwyer jw, duncan rp. recruitment and retention of rural physicians: issues for the 1990s. j rural health. 1990;6(1):19-38. 8. 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http://www.kumc.edu/school-ofmedicine/education/premedical-programs/scholars-inrural-health.html. september 2, 2018. 13. university of missouri health school of medicine lester r. bryant scholars pre-admissions program. https://medicine.missouri.edu/admissions/bryantscholars-pre-admissions-program. accessed september 2, 2018. 14. university of mississippi medical center mississippi rural physicians scholarship program. https://www.umc.edu/mrpsp/. accessed september 2, 2018. 15. university of alabama school of medicine at birmingham, tuscaloosa rural medical scholars program. https://cchs.ua.edu/ruralprograms/rural-medicalscholars/. accessed september 2, 2018. 16. university of alabama school of medicine at birmingham, huntsville rural pre-medical internship. https://www.uab.edu/medicine/home/ruralmedicine/huntsville-rural-pre-medical-internship. accessed september 2, 2018. 17. university of louisville school of medicine trover campus college rural scholar program. https://www.baptisthealth.com/madisonville/pages/abo ut-baptist-health/education/university-of-louisvilleschool-of-medicine-trover-campus/college-rural-scholarprogram.aspx. accessed september 2, 2018. 18. crump wj, fisher sm, fricker rs. community service as learning laboratory: a report of six years of a rural community-academic partnership. journal of the kentucky medical association. 2014; 122: 131-136. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 5 original reports 19. kassirer jp. teaching clinical reasoning: case-based and coached. academic medicine 2010; 85(7):1118-24. 20. crump am, jeter k, mullins s, shadoan a, ziegler c, crump wj. rural medicine realities: the impact of immersion on urban-based medical students. journal of rural health. 2017 may 2. doi: 10.1111/jrh.12244. [epub ahead of print]. 21. crump wj, fricker rs, flick, kf, gerwe-wickham k, greenwell, k, willen kl. a rural pathways program for high school students: reinforcing a sense of place. family medicine. 2014; 46(9): 713-717. 22. crump wj, fricker rs. keeping rural medical students connected to their roots: a “home for the holidays” immersion experience. marshall journal of medicine. 2016; 2(1):8 jm.2016.vol2.iss1.8. doi: dx.doi.org/10.18590/m 23. rabinowitz hk, diamond jj, markham fw, rabinowitz c. long-term retention of graduates from a program to increase the supply of rural family physicians. acad med. 2005 aug;80(8):728-32. microsoft word ultrasoundcurriculumarticle.docx published by university of minnesota libraries publishing ultrasound curriculum integration review and a survey of its utility in regional medical campuses ashley fankhauser, morgan kessler, cathy mccarty, amy greminger doi: https://doi.org/10.24926/jrmc.v4i4x.3925 journal of regional medical campuses, vol. 4, issue 4 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc ashley fankhauser morgan kessler cathy mccarty amy greminger all work in jrmc is licensed under cc by-nc volume 4, issue 4 (2021) journal of regional medical campuses original reports ultrasound curriculum integration review and a survey of its utility in regional medical campuses ashley fankhauser, morgan kessler, cathy mccarty, amy greminger abstract ultrasonography is a common technique used to visualize anatomic structures for diagnosis and to guide procedures. as the technology becomes more portable and affordable, schools have increasingly utilized this technology in training physicians. ultrasonography may be especially useful in rural settings to fill the limitations that rural hospitals have in terms of imaging. the mission of many regional medical campuses is to train physicians to work in rural or underserved communities. given this goal, we wanted to explore how regional medical campuses are utilizing ultrasound preclinically and determine the best approach for developing a standardized ultrasound curriculum, keeping regional medical campus resources in mind. a literature review of medical schools’ preclinical ultrasound curriculum was completed, and information was collected regarding curriculum programming, faculty, assessment, and student feedback. based on data from this search, a 14 question qualtrics survey was sent out to regional medical campuses with questions regarding the use of ultrasound in their own preclinical curriculum. of the 11 campuses that responded, 10 (90.9%) indicated that they include ultrasound in their curriculum. respondents from 9 of these schools progressed through the survey and information regarding topics covered in ultrasound curriculum, teachers of curriculum, patients used, ultrasound equipment used, and assessment of student knowledge all varied among medical campuses. the data suggested that regional medical campuses are focusing on similar aspects of ultrasound curriculum, however a standardized curriculum does not currently exist to ensure that all students are receiving similar ultrasound training. introduction the use of ultrasound has been increasing since 1956 due to the ability to perform quick evaluations and procedures at the bedside, with increased training and technological advantages.31 some research has stated that ultrasound should be considered the “visual stethoscope of the 21st century” due to the ease at which physicians can supplement their physical examinations with ultrasound imaging.10 more recently, ultrasound has become topical in medical school curriculum as medical educators have started to incorporate this rapidly growing technology into preclinical education. many experts believe that ultrasound will be increasingly important in student careers.21 while ultrasonography undoubtedly has the ability to improve patient care everywhere, there is no doubt that this technology is particularly important in rural and underserved areas that may not have access to more expensive technology.31 within rural, smaller emergency departments there is often less access to ct and high-slice scanners, and mris.11 with the emergence of point of care ultrasound and its increased affordability, the health care system can elevate the level of care that can be provided in rural emergency room and primary care settings. as we begin to see the benefits that ultrasound may have to offer within the rural settings, we must also recognize the importance of ultrasound implementation at the campuses that are producing the highest number of rural physicians.17 exposing medical students to ultrasound in the preclinical years equips them with foundational knowledge as they move on in clerkships, residencies, and as practicing physicians. in one study it was determined that 62.2% of medical schools in the united states integrate ultrasound in the first or second year of medical school.2 ultrasound has been shown in multiple studies to drastically increase the knowledge of students in identifying anatomical structures.1,4,16 ultrasound training during the gross anatomy course led to faster interpretation of ultrasound anatomical images. 13 this fast journal of regional medical campuses, vol. 4, issue 4 original reports interpretation of anatomical structures using ultrasound could be linked to a broader and more indepth understanding of the anatomy using imaging to link 2d pictures from books and lecture slides with a 3d picture online. ultrasound has also been used as an extension of physical examination skills.20 the research on this topic varies as some studies show that integration of insonation with the other core principles of physical examination skill teaching (observation, auscultation, palpation, and percussion) have increased students’ physical exam techniques while other studies have indicated that adding insonation to physical exam might increase the cognitive load to where students aren’t retaining important material. compared to students without any undergraduate ultrasound training, integration of insonation led to better scores and performance on a year-end osce that included a comprehensive physical examination of a patient supplemented with ultrasound examination of many body systems including lymph nodes, thyroid, lung, and cardiac anatomy.6 similar studies indicate that teaching medical students to use handheld ultrasound increases traditional physical examination skills while improving diagnostic accuracy,13,18 although there is still debate on this in the literature.14 although ultrasound is a promising modality for teaching use in medical schools, there are still many challenges associated with the use of ultrasound in both regional medical schools as well as all medical schools. these challenges include lack of space in current curriculum, increased cognitive load for students, access to expensive equipment, and trained faculty.2,3 specific problems for regional medical campuses could include lack of access to sufficient equipment and lack of faculty experience with this modality.4 the probability of incidental findings when using peers as models is a concern for many schools that may push schools toward using standardized patients,26 and the expense of using standardized patients may be a barrier to expanding ultrasound teaching. despite the amount of research and interest that is being done to introduce ultrasound into undergraduate medical education, training in medical schools is variable regarding both the use in preclinical years as well as longitudinally across all 4 years without any national standards or guidelines.29 the american academy of emergency medicine released a statement that ultrasound should be integrated into the core curriculum of undergraduate medical education.28 in the future, we hope to see the development of further curricular standards that can guide the teaching of ultrasound to future physicians. the goal of our research was to compare different regional medical campuses' ultrasound curriculum to each other using a survey as well as comparing them to a literature review that looks more closely at what medical schools across the united states are doing to teach their students ultrasound. we aimed to use this information to seek a better understanding of what a broader ultrasound curriculum should look like in a regional medical campus and develop a comprehensive list of standards for early ultrasound exposure while guiding best practices for medical education. methods literature review a literature review was conducted with the help of the university of minnesota health sciences librarians using the search database ovid medline. the keywords used in this search included “ultrasound”, “curriculum or curricula or training or teaching”, “preclinical or year 1 or year 2 or foundational or undergraduate”, and “medical school”. this yielded a total of 149 results. no limitations on the year of publication were applied. from there, rayyan qcri was used to narrow the articles based on exclusion criteria. papers that were kept were based on the following criteria: 1. the main subject was ultrasound curriculum for medical students. 2. the medical school research came from within the united states. 3. the article’s focus was on preclinical curriculum (years 1 or 2). if there was discussion of a longitudinal program covering years 1 through 4 the article was included. 4. the research either discussed implementation or review of ultrasound curriculum. 5. the article had a focus on improving anatomy or physical exam skills as a whole through ultrasound inclusion in the curriculum. if a procedure was included in a curriculum with other more general anatomy the article was included. papers were excluded based on the following criteria: journal of regional medical campuses, vol. 4, issue 4 original reports 1. articles written in a language other than english were excluded. 2. articles that discussed the creation of an ultrasound elective were excluded. 3. articles with information regarding ultrasound curriculum in years 3 and 4 of medical school only were excluded. 4. articles that focused on a workshop or experimental ultrasound sessions were excluded. 5. articles focusing on specific ultrasound assisted procedures (such as central line) or only focused on specific anatomical regions were excluded. 6. articles that compared the use of ultrasound to cadavers or arthroscopy were excluded. using these criteria, 17 articles were included for review as relevant to discussing ultrasound curriculum in medical schools and what it can be used for. additional sources were then reviewed and selected using google scholar and the university of minnesota libraries. secondary references were added from this process due to their relevance in discussing the importance of understanding and using ultrasound and in rural medicine. fourteen additional articles were included using this process to supplement our additional knowledge of ultrasound. ultrasound curriculum directors at both the university of minnesota twin cities medical school and the university of minnesota duluth medical school were contacted over email regarding what the ultrasound curriculum specifically entails on each campus within the first 2 years of medical school. survey an anonymous online survey was created by the authors and formatted in qualtrics software. the link to the survey was sent out via the university of minnesota medical school duluth regional campus dean to other regional medical schools through the aamc group on regional medical campuses (grmc) listserv. this listserv contains 415 different regional medical campuses across the us. the survey consisted of 14 questions, which are listed at the end of this article. the first 3 questions were used to determine what campuses the surveys were coming from and if those campuses included medical students years 1 through 4 or a different combination. the last question was optional and was a way for those who were interested in the survey results to receive a summary. all other questions were required and were available depending on previous answer selections. to maximize the response rate, questions were kept simple and were in the format of multiple choice, select all that apply, and free response. participants were given 10 days to respond to the survey. the institutional review board at the university of minnesota reviewed the study design, and the study was determined to be exempt. survey participants an invitation to participate in the survey was sent to the listserv for the aamc group on regional medical campuses. no specific schools were targeted. the survey included 8 questions regarding ultrasound curriculum that was estimated to take about 10 minutes to complete. medical schools receiving the survey were asked to reply in 10 days. results table 1. literature review journal of regional medical campuses, vol. 4, issue 4 original reports the findings from the literature review are summarized in table 1. three major topics that were identified within the literature review were: what was being taught at each school in the preclinical medical education years, who the instructor was for the ultrasound curriculum, and how students were being assessed on this curriculum. the content of many of the ultrasound curriculums were primarily introductions to ultrasonography and then anatomy sessions that were supplemented by ultrasound. common anatomical regions that were focused on included cardiovascular, abdominal, thorax, musculoskeletal, head/neck, urinary, and some vasculature. many schools incorporated the teaching of the fast exam for second year medical students as well. less commonly, ultrasound guided procedures and diagnostic ultrasound were taught to second year medical students. the nature of these curricular sessions was a combination of bedside ultrasound sessions, lectures regarding ultrasound material, use of ultrasound within the anatomy laboratory, webbased learning modules, and short videos describing ultrasound scanning assignments.8 after reviewing much of the literature, it is notable that many medical schools use ultrasound as a way to supplement their anatomy courses and allow students to delve deeper into a further understanding of anatomy by viewing it on an ultrasound machine. it was less common for diagnostic ultrasound or ultrasound guided procedures to be taught within the preclinical years. teaching anatomy using small ultraportable ultrasound machines has shown to be successful in helping medical students’ study as they have the ability to use the machine at their own leisure and to study at their own pace.4,13 each campus also greatly varied in who taught their ultrasound curriculum. faculty with prior experience in ultrasound, emergency medicine physicians trained in point of care ultrasound, various faculty members, anatomy professors, physicians and residents from a variety of specialties, fourth-year medical students, and peer teachers were all listed as those who were responsible for teaching the ultrasound curriculum. professionals from radiology and emergency medicine departments seem to be the most common contributors in ultrasound curriculum.23 many schools had separate training sessions for physicians, faculty, and anatomy professors alike. instructors of the ultrasound curriculum varied widely throughout each school in order to fit their needs. across other regional medical campuses, it is also common to use faculty and clinicians except for a few who use third and/or fourth year students. the last topic that was focused on within the literature review was how schools were assessing student knowledge. many campuses reported no assessments of ultrasound material or skills whatsoever. those schools that did assess students used osces, physical examination skills with journal of regional medical campuses, vol. 4, issue 4 original reports ultrasound, questions on multiple choice exams, and evaluation in real time by faculty. many schools graded their students solely based on their attendance and participation, placing more emphasis on using ultrasound as a learning tool for anatomy, rather than assessment of competency. survey table 2. survey responses we received responses from 11 regional medical campuses within the united states (response rate of 11/415). of the respondents, 9 (81.8%) indicated their institution educates years 1 through 4, one (9.1%) years 3 and 4 only, and 1 (9.1%) years 2 and four. out of those 11 schools, 10 (90.9%) reported that they used ultrasound within their curriculum and 1 (9.1%) reported that they did not use ultrasound. one of the 10 institutions that indicated they used ultrasound in their curriculum did not continue through the rest of the survey, so the following data are based on 9 total schools. ultrasound has been included in preclinical (years 1 and 2) curriculum for less than 6 years for all the responding institutions, with 2 (22.2%) schools indicating the presence of ultrasound for 2 years, 3 (33.3%) schools for 3 years, 2 (22.2%) schools for 4 years, and 2 (22.2%) schools for 5 years (table 2). within these 9 regional medical campuses over half the schools (5/9 [55.6%]) taught ultrasound for 0 to10 hours during years 1 and 2. the 4 remaining schools taught ultrasound curriculum for 11 to 20 hours (1/9 [11.1%]), 21 to 30 hours (1/9[11.1%]), 31 to 40 hours (1/9[11/1%]), and 40+ hours (1/9[11.1%]) (table 3). information included in the preclinical ultrasound curriculum varied between the regional medical campuses. however, all the institutions included cardiac and abdominal anatomy within their curriculum and 8 (88.9%) indicated that lung anatomy and physical exam skills were included. a further breakdown of topics included within the curriculums can be seen in table 4. out of the 9 schools completing the survey, 4 campuses (44.4%) indicated that their ultrasound is unique to their specific campus. three campuses (33.3%) indicated that their ultrasound is identical to an ultrasound curriculum at a different campus within their institution. two campuses (22.2%) selected “other”, indicating both that the curriculum was only currently offered at one of their campuses and another campus indicating that the curriculum was structured from a main campus curriculum and changed to meet the individual needs of that campus. as indicated in table 5, four campuses (44.4%) used anatomists to teach ultrasound, 6 (66.77%) used clinicians, 2 (22.2%) used peer teaching, 7 (77.7%) used faculty members, 3 (33.3%) used third and fourth years medical students, and 2 (22.2%) selected the “other” box indicating the use of local radiologists and an ultrasonographer as well. journal of regional medical campuses, vol. 4, issue 4 original reports patients used in the teaching of ultrasound within each campus are reported in table 6. seven campuses (77.7%) indicated the use of medical students as the patients, 0 (0.0%) indicated that they used other health care profession students, 4 (44.4%) indicated the use of volunteer patients, 5 (55.5%) used paid patients, and 2 (22.2%) selected the use of “other” individuals. types of ultrasound equipment used at each campus were reported as either ultra-portable devices (such as ipad, pocket sized machines, etc.) or larger ultrasound machines (table 7). eight campuses (88.9%) indicated the use of ultra-portable devices, while 2 campuses (22.9%) indicated the use of larger ultrasound machines. lastly, data regarding the assessment of student satisfaction and success in ultrasound curriculum was gathered (table 8). eight campuses (88.9%) indicated the use of student surveys, 1 (11.1%) indicated the use of faculty surveys, 3 (33.9%) indicate the use of multiple choice questions on exams, 3 (33.3%) indicated assessments performed on simulators, and 3 (33.3%) indicated the “other” category. the answers indicated within the other category indicated the use of informal feedback, assessment in simulated patient cases, and a final fast exam. no significance values were included for any data because our sample size was too small. table 4. summary of guidelines for ultrasound curriculum using information from our survey, guidelines were compiled together into table 4 to summarize what was discovered to be the most used methods of instruction in ultrasound curriculum. discussion while there is variability in the ultrasound curriculum throughout medical schools in the united states, our survey of regional medical campuses and overall literature review found some similarities that guide our recommendations for a standardized ultrasound curriculum. we recommend starting undergraduate medical education with a module containing background information on ultrasound such as knobology, probe specifics, and the basic physics. this type of curriculum is used by most regional medical campuses within our survey and would ensure that students have a general understanding of the machine to move on to more cognitively demanding modules such as anatomical understanding of ultrasound.14 we also recommend that a standardized ultrasound curriculum for medical school focus on modules within anatomy, specifically, cardiac, abdominal, lung, head/neck, and musculoskeletal, specific areas that are already being implemented by most of the regional medical campuses within our survey and were highlighted as important topics throughout our literature review. different approaches to integrating ultrasound certainly exist but given that the evidence was strongest for aligning ultrasound skills with anatomy, that is an approach we would recommend taking at this time.16 these skills could be critical in helping integrate ultrasound into routine physical examination to create a better understanding of the clinical presentation,1,6 but evidence around aligning ultrasound modules with clinical exam in the preclinical years is currently more mixed. the mode of delivery was something that greatly varied between schools. variations in who taught the ultrasound curriculum, patients used, and equipment used made for differences in curriculum between schools that best fit their own goals. as stated above, trained faculty or local physicians, anatomists, and other students have all been utilized for delivering curriculum.15, 27 medical student involvement in ultrasound curriculum teaching can help to enhance leadership skills and provide more opportunities for feedback on ultrasound curriculum.5, 9 after reviewing results both from the literature review and the survey journal of regional medical campuses, vol. 4, issue 4 original reports regarding the best instructor for ultrasound curriculum, either faculty physicians or physicians from local hospitals with special training in ultrasound provide for the best experience and learning environments for students. while trained faculty may be a preferred option, they are by no means the only option. this is excellent news for regional campuses that may have fewer faculty, as it empowers regional campuses to seek alternative creative solutions for delivering this curriculum. deciding who to use as patients for ultrasound training can be challenging. having medical students scan each other is the most used method amongst students surveyed, which does prove to have many benefits. finding volunteer or paid patients can be difficult and allowing medical students to scan each other can allow each student to have more time with the ultrasound equipment and visualizing structures, which may lead to better retention of knowledge.22 however, the issue of privacy and discovering pathology unknown by the medical student can lead schools away from this. volunteer and paid patients are preferred in this regard because they are anonymous to the students. at this time, our data does not suggest that one method is better than the other as each method has advantages and disadvantages, and the flexibility of different methods may be helpful at a regional medical campus. we do suggest that if students are scanning each other, faculty discuss the possibility of discovering something unknown, emphasize that this is being done for anatomical rather than diagnostic purposes, and give students the opportunity to opt out if they are uncomfortable, much as they would if a standardized patient was engaged in teaching.26 the most common piece of equipment used by schools for ultrasound scanning is ultra-portable devices (ipad, pocket sized, etc.). these devices can allow ease of movement when scanning and might be preferable in providing each student their own ultraportable machine that they can use on their own time as well as in the presence of an instructor. the ultraportable devices are also much less expensive than the larger ultrasound machines and may offer more flexibility within curriculum if renting the machines and scheduling proves to be difficult. in summary, our research would suggest that schools would have good results with both smaller and larger machines and should have the freedom to explore which machines make the most sense for them. the literature review and survey results noted that few schools assessed their students based on the knowledge obtained within the ultrasound session. instead, they were often graded solely on attendance and participation and success of the sessions were based on surveys of student satisfaction. while this approach has merit, we would encourage schools to consider more objective assessments, such as assessing student performance in simulation or osces, or multiple-choice exams. formal assessment of this material may instill a sense of importance of the material to the students through providing points based on understanding of the material.19 medical school curriculums are crowded, and implementing a hands-on approach, may mean that other material needs to be left out. as such, as this field grows it is critical to understand what outcomes this type of education achieves. we recognize that this is a challenge but feel that this first step of learning is fundamental to prepare students for the next stages and eventual future scope of practice that their career will encompass. a focus on residencies perceptions of student preparedness could be another opportunity for future assessment and research to further understand the implications of early ultrasound teaching during years 1 and 2 of medical school. limitations limitations within this study include the limited response rate from regional medical campuses. more responses for our survey could have given us a better idea of exactly what other regional medical campuses are doing for their ultrasound curriculum. in the future, it could be possible to engage similar campuses in more targeted surveys where we identify and contact campuses directly, rather than rely on a survey. despite this limitation, our literature review did give us a knowledge base regarding how ultrasound curriculum is conducted in medical schools across the united states. this knowledge base not only helped us shape the survey, but it also complemented and supplemented the results, allowing us to draw additional conclusions. another limitation of our work is that as intended, it speaks most to preclinical outcomes, and does not consider clinical outcomes. as point of care ultrasonography journal of regional medical campuses, vol. 4, issue 4 original reports gains popularity, undoubtedly this will be part of the clinical future for many physicians—future studies could look at clinical skills more explicitly. additionally, currently the evidence is strongest when ultrasound is used to supplement anatomy knowledge. further ultrasound research could be focused on whether ultrasound should be used to supplement physical examination skills or how curriculum could be tailored to serve rural or underserved communities.7 finally, selection bias is a potential in study like this which uses survey data. there is a potential that only schools who do use ultrasound in their preclinical curriculum responded to the survey and this would skew the results that we received. conclusions the results of the literature review and survey data suggest that many medical schools, regional and main campuses, contain similar aspects within their ultrasound curriculum. however, a standardized approach with specific modules as outlined above might be helpful to ensure schools provide similar training.2, 23 the literature also would suggest an inclusion of anatomical ultrasound would be important to a standardized curriculum required by medical schools. when creating a standardized approach to ultrasound curriculum in medical schools it is important to consider that regional medical campuses may not have the same access and funding as their main campus counterpart.22 at the main campus of many medical schools, their proximity to multiple hospitals offers access to a wide variety of local clinicians. however, their regional counterpart has less available clinicians. finding time in a busy medical school curriculum is also a limitation for all medical schools, but this may be compounded with slight variations in curriculum that are already in place for regional medical campuses.30 these aspects make implementing and maintaining an ultrasound program at regional campuses more difficult than their main campuses, but as noted above, programs have solved these issues by being creative with their use of models, equipment, and facilitators. we are excited to see how the benefits of teaching students at regional medical campuses preclinical ultrasound skills can benefit future patients in their practices, which are often in underserved areas. section header text goes here. references 1. afonso n, amponsah d, yang j, et al. adding new tools to the black bag--introduction of ultrasound into the physical diagnosis course. j gen intern med. 2010;25(11):1248-1252. doi:10.1007/s11606-010-1451-5 2. bahner dp, goldman e, way d, royall na, liu yt. the state of ultrasound education in u.s. medical schools: results of a national survey. acad med. 2014;89(12):1681-1686. doi:10.1097/acm.0000000000000414 3. blackstock u, carmody k. transforming learning anatomy: basics of ultrasound lecture and abdominal ultrasound anatomy hands-on session. mededportal publ. 2016;12(101714390):10446. doi:10.15766/mep_2374-8265.10446 4. brown b, adhikari s, marx j, lander l, todd gl. introduction of ultrasound into gross anatomy curriculum: perceptions of medical students. j emerg med. 2012;43(6):1098-1102. doi:10.1016/j.jemermed.2012.01.041 5. chiem at, soucy z, dinh va, et al. integration of ultrasound in undergraduate medical education at the california medical schools: a discussion of common challenges and strategies from the umecali experience. j ultrasound med. 2016;35(2):221-233. doi:10.7863/ultra.15.05006 6. dinh va, dukes ws, prigge j, avila m. ultrasound integration in undergraduate medical education: comparison of ultrasound proficiency between trained and untrained medical students. journal of ultrasound in medicine. 2015;34(10):1819-1824. doi:10.7863/ultra.14.12045 journal of regional medical campuses, vol. 4, issue 4 original reports 7. dinh va, frederick j, bartos r, shankel tm, werner l. effects of ultrasound implementation on physical examination learning and teaching during the first year of medical education. journal of ultrasound in medicine. 2015;34(1):4350. doi:10.7863/ultra.34.1.43 8. dreher sm, dephilip r, bahner d. ultrasound exposure during gross anatomy. the journal of emergency medicine. 2014;46(2):231-240. doi:10.1016/j.jemermed.2013.08.028 9. fu jy, krause c, krause r, et al. integration of point-of-care ultrasound training into undergraduate medical curricula–-a perspective from medical students. journal of medical education and curricular development. 2016;3:jmecd.s38240. doi:10.4137/jmecd.s38240 10. gillman lm, kirkpatrick aw. portable bedside ultrasound: the visual stethoscope of the 21st century. scand j trauma resusc emerg med. 2012;20(1):18. doi:10.1186/1757-7241-20-18 11. ginde aa, foianini a, renner dm, valley m, camargo, jr ca. availability and quality of computed tomography and magnetic resonance imaging equipment in u.s. emergency departments. academic emergency medicine. 2008;15(8):780-783. doi:10.11/j.15532712.2008.00192.x 12. hoppmann ra, rao vv, bell f, et al. the evolution of an integrated ultrasound curriculum (iusc) for medical students: 9-year experience. crit ultrasound j. 2015;7(1):18. doi:10.1186/s13089-015-0035-3 13. ireson m, warring s, medina-inojosa jr, et al. first year medical students, personal handheld ultrasound devices, and introduction of insonation in medical education. ann glob health. 2019;85(1):123. doi:10.5334/aogh.2565 14. jamniczky ha, mclaughlin k, kaminska me, et al. cognitive load imposed by knobology may adversely affect learners’ perception of utility in using ultrasonography to learn physical examination skills, but not anatomy. anat sci educ. 2015;8(3):197-204. doi:10.1002/ase.1467 15. jurjus ra, dimorier k, brown k, et al. can anatomists teach living anatomy using ultrasound as a teaching tool?. anat sci educ. 2014;7(5):340-349. doi:10.1002/ase.1417 16. kondrashov p, johnson jc, boehm k, rice d, kondrashova t. impact of the clinical ultrasound elective course on retention of anatomical knowledge by second-year medical students in preparation for board exams. clin anat. 2015;28(2):156-163. doi:10.1002/ca.22494 17. liaw w, cheifetz c, luangkhot s, sheridan m, bazemore a, phillips rl. match rates into family medicine among regional medical campus graduates, 2007-2009. the journal of the american board of family medicine. 2012;25(6):894-907. doi:10.3122/jabfm.2012.06.110336 18. mircea p-a, badea r, fodor d, buzoianu ad. using ultrasonography as a teaching support tool in undergraduate medical education time to reach a decision. med ultrasonography. 2012;14(3):211-216. 19. mullen a, kim b, puglisi j, mason nl. an economical strategy for early medical education in ultrasound. bmc med educ. 2018;18(1):169. doi:10.1186/s12909-018-1275-2 20. nelson bp, hojsak j, dei rossi e, karani r, narula j. seeing is believing: evaluating a pointof-care ultrasound curriculum for 1st-year medical students. teach learn med. 2017;29(1):85-92. doi:10.1080/10401334.2016.1172012 21. nelson bp, narula s, argulian e, bhagra a, narula j. including insonation in undergraduate medical school curriculum. ann glob health. 2019;85(1):135. doi:10.5334/aogh.2472 22. patel sg, benninger b, mirjalili sa. integrating ultrasound into modern medical curricula. clin anat. 2017;30(4):452-460. doi:10.1002/ca.22864 journal of regional medical campuses, vol. 4, issue 4 original reports 23. phelps a, wan j, straus c, naeger dm, webb em. incorporation of ultrasound education into medical school curricula. academic radiology. 2016;23(7):830-835. doi:10.1016/j.acra.2016.02.012 24. rempell js, saldana f, disalvo d, et al. pilot point-of-care ultrasound curriculum at harvard medical school: early experience. west j emerg med. 2016;17(6):734-740. 25. siegel-richman y, kendall j. establishing an ultrasound curriculum in undergraduate medical education: how much time does it take?. j ultrasound med. 2018;37(3):569-576. doi:10.1002/jum.14371 26. siegel-richman y, kendall jl. incidental findings in student ultrasound models: implications for instructors. j ultrasound med. 2017;36(8):1739-1743. doi:10.7863/ultra.16.08014 27. smith jp, kendall jl, royer df. improved medical student perception of ultrasound using a paired anatomy teaching assistant and clinician teaching model. anat sci educ. 2018;11(2):175-184. doi:10.1002/ase.1722 28. soucy zp, mills ld. american academy of emergency medicine position statement: ultrasound should be integrated into undergraduate medical education curriculum. the journal of emergency medicine. 2015;49(1):8990. doi:10.1016/j.jemermed.2014.12.092 29. tarique u, tang b, singh m, kulasegaram km, ailon j. ultrasound curricula in undergraduate medical education: a scoping review: ultrasound curricula in undergraduate medical education. j ultrasound med. 2018;37(1):69-82. doi:10.1002/jum.14333 30. webb em, cotton jb, kane k, straus cm, topp ks, naeger dm. teaching point of care ultrasound skills in medical school. academic radiology. 2014;21(7):893-901. doi:10.1016/j.acra.2014.03.001 31. zhao pj. ultrasound in the rural and remote healthcare setting. uwomj. 2014;83(1):30-31. doi:10.5206/uwomj.v83i1.4491 journal of regional medical campuses, vol. 4, issue 4 original reports survey questions attachment 1. university/institution name: 2. campus: 3. is your campus · years 1 and 2 only · years 3 and 4 only · years 1-4 · other (please specify) 4. do you include ultrasound in your preclinical (years 1 and 2) curriculum? · yes · no 5. how many years has ultrasound been included in your preclinical (years 1 and 2) curriculum? (fr) 6. how many hours are used to teach ultrasound in years 1 and 2? (fr) 7. do you have a unique ultrasound curriculum or is it identical to the curriculum at a different campus? · the ultrasound curriculum is unique to our campus · the ultrasound curriculum is identical to another campus 8. what is included in your preclinical ultrasound curriculum? (select all that apply) · anatomy-cardiac · anatomy-abdominal · anatomy-lung · anatomy-head/neck · anatomy-musculoskeletal · anatomy-reproductive · anatomy-other · physiology-cardiac · physiology-abdominal · physiology-lung · physiology-head/neck · physiology-musculoskeletal · physiology-reproductive · physiology-other · physical exam skills · procedures · pathology/diagnosis · targeted workshops/sessions · other? please list: 9. who is teaching your ultrasound curriculum? (select all that apply) · anatomists · clinicians · peers · faculty · medical students in years ¾ · other? please specify 10. who acts as the patient for teaching ultrasound? (select all that apply) · medical students · other health care students · volunteer patients · paid patients · other? please specify 11. what type of ultrasound equipment is being used in your curriculum? (select all that apply) · ultra-portable devices (ipad, pocket sized, etc) · larger ultrasound machines 12. how are you assessing success and student satisfaction of the ultrasound curriculum? (select all that apply) · surveys of students · surveys of faculty · multiple choice questions/exams · assessment on simulators · other? please specify 13. is there anything else we should know about your ultrasound program? (fr) 14. if you are interested in receiving a summary of our findings, when available, please include an email address: (fr) microsoft word applicantselectiontoaregionalarticle.docx published by university of minnesota libraries publishing applicant selection to a regional medical training program: interviewer predictions of mission-specific outcomes terry d. stratton, paula k. arnett, anthony d. weaver, j. bodie stevens, carol l. elam doi: https://doi.org/10.24926/jrmc.v3i1.2240 journal of regional medical campuses, vol. 3, issue 1 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc terry d. stratton paula k. arnett anthony d. weaver j. bodie stevens carol l. elam all work in jrmc is licensed under cc by-nc volume 3, issue 1 (2020) journal of regional medical campuses original reports applicant selection to a regional medical training program: interviewer predictions of mission-specific outcomes terry d. stratton, paula k. arnett, anthony d. weaver, j. bodie stevens, carol l. elam introduction long recognized as a public health concern,1 the detrimental health effects of being rural2 remain exacerbated by the maldistribution of physicians and other health personnel away from these areas. in the united states, where expansion of the affordable care act (aca) has recently heightened the demand for primary care providers,3 rising student debt and comparatively lower physician salaries have further dissuaded interest in rural practice.4,5 these and other factors have motivated many medical schools to develop or expand specialized tracks and/or regional medical campuses (rmcs). during the past decade, the rise in rmcs – many with uniquely-dedicated rural service missions6 – has been a characteristic offshoot of many established training programs. such examples include the university of alabama’s rural medical scholars program (rmsp),7 the university of illinois-rockford’s rural medical education (rmed) program,8 michigan state’s rural physician program (rpp),9 and the rural physician associate program (rpap) at the university of minnesota,10 to name but a few. modeled in part after these existing programs, the rural physician leadership program (rplp) was created in 2008 at the university of kentucky college of medicine (uk com) to attract and train applicants interested in practicing medicine in rural areas. students’ pre-clerkship years (m1 and m2) occur at the main uk com campus in lexington (ky), while their third and fourth years are completed at a regional campus located approximately one hour away in morehead (ky) – where they receive clinical instruction and leadership training. ten students are admitted annually, with preference given to applicants with the backgrounds, interests, and experiences that might encourage eventual medical practice in rural areas, in general, and kentucky, in particular. rplp admission process for more focused medical training programs, the task of admission is to assess: 1) professional suitability and preparedness and 2) the likelihood of achieving missionspecific outcomes. for this reason, we conduct semistructured, face-to-face interviews with academically qualified applicants to compliment written responses to items contained on our secondary application form. over 2 consecutive days, rplp applicants complete interviews at both main and regional medical campuses. at each site, 2 trained interviewers (4 per applicant) with access to standardized applicant data (e.g., demographic characteristics, residency status, undergraduate college and grade point average (gpa), medical college admission test (mcat) scores, and relevant experiences) independently offer subjective, narrative assessments of applicants’ backgrounds and qualifications – as well as an overall rating of acceptability on a 7-point scale ranging from “unacceptable” (1) to “outstanding, clearly superior” (7). using a scale from 0 (“no chance”) to 100 (“absolute certainty”), interviewers at both sites are also asked to estimate the likelihood that the rplp applicant will ultimately practice rural medicine. composite ratings for both measures consisted of averages across all 4 interviewers. all decisions to admit or reject rplp applicants are made by the college’s standing admissions committee with input from a voting rplp faculty member who summarizes the opinions of the rplp interview board. toward this end, we posed the following research questions: 1) what academic and socio-demographic characteristics are associated with interviewers’ ratings of applicants’ likelihood of rural practice in kentucky? and 2) do these characteristics coincide with where rplp graduates, thus far, have chosen to practice medicine? methods for the first research question, the study population consisted of 210 first-time rplp applicants granted admission interviews from 2009-2016. for the 10 repeat applicants who interviewed in multiple years, initial interview data were used. u.s. counties followed u.s. census bureau designations as being “mostly urban,” “mostly rural,” or “completely rural” per the last (2010) decennial census.11 appalachian counties were designated according to appalachian regional commission (arc) definitions.12 rplp applicants from outside the u.s. (n = 8) were excluded, since comparable demographic origins could not be established. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 original reports along with interviewers’ ratings of overall acceptability and likelihood of rural practice, the following demographic and academic variables were examined: 1) gender, 2) race/ethnicity (white, non-white), 3) age [traditional (< 26), non-traditional (> 26)], 4) undergraduate major (biological science, other), 5) undergraduate institution (doctoral, master’s, baccalaureate granting), 6) residency status (instate, out-of-state), 7) county of origin (rural, non-rural), 8) county of origin (appalachian, other), 9) total mcat score and, 10) cumulative undergraduate gpa. the study population for the second research question consisted of 35 rplp graduates completing the program from 2013-2016 (i.e., entering in 2009-2012). this time frame affords maximal opportunity to include some graduates who, having completed residency training, have gone on to establish medical practices. a critical value of p = < .05 was specified for inferential analyses. all analyses were conducted using spss13 (version 25). this study protocol was approved as exempt by our local institutional review board. results sample demographics as shown in table 1, of the 163 first-time u.s. applicants having complete interviewer rating data, 127 (77.9%) were instate and 36 (22.1%) were out-of-state residents. among instate residents, 47 (37.0%) originated from primarily urban counties and 80 (63.0%) from rural counties. of the in-state applicants, 76 (59.8%) hailed from appalachian counties. in total, 109 (66.9%) and 80 (49.1%) rplp applicants originated from rural and appalachian counties, respectively. ninetyfour (57.7%) applicants were male and 69 (42.3%) were female. regarding undergraduate education, 74 (45.4%), 70 (42.9%), and 19 (11.7%) of applicants held degrees from doctoral, master’s, and baccalaureate granting institutions, respectively. applicants’ average total mcat score was 27.9 (median = 27.0, sd = 3.1), and their cumulative undergraduate gpa was 3.68 (median = 3.76, sd = 0.30). interviewers’ combined ratings of applicant acceptability averaged 5.3 (median = 5.4, sd = 1.01) and ranged from 2.5 to 7.0. for the likelihood of practicing in rural kentucky, mean ratings were 76.6% (median = 81.3%, sd = 25.1%) and ranged from 10.0% to 99.8%. an assessment of composite and campus-specific interviewer reliabilities has been presented elsewhere.14 table 1. key descriptive variables of applicants to a rural physician leadership program (rplp), 2009-2016 ‡ includes african american, asian, hispanic, and other races/ethnicities. ¥ counties designated as “mostly rural” or “completely rural” by the u.s. census bureau. † counties designated by the appalachian regional commission (arc). & designations are based on the carnegie classification of institutions of higher learning. € includes majors in biology, biomedical science, biochemistry, chemistry, nutrition, physiology, psychobiology, and pre-med. likelihood of rural practice a multivariate regression analysis was conducted to generate estimates reflecting the size and direction of various predictors on applicants’ predicted likelihood of eventual rural in-state practice. the dependent variable (likelihood of eventual rural in-state practice) was transformed to approximate a more normal distribution by squaring the original values. as shown in table 2, the results of this analysis predicting interviewers’ assessments of rplp applicants’ likelihood of practicing in rural kentucky was statistically significant (f (9.50) = 10.42, p < .001) and comprised largely of sociodemographic factors: 1) residence (β = .345), 2) rural (β = .215), 3) appalachian (β = .164); (4) race/ethnicity (β = .187), and 5) gpa (β = .149) – collectively explaining roughly 43% of the variance in the dependent variable. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 original reports table 2. predictors of estimated likelihood of rural in-state practice of rural physician leadership program (rplp) applicants to more closely approximate a standard normal distribution, the dependent variable (“likelihood of rural practice”) has been transformed by squaring the original values. practice location of the 35 graduates admitted to the rplp from 2009-2012, 2 were fulfilling military obligations, 5 remained in residency training, and 3 were completing advanced fellowship training at the time of this analysis. subsequently, 25 had fully completed graduate training and had established medical practices. of these 25, all but one (96.0%) were in-state residents. eighteen (72.0%) completed primary care residencies (family medicine, general internal medicine, pediatrics, or obstetrics/gynecology) – 12 (48.0%) in the state of kentucky. equal proportions (44.0%) originated from “mostly urban” and “mostly rural” kentucky counties; 2 (8.0%) hailed from “completely rural” counties. fourteen (58.3%) were raised in an appalachian area of kentucky. the vast majority (92.0%) were white, and most (64.0%) were female. a majority (12/18, or 66.7%) of rplp graduates practicing in kentucky completed their residency training in-state; all 7 (100.0%) graduates practicing out-of-state completed residencies outside the state of kentucky. (see table 3). among all 25 rplp graduates, 8 (32.0%) were practicing in “mostly rural” and 17 (68.0%) in “mostly urban” counties. no rplp graduate was practicing in a “completely rural” county. of the 18 (72.0%) graduates practicing in kentucky, the percentages were slightly more evenly distributed: 8 (44.4%) were in “mostly rural” and 10 (55.6%) were in “mostly urban” counties. table 3. socio-demographic characteristics of rplp graduates by state and county of current medical practice (n = 25) ‡ includes african american, asian, hispanic, and other races/ethnicities. ¥ counties designated as “mostly rural” or “completely rural” by the u.s. census bureau. † counties designated by the appalachian regional commission (arc). although the decision to practice medicine in kentucky did not vary between males and females, gender was implicated in where graduates chose to establish their in-state practices: all 9 males (100.0%) were located in “mostly urban” counties, while females were evenly split between “mostly urban” (50.0%) and “mostly rural” (50.0%) counties. neither specialty choice (primary vs. non-primary care) nor rural/appalachian origin moderated this relationship. for the 20 practicing rplp graduates for whom complete “likelihood” data were available, there was no significant difference in the median ratings between those currently practicing in kentucky (n = 7) and those currently practicing outside the state (n = 13). mean ratings varied by about 10 points (79.9 vs. 88.8, respectively); however, the small sample size tempers the rigor of these estimates. the magnitude of association was modest (rs = 0.34, p = 0.15). discussion the likelihood of rplp graduates’ practice in rural areas was determined largely by applicants’ socio-demographic background characteristics – namely, originating from a rural kentucky county. these findings corroborate earlier research suggesting rplp applicants’ rural values, as expressed in admission essays, are unrelated to interviewers’ assessments of overall acceptability.15 doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 original reports since interviewers’ assessments of applicants’ overall acceptability did not differ by race/ethnicity,14 that noncaucasian rplp applicants were deemed less likely to establish medical practice in rural kentucky may reflect the relative homogeneity of the state – especially in rural areas. however, the limited number of rplp graduates in medical practice precludes any meaningful analysis. successfully recruiting practicing physicians to rural settings is a task involving both tangible16 and intangible17,18 considerations. pipeline programs, some starting as early as middle school, encourage and kindle early interest in medical careers; dedicated rural training programs must then select applicants “culturally-attuned” to these areas of medical need. a part of this “experiential integration with place”17 involves some level of community engagement or immersion19-21 that allows learners to nurture their “rural identities”.21 from prior research on rural medical practice, considerable attention has been paid to applicants’ related backgrounds, interests, and experiences.21-24 indeed, of the 107 (38.8%) rplp applicants not invited for interviews during our study time frame, most lacked meaningful rural experience and/or sufficient academic performance. other programs which train providers specifically for practice in rural appalachia also target recruitment efforts on those from the region or, interestingly, on those having military experience as medics.25 similarly, elective “externships” like east tennessee state university’s month-long appalachian preceptorship provide a combined clinical/classroom experience in rural culture and medical practice.26 hence, our findings reflect the consideration of applicant backgrounds most amenable to addressing an area’s dominant healthcare needs. some programs have experimented with giving added consideration to rural applicants,27 although not all have noted differences in the competitiveness or academic qualifications of rural versus non-rural applicants.28 wright and woloschuk, for example, found that despite the lower number of rural applicants relative to the population, there were no differences in ratings issued by admissions reviewers.29 in contrast, australian researchers found that applicants from rural or remote regions had significantly lower entrance and interview scores and, when admitted, lower academic performance in medical school.30,31 obviously, any admission considerations will depend, among other things, on the pool from which rural applicants are drawn. predicting future events be it academic performance, specialty choice, or eventual practice locale – is at best an inexact science. still, since the overriding goal of the rplp is to recruit and train physicians who will practice medicine in rural kentucky, it makes sense that this prospect be explicitly addressed during the admission process. in addition, to the extent that rplp graduates are expected to practice not just in rural areas, but in rural underserved areas, assessing applicants’ initial interest in primary care may also be warranted. limitations these findings are limited by several factors. first, this study is based on a singular rural track training program at one institution. as a result, how widely these findings may generalize beyond this context is unknown. second, our training protocol did not emphasize a standardized definition of “rural”. as a result, interviewers’ assessments of likelihood of rural practice may have been confounded by varying conceptions of what this entails.32 finally, given the brief history of the rplp, efforts to assess rplp graduates’ practice location are necessarily preliminary – and these associated analyses are relatively underpowered based on the small cell sizes. conclusions dedicated rural medical tracks or programs have been shown to be effective strategies in producing primary care physicians for practice in rural, often underserved areas33 – especially when provided in settings (like rmcs, for example) that offer meaningful learning experiences outside the larger, urban environment.34 key to the success of these efforts is the selection of candidates most qualified to meet programmatic goals. in the case of the rplp, interviewers positively weighted instate residence, rural, and appalachian origins as indicators of eventual rural in-state practice. while outcome data are perhaps too limited to draw firm conclusions, these factors appear to exert a general influence on in-state practice – but not necessarily in rural areas. indeed, virtually all 7 rplp graduates who chose to practice medicine outside of kentucky are doing so in non-rural areas. with 12 of 18 of those practicing in kentucky having also completed in-state residencies (compared with 0/7 practicing out-of-state), the best predictor of in-state practice, thus far, is residency location. unfortunately, this provides little predictive utility at the admission stage. perhaps more useful in this capacity is the greater prevalence of female rplp graduates practicing in rural areas (50% vs. 0%). since all current rural medical practices are also in kentucky – and no males report rural practices – further disentangling these effects is problematic. it is worth noting, however, that rplp doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 original reports admissions interviewers did not differentially weight applicant sex in their assessments of eventual practice locale. in kentucky, the rplp was designed to meet this need by admitting applicants who rural practice preferences and training them in settings with supportive physician and community role models. these findings suggest that recruiting academically capable applicants with substantive rural backgrounds plays a guiding role in their choice of future practice locales – even if beyond the borders of kentucky. as the rplp matures, the continued follow-up of graduates will help determine the accuracy with which longer-term outcomes can be optimized during the very early stages of admission into the profession. while the initial results are preliminary, the number of rplp program graduates practicing in rural areas is encouraging. as the number of rplp graduates continues to grow, follow-ups are planned with those who have entered practice to identify potential factors influencing their decisions regarding rural medicine and practicing in kentucky. seeking such targeted input from our graduates will help the rplp in refining not only its selection processes, but also the associated curriculum and socio-cultural learning experiences. future research should expand our understanding of factors that contribute to the choice of rural practice and examine the role of rural experiences and unique curricula developed for rplp students. references 1. pusey wa. medical education and medical service, i: the situation. journal of the american medical association 1925; 84:281-285. doi: 10.1001/jama.1925.26620300002013. 2. matthews ka, croft jb, liu y, et al. health-related behaviors by urban-rural county classification — united states, 2013. mmwr surveillance summary. 2017; 66 (no. ss-5):1–8. doi: 10.15585/mmwr.ss6605a1. 3. huang es, finegold k. seven million americans live in areas where demand for primary care may exceed supply by more than 10 percent. health affairs 2013; 32(3):614-621. doi: 10.1377/hlthaff.2012.0913. 4. palmeri m, pipas c, wadsworth e, zubkoff m. economic impact of a primary care career: a harsh reality for medical students and the nation. academic medicine 2010; 85(11):1692-1697. doi: 10.1097/acm.0b013e3181f5b754. 5. wendling al, shipman sa, jones k, kovar-gough i, phillips j. defining rural: the predictive value of medical school applicants’ rural characteristics on intent to practice in a rural community. academic medicine 2019. doi: 10.1097/acm.0000000000002924. [epub ahead of print] 6. norris te, coombs jb, house p, et al. regional solutions to the physician workforce shortage: the wwami experience. academic medicine 2006; 81(10):857-862. doi: 10.1097/01.acm.0000238105.96684.2f. 7. avery dm, wheat jr, leeper jd, et al. admission factors predicting family medicine specialty choice: a literature review and exploratory study among students in a rural medical scholars program. journal of rural health 2012; 28:128-136. doi: 10.1111/j.1748-0361.2011.00382.x. 8. macdowell m, glasser m, hunsaker j. a decade of rural physician workforce outcomes for the rockford rural medical education (rmed) program, university of illinois. academic medicine 2013; 88(12):19411947. doi: 10.1097/acm.0000000000000031. 9. wendling al, phillips j, short w. fahey c, mavis b. thirty years training rural physicians: outcomes from the michigan state university college of human medicine rural physician program. academic medicine 2016; 91(1):113-119. doi: 10.1097/acm.0000000000000885. 10. zink t, center b, finstad d, et al. efforts to graduate more primary care physicians and physicians who will practice in rural areas: outcomes from the university of minnesota-duluth and the rural physician associate program. academic medicine 2010; 85(4):599-604. doi: 10.1097/acm.0b013e3181d2b537. 11. county classification lookup table. united states census bureau. accessed 09/09/19 at: https://www.census.gov/geo/reference/urbanrural.html. 12. counties in appalachia. appalachian regional commission (arc). accessed 09/09/19 at: https://www.arc.gov/counties. 13. ibm corp. ibm spss for windows, version 25.0. armonk, my: ibm corp. 14. stratton td, kreiter cd, elam cl. main and regional campus assessments of applicants to a rural physician leadership program: a generalizability analysis. journal of regional medical campuses 2019; 2(2). doi: 0.24926/jrmc.v2i1.1981. 15. elam cl, weaver ad, whittler et, et al. discerning applicants’ interests in rural medicine: a textual analysis of admission essays. medical education online 2015; march 19;27081. doi: 10.3402/meo.v20.27081. 16. daniels zm, vanleit bj, skipper bj, sanders ml, rhyne rl. factors in recruiting and retaining professionals for rural practice. journal of rural health 2007; 23(1):62-71. doi: 10.1111/j.17480361.2006.00069.x. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 original reports 17. cutchin mp. community and self: concepts for rural physician integration and retention. social science and medicine 1997; 44:1661-1674. doi: 10.1016/s0277-9536(96)00275-4. 18. hancock s, steinbach a, nesbitt ts, adler sr, auerswald cl. why doctors choose small towns: a developmental model of rural physician recruitment and retention. social science and medicine 2009; 69:1368-1376. 19. eidson-ton ws, rainwater j, hilty d, et al. training medical students for rural, underserved areas: a rural medical education program in california. journal of health care for the poor and underserved 2016; 27:1674-1688. doi: 10.1353/hpu.2016.0155. 20. greer t, kost a, evans dv, et al. the wwami targeted rural underserved track (trust) program: an innovative response to rural physician workforce shortages. academic medicine 2016; 91(1):65-69. doi: 10.1097/acm.0000000000000807. 21. florence ja, goodrow b, wachs j, grover s, olive ke. rural health professions education at east tennessee state university: survey of graduates from the first decade of the community partnership program. journal of rural health 2007; 23(1):77-83. doi: 10.1111/j.1748-0361.2006.00071.x. 22. brokaw jj, mandzuk ca, wade me, et al. the influence of regional basic science campuses on medical students’ choice of specialty and practice location: a historical cohort study. bmc medical education (online) 2009; jun 6;9:29. doi: 10.1186/1472-6920-9-29. 23. sureshkumar p, roberts c, clark t, et al. factors related to doctors’ choice of rural pathway in general practice specialty training. australian journal of rural health 2016;jul 5. doi: 10.1111/ajr.12311. 24. stagg p, greenhill j, worley ps. a new model to understand the career choice and practice location decisions of medical graduates. rural and remote health 2009; 9(4):1245. 25. bushardt rl, whitt fk, gregory t. training physician assistants for rural appalachia: an academic partnership for interprofessional collaboration. north carolina medical journal 2014; 75(1):53-55. 26. lang f, ferguson kp, bennard b, zahorik p, sliger c. the appalachian preceptorship: over two decades of an integrated clinical-classroom experience of rural medicine and appalachian culture. academic medicine 2005; 80(8):717-723. doi: 10.1097/00001888-200508000-00002. 27. basco wt, gilbert ge, blue av. determining the consequences for rural applicants when additional consideration is discontinued in a medical school admissions process. academic medicine 2002; 77(10 suppl):s20-s22. doi: 10.1097/00001888-20021000100007. 28. longo dr, gorman rj, ge b. rural medical school applicants: do their academic credentials and admission decisions differ from those of non-rural applicants? journal of rural health 2005; 21(4):346350. doi: 10.1111/j.1748-0361.2005.tb00105.x. 29. wright b, woloschuk w. have rural background students been disadvantaged by the medical school admission process? medical education 2008; 42:476479. doi: 10.1111/j.1365-2923.2007.02938.x. 30. ray ra, woolley t, sen gupta t. james cook university’s rurally oriented medical school selection process: quality graduates and positive workforce outcomes. rural and remote health 2015; 15(4):3424. 31. raghavan m, martin bd, burnett m, et al. multiple mini-interview scores of medical school applicants with and without rural attributes. rural and remote health 2013; 13(2):2362. 32. owen ja, conaway mr, bailey ba, hayden gf. predicting rural practice using different definitions to classify medical school applicants as having a rural upbringing. journal of rural health 2007; 23(2):133140. doi: 10.1111/j.1748-0361.2007.00080.x. 33. rabinowitz hk, petterson s, boulger jg, et al. medical school rural programs: a comparison with international medical graduates in addressing statelevel rural family physician and primary care supply. academic medicine 2012; 87(4):488-492. doi: 10.1097/acm.0b013e3182488b19. 34. roseamelia c, greenwald jl, bush t, et al. a qualitative study of medical students in a rural track: views on eventual rural practice. family medicine 2014; 46(4):259-266. microsoft word advance care planning article.docx published by university of minnesota libraries publishing advance care planning and advance directives completion of elderly patients at a rural health clinic on a regional medical campus sarah irvin; melissa mcgowan; adrienne zavala, md doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 3, issue 2 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc sarah irvin melissa mcgowen adrienne zavala, md all work in jrmc is licensed under cc by-nc volume 3, issue 2 (2020) journal of regional medical campuses original reports advance care planning and advance directives completion of elderly patients at a rural health clinic on a regional medical campus sarah irvin; melissa mcgowan; adrienne zavala, md abstract advance care planning is the shared decision-making process between physicians, patients, and families regarding the patient’s preferences for end of life care. these conversations increase compliance with patient wishes, decrease hospitalizations, increase likelihood of patient selected location of death, and decrease stressors that may lead to depression in surviving family members.3 even though there is proven benefit from advance care planning, these discussions are often not prioritized. the purpose of this study is to evaluate rates of advance care planning and advance directive completion rate of 245 geriatric patients at our rural health clinic training site. we searched the electronic medical record to determine the number of patients who were asked about advance directives, stated they had a living will or medical power of attorney (mpoa), and had a living will or mpoa scanned into their chart. out of the study population, 45% of patients stated they had some form of advanced directives. of these patients, only 22% and 25% had a living will and mpoa scanned into their chart, respectively. this study demonstrates the need for detailed discussion about advance care planning with patients and additional follow-up to ensure documentation is readily available. introduction advance care planning (acp) is the ongoing shared decisionmaking process between patients, family, and healthcare providers regarding patient preferences for end of life care. conversations should include the patient’s medical conditions, prognosis, options, and values. it is best for this dialogue to take place in primary care offices where patients have built relationships with their providers and have more time to discuss their goals in a low-pressure environment. however, it is also imperative for patients’ wishes to be revisited with each hospital admission and/or changes in health status. acp increases the likelihood that patients receive the care they want, decreases the probability that family stress over making difficult decisions, and decreases the chance that healthcare providers face ethical dilemmas.1 additionally, this planning decreases hospitalizations and life-sustaining treatments prior to death, reducing healthcare costs without increasing mortality.2 planning also increases utilization of options for hospice and in-home deaths, increasing patient quality of life and family satisfaction.2,3 furthermore, acp increases advance directive completion.3 advance directives (ad) are legal documents completed by patients when they have medical decision-making capacity that outline their end of life care preferences. these documents are only used in the instance that the patient loses medical decision-making capacity as deemed by a physician. the most common types of ad documents include living will, medical power of attorney (mpoa), and physician orders for scope of treatment (post). a living will defines a patient’s wishes for future medical care, including cpr, intubation/ventilation, tube feeds, implantable defibrillators, dialysis, pain control, and chemotherapy. a mpoa designates the person that the patient would like to make medical decisions on their behalf. this is still important even if a patient has a living will as a living will cannot cover every possible medical scenario. a combined directive incorporates both a living will and mpoa into one document. a post indicates physician orders for life-sustaining treatment, including cpr, intubation/ventilation, and tube feeds, which is portable across most states. this covers outof-hospital dnr orders and more and is particularly important in emergencies. patients are more likely to complete ad if they have the following features: caucasian, elderly, suffering from chronic disease, high socioeconomic status, and high education level.5 although all participants were elderly and many participants were caucasian with chronic disease, few were of high socioeconomic status or education level. low education level is associated with low health literacy. although there are numerous benefits, only 70% of elderly americans have completed an ad.4 based on observations in clinic, it was hypothesized that the advance directive completion rate of elderly patients at our rural health clinic would be below the national average. methods the charts of 245 patients who met inclusion criteria – age 65 years and older who visited our rural clinic between 1/23/2019 and 1/30/2019 – were reviewed by these authors. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 original reports there were no exclusion criteria. our clinic provides over 30 000 visits per year with an average of 655 visits per week. the most common insurances used by our patients are: medicaid (25%), blue cross and blue shield (22%), commercial (22%), and medicare (7%). an average of 7% are self-pay visits. this rural health clinic is located in a county of 57 146 people where the median age is 40.2 years old.4 the poverty rate is 9.1%,4 the population is 88.9% white,4 and 30.8% of people have a bachelor’s degree or higher level of education.4 demographic data, including age, gender, and marital status were noted. then, the following terms were searched in each chart: “advance directive”, “living will”, “mpoa”, “dnr”, and “post form”. next, the “encounter” portion of the chart was reviewed for the most recent hospital admission date. then, the “media” portion of the chart was reviewed for upload of advance directive documents, including a living will, mpoa, and post form. finally, data was entered into microsoft excel and then analyzed to create the tables and graphs presented in the results section. results demographic information is summarized in charts 1, 2, and 3. the age breakdown (figure 1) was twenty-six percent 65-69 years old, thirty-one percent 70-74 years old, eighteen percent 75-79 years old, fifteen percent 80-84 years old, seven percent 85-89 years old, and three percent 90+ years old. the gender breakdown (figure 2) was 33% males and 67% females. the marital status breakdown (figure 3) was 53% married, 13% single, 12% divorced, and 22% widowed. out of the study population (n=245), 99.6% of patients has been asked if they had a living will or mpoa. out of the patients that stated they had a living will and mpoa (n=110), only 22% and 25% had a living will and mpoa scanned into their chart, respectively. of the patients who stated they did not currently have a living will or mpoa (n=134), 74% were offered additional handouts about advance directives. only 5% of patients stated they had a post form and only 2% had one scanned into their chart. of the patients with a recorded hospital admission (n=184), 62.5% had a code status recorded in their charts. figure 1 figure 2 figure 3 26% 31% 18% 15% 7% 3% age ranges 65-69 70-74 75-79 80-84 85-89 33% 67% gender male female 53% 13% 12% 22% marital status married single divorced widowed doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 original reports figure 4 table 1 discussion unfortunately, our internal chart review demonstrated that the ad completion rate at our clinic of 45% is well below the national average of 70%.5 a number of factors may be contributory to this discrepancy. one theory identified by the authors is that while ad status is being briefly addressed by the medical assistant (ma) during the check-in process, it is not being followed up by the provider and thus informative conversations and documentation are not taking place. providers should ask the patient for their understanding of their condition and prognosis and offer information on their prognosis and options. patients should identify their preferences and providers should encourage patients to document their preferences and discuss with family. future interventions could provide education and set expectations with providers to see if documentation rates change. similar to how medicare reimburses documentation of acp, our clinic could consider incentivizing acp and ad discussion and documentation. another contributor may be the effects of low socioeconomic status and/or low education levels of our patients. one limitation of this study is that we did not collect socioeconomic status and health literacy data on patients whose charts were reviewed, and thus were unable to draw conclusions regarding whether patients with higher socioeconomic status and/or health literacy were more likely to have documented advance directives. future iteration of the study could track this information and document that patients received appropriate education materials to see if this resulted in higher uptake of advance directives being completed and documented. in the future, our providers should ensure the informational packet offered to patients is of appropriate reading level. other specific tools that could be incorporated into a future intervention could be the “prepare for your care” website.7 not only does it offer step wise instructions in the form of video stories, but one study found that this resource increased ad completion by 10%.8 another tool providers could be encouraged to use in their approach to improve documentation would be to direct patients to the west virginia center for end-of-life care edirective registry website.9 west virginia is one of only 4 states with a statewide ad registry, allowing providers easy access to ad across health care settings.10 finally, yet another opportunity for increasing documentation of current ad wishes includes at the time of hospitalization. over one third of participants who were previously hospitalized (n=184) did not have code status documented (n=69). while these numbers are most likely inflated (hospitalizations date back to 1986 whereas notes and orders discussing code status do not), it is imperative that ad are revisited continually. although patient preferences are more likely to stay stable over time if they have an ad, 7-9% will change their preferences during admission.11,12 this is even more likely in the elderly.12 in the future, our providers should ensure they are readdressing ad, especially upon admission. while this chart review revealed some eye-opening data, it is only preliminary. future research should analyze a larger sample size at various primary care offices. they should incorporate how the rate of acp discussions differs between healthy and sick patients. they should also examine how ad completion rates vary depending on socioeconomic status, education, health literacy, and computer/internet access. conclusion 0% 20% 40% 60% living will mpoa post form percentage of patients with each advance directive stated they had scanned in doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 original reports although acp discussion is beneficial to patients, families, and health care providers, geriatric patients at our rural health clinic are falling short of the national ad completion rate for the elderly. routine follow up is necessary to ensure ad documentation, which will lead to more successful end of life care. references 1. sudore rl, lum hd, you jj, et al. defining advanced care planning for adults: a consensus definition from a multidisciplinary delphi panel. j pain symptom manage. 2017;53(5):821-823. doi: 10.1016/j.jpainsymman.2016.12.331 2. brinkman-stoppelenburg a, rietjens ja, van der ha. the effects of advance care planning on end-of-life care: a systemic review. palliat med. 2014;28(8):1000-1025. doi: 10.1177/0269216314526272 3. deterine km, hancock ad, reade mc, silverster w. the impact of advance care planning on end of life care in elderly patients: randomized controlled trial. bmj. 2010;340. doi: 10.1136/bmj.c1345 4. u.s. census bureau (2019). population estimates. retrieved from https://www.census.gov/quickfacts/jeffersoncounty westvirginia. 5. silveira mj, kim sh, langa km. advance directives and outcomes of surrogate decision making before death. n engl j med. 2010;362:1211-1218. doi: 10.1056/nejmsa0907901 6. kwak j, haley we. current research findings on endof-life decision making among racially or ethically diverse groups. gerontologist. 2005;45(5):634-41. doi: 10.1093/geront/45.5.634 7. home. national polst paradigm. https://polst.org. published 2019. accessed march 23, 2019. 8. sudore rl, boscardin j, feuz ma, mcmahan rd, katen mt, barnes de. effect of the prepare website vs an easy-to-read advance directive on advance care planning documentation and engagement among veterans: a randomized clinical trial. jama intern med. 2017;177(8):1102-1109. doi: 10.1001/jamainternmed.2017. 1607. 9. home. west virginia center for end-of life care. http://wvendoflife.org/for-providers/e-directiveregistry. published 2019. accessed march 23, 2019. 10. national polst registry information. national polst paradigm. http://polst.org/wpcontent/uploads/2018/04/2018.04.10-nationalpolst-registry-information.pdf. published 2018. accessed march 23, 2019. 11. auriemma cl, nguyen ca, bronheim r, kent s, nadiger s, pardo d, halpern sd. stability of end-oflife preferences:a systemic review of the evidence. jama intern med. 2014;174(4):1085-1092. doi: 10.1001/jamainternmed.2014.1183 12. kim ys, escobar gj, halpern sd, greene jd, kipnis p, liu v. the natural history of changes in preferences for life-sustaining treatments and implications for inpatient mortality in younger and older hospitalized adults. j am geriatr soc. 2016;64(5):981-989. oi: 10.1111/jgs.14048. microsoft word impactofvirtualinterviewing article.docx published by university of minnesota libraries publishing impact of virtual interviewing on time and financial costs for nrmp© applicants: did regional campus students save more? tiffany schwasinger-schmidt md, phd; tessa rohrberg md; anne walling mb chb; kari nilsen phd doi: https://doi.org/10.24926/jrmc.v4i4x.3925 journal of regional medical campuses, vol. 4, issue 4 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc tiffany schwasinger-schmidt md, phd; university of kansas school of medicine, wichita, department of internal medicine, 1010 north kansas, wichita, kansas 67214 tessa rohrberg md; university of kansas school of medicine, wichita, department of family and community medicine, 1010 north kansas, wichita, kansas 67214 anne walling mb chb; university of kansas school of medicine, wichita, department of family and community medicine, 1010 north kansas, wichita, kansas 67214 kari nilsen phd; university of kansas school of medicine, wichita, department of family and community medicine, 1010 north kansas, wichita, kansas 67214 corresponding author: kari nilsen, phd. university of kansas school of medicine-wichita, department of family and community medicine, 1010 north kansas, wichita, ks 67214. email. knilsen@kumc.edu all work in jrmc is licensed under cc by-nc volume 4, issue 4 (2021) journal of regional medical campuses original reports impact of virtual interviewing on time and financial costs for nrmp© applicants: did regional campus students save more? tiffany schwasinger-schmidt md, phd; tessa rohrberg md; anne walling mb chb; kari nilsen phd abstract background and objectives: the sudden change from in-person to remote interviews by the national residency matching program© (nrmp©) in 2020 was expected to result in significant financial and time savings for applicants. this project aimed to compare savings before and after the 2020-2021 interviewing season reported by students graduating from our institution’s regional and main campuses. methods: data were collected over a six-year period at a midwestern medical school. each year, approximately 120 main campus and 75 regional campus students are surveyed regarding specialty choice, number of applications and interviews, time, and expenses to complete the nrmp. chi-square and t-tests were used to determine statistical differences by campus and by specialty in savings during the 2020-21 interviewing season compared to the previous five years. results: data were provided by 957 students. the response rates were 81.5% (regional) and 82% (main campus). compared to the previous five years, in 2021 main campus students saved $3,990 (79.9%) and regional campus students saved $2,789 (77.1%). the previous highly significant differences in expenses between campuses ($1,386 ± $243) dropped to $185 (p = 0.3). on both campuses, applicants to non-primary care specialties saved more than their classmates applying to primary care. the largest average saving was reported by non-primary care applicants on the main campus ($4,207) and the smallest by regional applicants to primary care ($2,328). main campus applicants reported saving 13.1 and regional campus 15.4 days interviewing in 2021. the smallest average time saving was reported by main campus applicants to non-primary care (12.7 days) and the largest (16.2 days) by regional campus applicants to primary care. no significant changes occurred in number of applications, interviews, or match outcomes in 2021 compared to previous years. conclusion: prior to 2021, students from our institution’s regional campus reported lower costs and similar interviewing time than their peers on the main campus. cost and time were significantly decreased in 2021 for both regional and main campus students applying to any specialty and differences between campuses reduced to nonsignificant levels. the number of applications, completed interviews, and match outcomes remained similar to previous years. changes to the nrmp© incorporating remote interviewing may reduce applicant costs by 80% and provide up to two weeks of available curricular time in the senior year of medical school. introduction the dramatic change in 2021 to remote interviewing for residency applications by the national residency matching program© (nrmp©) in response to the covid-19 pandemic was expected to significantly reduce applicant costs and time requirements.1-3 such savings could be greater for regional campus students, especially those applying to non-primary journal of regional medical campuses, vol. 4, issue 4 original reports care specialties, who previously often travelled nationally to interview at competitive programs.4 prior to the pandemic, seniors at us allopathic medical schools reported spending an average of $3,000 to $4,000 interviewing for residency positions.5-7 expenses reported by individual applicants ranged from less than $100 to over $25,000 with lower expenses generally reported in primary care specialties (usually defined as internal medicine, family medicine, pediatrics, and medicine/pediatrics).5-7 travel accounted for 60% to 70% of all expenses with other costs predominantly for food and accommodation.6,8 none of the over 20 studies of nrmp© applicant expenses have reported data for regional campus students,5-23 but studies have commented on higher costs for “out of town” applicants and increased travel burden for those from non-metropolitan areas.21,22 one large study attributed lower costs for students from the northeastern region to the concentration of medical schools and residency programs in a single 500 mile area.8 to assess the impact of the nrmp© changes on costs and interviewing time for applicants based on both the regional and the main campus of our institution, we used data from an on-going annual survey of all fourth-year students participating in nrmp©. the main campus, with approximately 600 students, is part of an academic medical center located in a metropolitan area with a population of 2.2 million. the community-based regional campus has approximately 200 students and is situated in a metropolitan area with a population of approximately 650,000, located 200 miles southwest of the main campus. methods we examined data from a six-year study (2016-2021) of interviewing time and expenses for students at our institution that has been reported in previous publications.6,15,23 the participants were all fourthyear medical students who participated in the nrmp© to secure first-year residency positions. each year, approximately 120 students from the main campus and 75 from the regional campus apply nationwide to residencies in the full spectrum of medical specialties. the research team consists of faculty members involved in both medical student and graduate medical education plus students from the third-and fourth-year classes during each survey year. the initial survey questionnaire was based on literature reviews and piloted on the regional campus in 2015.15 modifications to the survey have been made each year based on feedback from students and faculty, developments in the literature, and changes in the nrmp© process. the current questionnaire contains 46-items addressing topics such as time and cost, number of applications and interviews, specialty choice, and sources of information utilized for residency program selection. the survey instrument is available for review in the appendix. the questionnaire is distributed annually by e-mail once a week for four weeks in late february to early march, after residency rankings have been submitted and before announcement of nrmp© match results. class leaders use social media reminders two to three times weekly and personal contacts to encourage classmates to complete the questionnaire. as an incentive, a donation proportional to the response rate is offered to the student graduation celebration fund. the school of medicine institutional review board has approved this study as “non-human subjects research” since inception. descriptive analyses provided demographic information about participants in all six years of the study and survey responses regarding specialty choice (primary care versus non-primary care); number of residency program applications, interview offers, interviews completed, and programs ranked; expenses incurred; and time spent interviewing. t tests and chi-square analyses were used to determine any statistical differences between applicants based on the regional campus and those on the main campus for all years, with special attention to changes between 2021 and previous years. comparisons were made for all applicants and by primary care vs. nonprimary care. internal validity measures included review of findings by student leaders, educational committees, and discussion of results with students and faculty. results participants (table 1) survey data were available from 957 students for an overall response rate of 81.8% (957/1170). the response rate was 81.5% (375/460) for regional campus students and 82.0% (582/710) for those from the main campus. approximately half of respondents journal of regional medical campuses, vol. 4, issue 4 original reports were male on both campuses (49.3%). a significantly greater proportion of regional campus respondents applied to primary care programs [52.8% vs. 39.0%; χ2(1) = 8.1, p = 0.004, 95% ci 4.3% to 23.0%]. changes in numbers of nrmp© applications, interviews and programs ranked (table 2) during 2016-20, students from the main campus consistently submitted significantly more applications [47.3 vs. 35.7; t(809) = 6.9, p < 0.001, 95% ci 8.9 to 16.0], received more interview offers [17.6 vs. 14.9; t(807) = 4.8, p < 0.001, 95% ci 1.7 to 4.1], and completed more interviews than those on the regional campus [12.2 vs. 10.3; t(807) = 5.9, p < 0.001, 95% ci 1.2 to 2.4]. main campus students also ranked more programs (11.6 vs. 10.5; p = 0.1). in 2021, while students from the main campus again submitted more applications (47.2 vs. 38.1; p = 0.08), received more interview offers (13.9 vs. 12.3; p = 0.2), completed more interviews, (12.2 vs. 10.3; p = 0.08), and ranked more programs (11.4 vs. 9.9; p = 0.7) than those on the regional campus, these differences were not statistically significant. changes in interviewing costs (tables 2 and 3, figure 1) for the years 2016-2020, regional campus students reported average costs $1,386 lower than colleagues on the main campus [$5,005 vs. $3,619; t(769) = 5.7, p < 0.0001, 95% ci $909 to $1,862]. they also reported approximately $70 less in cost per completed interview [$351 vs. $421; t(736) = 3.0, p = 0.003, 95% ci $25 to $116]. in 2021, costs dropped dramatically for all applicants. in 2021, regional students saved an average $2,789 [77.1% of pre-pandemic costs; t(350) = 6.1, p < 0.0001, 95% ci $1,887 to $3,692] and main campus students $3,990 [79.7%; t(542) = 10.2, p < 0.0001, 95% ci $3,225 to $4,755]. the difference between main and regional students’ total costs dropped from $1,386 to $185 [t(894) = 5.1, p < 0.0001, 95% ci $709 to $1,602] and the difference in cost per completed interview to approximately $5 ($83 vs. $78, p = 0.9). highly significant savings were reported by students on both campuses applying to both primary care and non-primary care specialties. the greatest savings were reported by main campus applicants to nonprimary care specialties [$4,207; 76.9%; t(323) = 7.6, p < 0.0001, 95% ci $3,119 to $5,296] but the greatest percentage saving was in regional campus applicants to primary care [$2,328; 85.1%; t(186) = 4.4, p < 0.0001, 95% ci $1,284 to $3,372]. the differences between campuses dropped by $687 [87.5%; t(487) = 2.1, p = 0.03, 95% ci $56 to $1,425] for non-primary care and $1,272 [81.1%; t(405) = 4.5, p < 0.0001, 95% ci $694 to $1,761] for primary care applicants. changes in interviewing time (tables 2 and 4, figure 2) during the 2016-2020 period, the one-day difference in total average time between campuses was not statistically significant (29.2 vs. 28.1 days; p = 0.3) but the 0.4-day average time per completed interview was significantly greater for regional campus students [2.8 vs 2.4 days; t(752) = -3.5, p = 0.001, 95% ci -0.6 to -0.2]. in 2021, students reported significant time savings of 13.1 days on the main campus [t(553) = 7.9, p < 0.0001, 95% ci 9.9 to 16.4] and 15.4 days on the regional campus [t(358) = 6.0, p < 0.0001, 95% ci 10.3 to 20.5]. the greatest time savings were reported by regional applicants to primary care [16.2 days; 60.9%; t(189) = 4.5, p < 0.0001, 95% ci 9.1 to 23.3] and nonprimary care specialties [15.3 days; 51.2%; t(167) = 4.1, p < 0.0001, 95% ci 7.9 to 22.7]. the time per completed interview was identical for main and regional campus applicants (1.2 days). discussion this study demonstrates that average estimated interviewing costs dropped by over 70% for all applicants in 2021. those based on the main campus reported larger savings in both total amounts (nearly $4,000) and as a percentage of previous expenditures (nearly 80%). the cost differences between campuses dropped dramatically from over $1,300 to $185 and cost differences between campuses per completed interview almost disappeared. despite these dramatic overall savings, applicants to non-primary care on the main campus spent almost double the amount of their classmates applying to primary care. this difference was even more pronounced on the regional campus where non-primary applicants reported expenses nearly triple those of applicants to primary care. students on the main campus continued to report higher numbers of applications and interviews in 2021 but neither campus showed a surge in applications in response to the uncertainties of the pandemic year and the removal of travel requirements. journal of regional medical campuses, vol. 4, issue 4 original reports while modest compared to the total debt of graduating medical students, estimated at a median of $200,000,24 these savings are especially welcome for those with limited resources considering nonprimary care specialties, and may contribute to improving diversity in some specialties.25-27 the time consumed by the residency interviewing process has received relatively little attention in the literature but is a major source of stress and impediment to leaning in the senior year of medical school.28-31 our results indicate savings of up to 16 days by replacing in-person interviewing with virtual interviews. in addition to the actual time spent on interviews, student narratives commented on reductions in time and stress throughout the fourth year (and end of third year) in arranging interviews and scheduling visits to multiple locations. students were also often able to obtain permission to videointerview during rotations and avoid the disruption and administrative implications of days away from coursework. the potential time savings in the senior year offer valuable curricular opportunities to better prepare students for the transition to residency and should be a major consideration in any redesign of the nrmp© system. the study has several limitations, principally that our findings are unique to one institution and one time period when many aspects of applicant interview process had to be improvised by each program and medical school. each institution and regional campus have distinctive features, and this study may not be generalizable to other institutions or to future years. in addition, the wide range of costs reported indicates that averages may have limited applicability to individual students or small groups of students such as those applying to highly competitive specialties, interviewing in more than one specialty, or students with academic disadvantages. the data depend on student report after interviewing and could be subject to inaccuracy or recall bias. the data also do not take into consideration the potential impact of the supplemental offer and acceptance program (soap©) process. additional studies of regional campus students at institutions across the country would provide more insight on the generalizability of our findings. nevertheless, the study adds to our understanding of how students navigated the changes in the nrmp© interviewing process and may contribute to discussions about the future of the process. as medical education considers strategies to alleviate student debt, the expenses incurred during interviews for residency positions must be considered. even with the dramatic reduction in costs documented after the change to remote interviewing, the pressure to overapply and to undertake excessive numbers of interviews must be addressed, not just to benefit applicants but also to alleviate residency programs that are currently overwhelmed by excessive numbers of applications. conclusion students interviewing in 2021 reported costs almost 80% lower than applicants in the previous years. the greatest average savings (over $4,000) were for main campus students applying to non-primary care specialties, but the highest percentage savings (85%) were reported by regional campus applicants to primary care. cost differences between the campuses diminished for both primary care and non-primary care applicants. students reported saving 13 to 16 days through the change to remote interviewing, with regional campus students reporting the largest time savings. conflict disclosure: tiffany schwasinger-schmidt, md, phd has conducted clinical trials research as principal investigator for the following pharmaceutical companies over the last twelve months: 1. allergan 2. eisai 3. lundbeck 4. janssen 5. sage pharmaceuticals 6. sarepta 7. corcept 8. boehringer ingelheim 9. astra zeneca 10. axsome all clinical trial and study contracts were with and payments were made to the university of kansas medical center research institute, which is a research institute affiliated with kansas university school of medicine-wichita (kusm-w). journal of regional medical campuses, vol. 4, issue 4 original reports the additional authors declare no conflicts of interest or competing interests. acknowledgements: the authors would like to thank the team of medical students, residents, and faculty who created the survey used to collect the data for this study, as well as drs. mark meyer and k. james kallail for their help collecting additional data for this manuscript references 1. haas mrc, he s, sternberg k, jordan j, deiorio nm, chan tm, yarris lm. reimagining residency selection: part 1-a practical guide to recruitment in the post-covid-19 era. j grad med educ. 2020 oct;12(5):539-544. doi:10.4300/jgme-d-20-00907.1. pmid: 33149819; pmcid: pmc7594771. 2. sternberg k, jordan j, haas mrc, he s, deiorio nm, yarris lm, chan tm. reimagining residency selection: part 2-a practical guide to interviewing in the post-covid-19 era. j grad med educ. 2020 oct;12(5):545-549. doi: 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2017 jun;156(6):1091-1096. doi: 10.1177/0194599816686538. epub 2017 jan 24. pmid: 28116996. 20. cabrera-muffly c, chang cwd, puscas l. current interview trail metrics in the otolaryngology match. otolaryngol head neck surg. 2017 jun;156(6):1097-1103. doi: 10.1177/0194599817690723. epub 2017 feb 7. pmid: 28168889. 21. fogel ha, liskutin te, wu k, nystrom l, martin b, schiff a. the economic burden of residency interviews on applicants. iowa orthop j. 2018;38:9-15. pmid: 30104919; pmcid: pmc6047386. 22. nikonow tn, lyon td, jackman sv, averch td. survey of applicant experience and cost in the urology match: opportunities for reform. j urol. 2015 oct;194(4):1063-7. doi: 10.1016/j.juro.2015.04.074. epub 2015 apr 23. pmid: 25912495. 23. nilsen km, walling a, grothusen j, irwin g, meyer m, unruh g. time and financial costs for students participating in the national residency matching program (the match©): 2015 to 2020. kans j med. 2021 mar 19;14:5363. doi: 10.17161/kjm.vol1414568. pmid: 33763180; pmcid: pmc7984744. 24. youngclaus j, fresne ja. physician education debt and the cost to attend medical school: 2020 update. washington, dc: aamc; 2020. https://store.aamc.org/downloadable/downlo ad/sample/sample_id/368/. accessed august 25, 2021. 25. vasquez r, jeong h, florez-pollack s, et al. what are the barriers faced by underrepresented minorities applying to dermatology? a qualitative cross-sectional study of applicants applying to a large dermatology residency program. j am acad dermatol. 2020 dec;83(6):1770-1773. 26. wilson lt, milliken l, cagande c, stewart c. responding to recommended changes to the 2020-2021 residency recruitment process from a diversity, equity, and inclusion perspective. acad med. 2021 aug 10. doi: 10.1097/acm.0000000000004361. epub ahead of print. pmid: 34380938. 27. coalition for physician accountability’s work group on medical students in the class of 2021 moving across institutions for post graduate training. final report and recommendations for medical education institutions of lcme-accredited, u.s. osteopathic, and non-u.s. medical school applicants. washington, dc: aamc; 2021. https://www.aamc.org/media/44736/downloa d. accessed august 14, 2021. 28. nilsen k., walling, a., callaway, p. et al. “the end game”students’ perspectives of the national residency matching program: a focus group study. med sci educ. 28, 729–737. 29. wolf sj, lockspeiser tm, gong j, guiton g. students' perspectives on the fourth year of medical school: a mixed-methods analysis. acad med. 2014 apr;89(4):602-7. 30. walling a, merando a. the fourth year of medical education: a literature review. acad med. 2010 nov;85(11):1698-704. doi: journal of regional medical campuses, vol. 4, issue 4 original reports 10.1097/acm.0b013e3181f52dc6. pmid: 20881826. 31. luftig d. the residency interview scheduling process: unintended consequences and a proposal for change. j grad med educ. 2015 mar;7(1):134. doi: 10.4300/jgme-d-1400603.1. pmid: 26217445; pmcid: pmc4507910. figure legend figure 1. average cost per year for primary care and non-primary care applicants by location figure 2. average time spent per year for primary care and non-primary care applicants by location journal of regional medical campuses, vol. 4, issue 4 original reports appendix ms4 nrmp match survey 2021 1. did you participate in the 2020-2021 nrmp© match process? • no i. if no, in which process did you participate to find a residency position? • yes **end of survey for participants who did not participate in the nrmp© process** 2. what was your primary specialty choice? 3. to how many specialties did you apply? • one • two three or more 4. why did you apply to more than one specialty? • interest in more than one specialty • need for a “safety net” option • other (please specify) 5. did you attend meet-and-greets in your specialty(ies) of choice prior to submission of your application to those programs? • no • yes 6. was the list of programs to which you applied affected by your participation in presubmission meet-and-greets? • no • if yes, did your participation result in your applying to: i. more programs? ii. fewer programs? 7. did you apply to any transitional/preliminary programs? • no • if yes… i. to how many transitional/preliminary programs did you apply? ii. how many transitional/preliminary programs offered you an interview? iii. how many transitional/preliminary program interviews did you complete? iv. how many transitional/preliminary programs did you include on your rank list? 8. to how many categorical residency programs did you apply? 9. how many categorical residency programs offered you an interview? 10. how many categorical residency program interviews did you complete? 11. how many categorical residency programs did you include on your rank list? 12. in retrospect, do you think the number of programs you applied to was: • too many • about right • too few 13. in retrospect, was the number of interviews you completed: journal of regional medical campuses, vol. 4, issue 4 original reports • too many • about right • too few 14. did you participate in couples match? • no • yes 15. did you apply to more programs due to the virtual format? • yes, absolutely • maybe • no • i am not sure 16. did you accept more interviews due to the virtual format? • yes, absolutely • maybe • no • i am not sure 17. did you complete more interviews due to the virtual format? • yes, absolutely • maybe • no • i am not sure 18. to what extent did any of the following limit your decision to accept interview invitations? (response options: very limiting, somewhat limiting, not limiting) • cost associated with interviewing • time spent interviewing • issues with scheduling • participation in the program's presubmission meet-and-greet • virtual away experiences with programs • other (please specify) 19. other than cost and time, how important were the following factors in deciding which interviews to accept? (response options: not important, somewhat important, very important) • recommendation from student affairs • recommendation from medical school department or faculty • advice from residents • recommendation from classmates and other students • literature/websites and published information from programs • reputation of program including clinical/ medical expertise • program offered a good fit with my interests • experience working in the program (e.g., away rotation or sub-internship) • desire to stay in a specific city/ location • perception of program’s commitment to resident wellness and well-being • scholarship/ academics of the program • program commitment to diversity and/or underserved populations • program reputation • other (please specify) 20. what was your total estimated expense related to your interviews (in whole dollars)? 21. how did you pay for your interview expenses? please check all that apply: • personal savings • credit card • medical student loans • private loans • gift from family • other (please specify) 22. what platform(s) did you use to coordinate your interview schedule (i.e., eras, thalamus, etc.)? 23. if you used more than one program, which one did you prefer? 24. how many days in total did you participate in interviews? 25. how many interviews did you attend during: • october? ____ • november? ____ • december? ____ • january? ____ • february? ____ journal of regional medical campuses, vol. 4, issue 4 original reports 26. on average, how many days’ notice did you receive prior to your interview date? 27. what was the least amount of notice that you received prior to an interview date (in days)? 28. on average, how quickly did you need to respond to interview requests to secure a spot? • 1-5 minutes • 6-10 minutes • within an hour • within 24 hours • more than 24 hours 29. on average, how soon after receiving an interview invitation did you decline it? • 1-5 minutes • 6-10 minutes • within an hour • within 24 hours • more than 24 hours 30. what were the reasons you declined interviews upon receipt? please check all that apply: • i had personal or family reasons • i had logistical issues (travel, ms schedule, timing, etc.) • i had financial issues • i found issues with the residency program after applying • i changed my mind about the residency program • i was less likely to rank a program after receiving invitations from other programs (low priority of program) • other (please specify) 31. how many interviews did you accept but then cancel later? 32. what were the reasons you canceled scheduled interviews? please check all that apply: • i had personal or family reasons • i had logistical issues (travel, ms schedule, timing, etc.) • i had financial issues • i found issues with the residency program after applying • i changed my mind about the residency program • i was less likely to rank a program after completing interviews with other programs (low priority of program) • preference of spouse/significant other on where we should live • other (please specify) 33. on average, how close to the scheduled interview date did you cancel interviews? • same day • within a few days • within a week • within a month • never 34. did the programs you accepted invitations from offer preor post-interview resident meet-and-greets? • no • if yes, did you participate in: i. all meet-and-greets ii. some meet-and-greets iii. no meet-and-greets 35. did any programs request additional information before offering you an interview? • no • if yes, what additional information did they request? 36. did any programs require that you travel inperson to their location? • yes • no 37. did any of the programs you interviewed with offer post-interview activities? please check all that apply: • mandatory activities i. no ii. if yes, what kind of activities did expect you to attend? • optional activities i. no ii. if yes, what kind of activities did they offer? • no activities offered journal of regional medical campuses, vol. 4, issue 4 original reports 38. have you received any communication from programs following your interview with them (such as emails or letters)? • no • if yes, what additional communication have you received? demographics 39. what is your gender? • male • female • chose not to disclose • other (please specify) 40. what is your age? 41. which campus do you attend? 42. are you originally from [our state]? • yes • no 43. how would you characterize your hometown? • urban • suburban • midsize rural • small rural open-ended questions 44. how did you personally feel about the virtual format of residency interviewing? 45. if you could do anything to improve the nrmp© process, what would you do? 46. please provide any comments or feedback that you think we should know about your experience with the nrmp© process. thank you and best wishes for success in your residency career if you have any questions, please contact [the research lead]. microsoft word theimpactofbasicsciencearticle.docx published by university of minnesota libraries publishing the impact of basic science and clinical experience sequence on medical student performance jacob prunuske md, msph; amy prunuske phd; robert treat phd z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc jacob prunuske md, msph; assistant dean for clinical learning, associate professor of family & community medicine, medical college of wisconsin – central wisconsin; jprunuske@mcw.edu amy prunuske phd; faculty curriculum program manager, associate professor of microbiology and immunology, medical college of wisconsin – central wisconsin; aprunuske@mcw.edu robert treat phd; director of measurement and evaluation, associate professor of emergency medicine, medical college of wisconsin – milwaukee; rtreat@mcw.edu all work in jrmc is licensed under cc by-nc volume 2, issue 3 (2019) journal of regional medical campuses abstract the impact of basic science and clinical experience sequence on medical student performance jacob prunuske md, msph; amy prunuske phd; robert treat phd topic: character limit: medical schools have an obligation to prepare students to perform well on standardized exams, succeed in courses and clerkships, obtain desirable outcomes in national resident matching program, and achieve competency to start residency training. medical schools are implementing alternate curricular models that disrupt the traditional model of two years of basic sciences followed by two years of clinical sciences. schools that innovate and explore alternate structures and sequencing that transition toward competency-based education must evaluate the impact of these changes to assess advantages and disadvantages of various curricular models. the impact, benefits, and challenges of these alternate models must be evaluated to drive the best educational practices nationally. the innovative medical program at the medical college of wisconsin-central wisconsin (mcw-cw) campus provided an opportunity to compare student performance in an accelerated curriculum with student performance in the more traditional four-year curriculum at the milwaukee (mcw-mke) campus. in this session, we presented the differences of the three and four-year curricula, described results of student clerkship osce performance, and compared osce performance of students beginning clerkship experiences prior to the second-year basic science curriculum at mcw-cw with osce performance of students beginning clerkship experiences after the basic science curriculum at mcw-mke. short description: medical schools are implementing alternate curricular models that disrupt the traditional model of two years of basic sciences followed by two years of clinical sciences. the impact, benefits, and challenges of these alternate models must be evaluated to drive the best educational practices nationally. we compared student performance in an accelerated curriculum, in which students begin clerkships prior to completion of basic sciences, with student performance in the more traditional four-year curriculum. we presented structural curriculum differences, described results of student clerkship osce performance, compared osce performance of students beginning clerkship experiences prior to the second-year basic science curriculum with that of students beginning clerkship experiences after the basic science curriculum, and discussed implications for other institutions. four questions that were posed to/considered by session participants: 1) how essential is knowledge of pathophysiology for medical students to obtain basic clinical competencies in history taking, physical examination skills, and communication? 2) how does clinical exposure prior to pathophysiology instruction impact students’ ability to reach an appropriate differential diagnosis? 3) how appropriate is it to start clinical clerkship experiences prior to pathophysiology instruction? three take home points from our session: 1) compared to students in a traditional curriculum, medical students starting clinical clerkships prior to pathophysiology instruction achieved comparable osce competency evaluations by standardized patients for history taking, physical examination, and communication skills. 2) compared to students in a traditional curriculum, medical students without pathophysiology instruction achieved comparable osce competency evaluations by faculty on 2 of 4 cases for history and physical, differential diagnosis, and management plans. 3) compared to students in a traditional curriculum, medical students without pathophysiology instruction achieved lower competency evaluations by faculty on 2 of 4 cases for history and physical, differential diagnosis, and management plans and further evaluation is necessary to characterize this gap. microsoft word doesempathyreallydeclinearticle.docx published by university of minnesota libraries publishing does empathy really decline during residency training? a longitudinal look at changes in measured empathy in a community program william j. crump, m.d.; craig h. ziegler, ph.d.; r. steve fricker. m.p.a. doi: https://doi.org/10.24926/jrmc.v4i4x.4206 journal of regional medical campuses, vol. 4, issue 4 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc william j. crump, m.d., residency faculty, baptist health madisonville family medicine residency and associate dean of the university of louisville trover campus at baptist health madisonville, madisonville, kentucky craig h. ziegler, ph.d., biostatistician with the university of louisville school of medicine office of graduate/undergraduate medical education, louisville, kentucky r. steve fricker. m.p.a., director of rural health/student affairs of the university of louisville trover campus at baptist health madisonville, madisonville, kentucky corresponding author: william j. crump, m.d. associate dean, university of louisville trover campus at baptist health madisonville 200 clinic drive, third north madisonville, ky 42071 p. 270.824.3515 f. 270.824.3590 e. bill.crump@bhsi.com all work in jrmc is licensed under cc by-nc volume 4, issue 4 (2021) journal of regional medical campuses original reports does empathy really decline during residency training? a longitudinal look at changes in measured empathy in a community program william j. crump, m.d.; craig h. ziegler, ph.d.; r. steve fricker. m.p.a. abstract introduction some studies, most cross sectional and urban, have shown a decline in empathy during residency training prompting medical educators to consider changes in curriculum or training environment. our aim was to determine if there was a decline using a longitudinal, paired annual empathy measure across 3 years of a family medicine residency in a rural community hospital. methods we administered the jefferson scale of empathy from 2015 through 2020 and of the 116 opportunities for survey completion, 112 from 48 residents were available for scoring. we also asked our residents to rank 10 factors that affected their empathy scores. the baptist health madisonville irb approved the protocol as exempt and the authors have no conflicts of interest. results with a response rate of 97%, we found no statistically significant decrease in our resident scores across the 3 years. scores after our pg-1 year were significantly lower than 2 previous comparable studies. the longitudinal, paired study design revealed very wide ranges among individual residents even when group means indicated a statistical difference. residents also differed widely on their rankings of factors that could affect the score, with only outlook on life showing a narrow range and high ranking. conclusions the very wide range of individual paired scores as well as the broad range of factors the residents thought affected their scores indicate that empathy is a very individual concept. some of our residents increased scores leading to resilience and others declined toward cynicism. those seeking to make changes to curriculum or training environment to facilitate empathy during residency should consider this diversity of individual resident training experience. introduction empathy is considered a key requirement to be an effective physician, but defining this characteristic is difficult. this is important for medical educators who seek to make modifications in curriculum or environment to assist learners in developing and then maintaining empathy for patients. some authors have considered empathy in the affective domain similar to sympathy and others consider it as more of a cognitive process much like curiosity.1 the differentiation we used as we designed our professional identity curriculum was that sympathy is journal of regional medical campuses, vol. 4, issue 4 original reports “i feel your pain,” and empathy is “i understand your suffering”.2 the jefferson scale of empathy, the most widely used and well-validated measure, was produced by a group that views empathy as largely cognitive.3 higher values by students on this empathy measure have been associated with positive clerkship faculty ratings of student clinical competence1 and patients with diabetes cared for by physicians with higher scores had better outcomes.4-5 there is some evidence that scores on these empathy measures decrease during the clinical phase of medical school, although the absolute change is small.6 there have been several publications documenting a decline in self-reported empathy across the years of residency training. we summarize the most pertinent ones here and they are compared in table 1. table 1: published studies showing decline of empathy during resident training ano statistics reported iri = interpersonal reactivity index jse = jefferson scale of empathy a report studied a cohort of 61 internal medicine residents at the university of pennsylvania from 2000 to 2003.7-8 the measure used was the interpersonal reactivity index (iri) and as the residents began their internship (pg-1) year they had better baseline scores for perspective taking and empathetic concern compared to general adult and college student populations. five months into the internship, there was a statistically significant decrease in empathetic concern measures. these residents then completed the measures through the end of their 3 years of training and the empathetic concern scores never recovered and were significantly lower than when the residents began. this was one of very few studies that were longitudinal, but scores were not paired by individual resident. another study conducted during 2002-2003 reported 47 interns in the internal medicine program at the university of pennsylvania.9 compared to the beginning of the year, reported depression, burnout, and chronic sleep deprivation significantly worsened across the year. measures of empathetic concern using the iri were more favorable than the general population at the beginning of the year, declined and approached the general population norms at the end of the year, and the difference was statistically significant. this is the only study we found that paired the results, but it was only one year duration. the iri is an old measure that is not designed specifically for medical trainees and defines empathy as reactions of one individual to the observed experiences of another.10 more commonly used than the iri is the jefferson scale of physician empathy (jse), which was designed for medical trainees and practitioners and has a very large reliability and validity literature.1,3-4,11-12 an early study using the jse addressed the hypothesis that empathy decreases during residency training.13 it was a cross-sectional study of 98 internal medicine residents at all 3 years of training at thomas jefferson university hospital, with a response rate of 84%. the residents were 43% women and, contrary to the jse reports from medical students,11 women did not have higher scores. their conclusions were that empathy remains stable across the entire 3 years of training, even though in the cross sectional design the individuals representing each year were different. they also compared jse scores to the american board of internal medicine humanistic qualities scale scores as assigned by the program director. they concluded that there was a positive but not significant relationship between the 2 measures and they thought the humanism instrument might be measuring something that is more like being respectful and sensitive rather than being empathic. they propose the jse as the better measure. a report from 2018 included 45 internal medicine residents in 3 community hospital training programs in flint michigan.14 one of the programs was osteopathic and 2 were allopathic. this was a crosssectional study done between may and september of 2014. a baseline was done in the first few months of the first postgraduate year and the others were done journal of regional medical campuses, vol. 4, issue 4 original reports in the summer at the end of each training year. there was a 35% response rate. they conclude that empathy increased over the first year of training and then declined across the next 2 years, but none of the changes were statistically significant. a 2019 study addressed the association of empathy and burn out among 35 emergency medicine residents and 33 attending physicians at a tertiary referral county hospital.15 it was cross-sectional and done in winter 2018/2019. they found self-reported empathy to decrease during residency training and to be higher among attendings. reported burnout was very high among residents and was lower in the attendings. they found a weak negative correlation between self-reported empathy and the category of burnout classified as patient-related, but not the personal-related or work-related burn out categories. statistics were not reported. in 2018, we published a pilot one-year study of paired jse results before and after implementation of a 6month professional identity curriculum with 18 family medicine residents at all 3 levels of training at a rural community hospital.16 we found stable jse scores at the end of the curriculum and then significant decline when measured 6 months after the end of the curriculum. residents who attended more professional identity sessions showed a nonsignificant smaller decline, and there were large standard deviations within each training level with some individual residents showing little change across the year. this curriculum was not continued beyond the pilot because of a change in the didactics schedule. our goal in this study was to measure empathy using the jse at baseline and annually across all 3 years of the family medicine residency at our rural community hospital. we used a methodology that allowed us to match each response to the individual, providing a truly longitudinal paired measure for comparison to previously published cross-sectional reports that were based in larger cities. methods setting our program is based in a town of 20 000 in a rural area in the upper southeast, with 6 residents in each year and no other residencies in town. it was begun in 1971, becoming the 85th family medicine program in the united states and the first in the state.17 the mission is focused on providing rural family physicians for our region, and at the last report 49% of graduates remain in rural practice and 41% were practicing within 100 miles of the program. the host hospital is part of a statewide system, with 312 licensed beds and 140 in operation. at last report, there were 5 189 annual discharges, 26 000 ed visits, 40 000 outpatient visits, and 640 births. the site is also host for our regional rural medical school campus, with the main campus in a metropolitan community 160 miles away.18 although administratively separate, in such a small site students and residents share all facilities, faculty, and most other resources. survey process beginning in 2015, 48 different residents completed the empathy survey either just as the new academic year began, or just as it ended, resulting in an annual survey for each resident. each survey had the resident’s name included for later matching, and residents placed the completed surveys into an envelope confidentially. participants were assured that a research assistant unknown to them would then assign their id number and subsequently no one would be able to connect their responses to their name. during the study period, one resident missed completing a baseline survey, one missed the postpg-2, and one missed the post pg-3 surveys. we excluded one resident survey because the name was not provided on the form, and so the final response rate was 112/116 (96.6%). the results reported by year of training are from the graduating classes of 2016-2023, with the full complement of all 4 surveys reported for the classes of 2019-2020. after the residents had completed the jse, we asked them to rank 10 factors that may have affected how they answered the empathy scale. we developed these factors during focus groups in 2015 after the conclusion of the 6-month implementation of our professional identity curriculum.16 these included 2 items that could be considered traits, 4 that were described as daily irritants that could affect empathy if it were a state that could change frequently, one that specifically addressed confidence in the doctor journal of regional medical campuses, vol. 4, issue 4 original reports role, 2 that addressed the negative effect of the “hidden curriculum”,19 and lastly the effect of continuity of patient care. residents were asked to rank 10 items with 1= most important and 10= least important in response to “i think the following explains the empathy score of an individual resident”. we drew resident demographics from their applications and summarized these using frequencies and percentages. we compared jse scores among ours and 2 previous reports at baseline, post pgy 1, post pgy 2, and post pgy 3 using one way analysis of variance at each time. if we found significant differences, we performed a tukey post hoc test. we used a one-way analysis of variance to find any difference among the training years as well as to compare ours with the other 2 previous reports. for our data, we created spaghetti plots showing the wide variation among individual resident scores. we used ibm spss statistics for windows (version 26.0, 2019, ibm corporation, armonk, ny, 877-426-6006) and the website statpages.info20 to analyze the data. we created figures with the r package ggplot2.21 statistical significance was set by convention at p <0.05. results as shown in table 2, most residents were male and white, with significant proportions of hispanic and asian. almost 21% were older than those who went directly through schooling with no gap years. seventythree percent graduated from medical schools outside of the u.s., and 28% were rural. table 2: demographics of residents (n=48) arural was defined as a hometown population of <30,000 and a non-metro rural urban continuum code (rucc).22 bn=40. eight residents were born outside of u.s. and rucc could not be applied to them to determine rurality. the second column in table 3 shows that there were no significant changes across the 3 years of training in our population. the last column and row labeled baseline shows that at baseline one previous study had a higher score than ours as well as higher than the baseline from the other program shown, but this was not significant. our residents showed a significant decline after the pg-1 year when compared to either of the other studies. as shown graphically in figure 1, it is noteworthy that one of the programs showed an increase in empathy scores after the pg-1 year. journal of regional medical campuses, vol. 4, issue 4 original reports table 3: jse means of training by year of 3 programs areflect p-value of .057 between current data and foreback using tukey’s post hoc test breflect p-value of .057 between current data and mangione tukey’s post hoc test creflects one way analysis of variance for differences of means for current data. dreflects one way analysis of variance for differences of means as reported by foreback ereflects one way analysis of variance for differences of means as reported by mangione. figure 1: changes of empathy across time for residents of selected programs the above comparisons use group means to demonstrate differences. given the relatively large standard deviations, figure 2 shows the individual resident paired scores across all 4 measures, and figure 3 shows the same for a larger group including some who began our program before we started doing a baseline survey. figure 2: individual resident jse scores by training year (n=9) figure 3: individual resident jse scores by training year (n=15) table 4 shows the ranking of the 10 factors that the residents thought explained their empathy scores, with general outlook on life clearly the highest rank with a narrow range. all the others showed very wide ranges, with continuity of care the lowest ranking factor. journal of regional medical campuses, vol. 4, issue 4 original reports table 4. ranking of empathy factors identified by residentsa (n = 41). aanswers in response to “please rank order each factor from 1 to 10, using each number only once: 1 = most important in explaining an individual resident’s empathy score; 10 = least important in explaining an individual resident’s empathy score” discussion for many, the evidence that empathy declines during residency is not convincing.6 the 3 previous publications that reported jse score decline were cross sectional and did not find any statistically significant differences.13-15 the 2 reports that did find a significant decline during residency training were done using the iri that is designed to be used in the general population. these were both done in the same university hospital in philadelphia, and both were limited to internal medicine.7-9 the iri did have a moderate correlation (r=0.45, r2=0.20, p<.01) with the jse in a study at another philadelphia university hospital internal medicine program.23 even with this finding, 80% of the variation in the iri was not explained by the jse, suggesting they may not be measuring exactly the same thing. focusing just on studies using the jse, there are very wide standard deviations around the means, including the results reported here. how can we explain that in our previous study there was a significant decline after our professional identity curriculum ceased and in this study that we found significantly lower scores after the pg-1 year when compared to the other 2 comparable reports? it is tempting to echo what many other reports have cited as explanations including the dehumanizing effects of medical training and the stress and time demands of residency.7-8,24 there is certainly some degree of truth in those explanations, probably different among programs and perhaps changing with more recent duty hour limitations and night float routines, but it may be that empathy is such an individually defined concept that inferential statistics may not provide a view of the full truth. there are clear advantages to using means to display inferential statistical results, but in the case of empathy, this may obscure more important findings. in our previous study, the significant decline when looking at all 18 residents after the end of our professional identity curriculum was almost entirely explained by the sharp decline in our pg-3 class, as there were no significant changes across the year in the other 2 classes.16 this prompted us to look more closely at individual scores in the current study. our study design allows us to match individual scores across all longitudinal jse measures. review of figure 2 shows that while the mean did decrease from baseline to post pg-1, 3 of the 9 residents showed very little change and 2 actually increased. in addition, one showed a marked decrease after the pg-2 year, 2 showed a remarkable recovery after the pg 2 year, and one showed a steady decline after the pg-1 year. figure 3 shows similar findings including a class that began before we started doing the baseline measures, thus increasing the group to 15. this mirrors what we previously reported where the means changed very little during the 6-month implementation of our professional identity curriculum and then significantly decreased 6 months after it was completed.16 looking at the individual jse scores from that study, only 6 of the 18 residents showed a decrease, 8 showed little change, and 4 actually increased. these findings suggest that even using a very reliable and valid survey, measured empathy varies widely among individual residents, as they experience their training time differently. this raises the possibility that there may be individual resident characteristics or other life experiences that modulate the effect of the training period, leading some to resilience and others to cynicism. this assumes that the exposure of journal of regional medical campuses, vol. 4, issue 4 original reports each resident to the effects of the “hidden curriculum”19 that may erode empathy is similar. the original use of this term referred to the institutional policies, resource allocation, evaluation systems, and institutional “slang” that explain what a student learns beyond the formal and informal curriculum. assuming similar exposure to the hidden curriculum is a questionable assumption in most large programs where month to month or even week to week the resident works in different environments from those their classmates experienced during the same rotation. our study site provides an opportunity to decrease this potential confounder significantly, as each resident works with the same small faculty of various specialties, residents at other levels, and nursing staff in the same physical facility as their classmates on each rotation, with no residents of other specialties or fellows present. to begin to explain the wide range of jse responses, we asked our residents first to brainstorm in a focus group all the factors that might affect a resident’s score on any given day, and then individually to rank their perceived importance. as shown in table 4, the rankings varied widely. some of these items are the daily irritants of being a resident and others, including the highest ranked item of “outlook on life” would be more stable day to day. our resident responses highlight the problem with the overly simplistic “state versus trait” debate about empathy and many other interpersonal attribute measures.25-29 if our residents saw empathy as more of a trait that is stable day to day, childhood experiences would not be expected to be ranked so low. the high rankings of sleep deprivation and administrative work suggest that many of our residents see empathy as more of a state that can change as often as daily. perhaps the most important message from table 4 is the very wide variability among our residents, further supporting that measured empathy is a nebulous and highly individual concept. strengths and limitations as with all single site studies including all previous reports on this issue, ours is subject to selection bias and limited generalizability. residents who match to a rural regional hospital in an upper southeastern town of 20 000 are likely very different from those who match to university hospitals in philadelphia7-9,13 and even from those at community hospitals in a town of 100 000 in michigan.14 since none of those previously reported sites are representative of residencies nationwide, our report may provide some balance for the evidence, and other study sites are needed. none of the previous publications provided details of their resident demographics for comparison. as other programs with different demographics and larger resident classes study measures of empathy, it would be useful to compare these to our findings. our results are also subject to type 2 error because of small group sizes, although ours is comparable in size to most previous studies. all but one previous report using the jse were cross sectional, and our study used longitudinal, matched data with a loss rate of only 3%. future studies from other sites would be more useful if a high response rate and matched individual results could be reported. our next research effort is to look more closely at individual factors that may be associated with an individual resident’s resilience and susceptibility to empathy decline during training. this will include demographics, measures of burnout, and individual resident opinions of the value of various methods to avoid burnout. we will also look more deeply into the overlap among faculty-perceived resident empathy and other resident characteristics such as respect, sensitivity, and curiosity. conclusions in our resident population, we found some nonsignificant declines in mean measures of empathy and our post pg-1 mean values were significantly lower than the 2 previous comparable studies. however, using individual paired comparisons there appear to be subsets of our residents who react very differently during their training time. some are resistant to decline or even improve measures of empathy, demonstrating resilience, and others move towards cynicism. interventions to change residency training to facilitate empathy should consider this diversity of individual resident experience. journal of regional medical campuses, vol. 4, issue 4 original reports references 1. hojat m, gonnela js, mangione, et al. empathy in medical students as related to academic performance, clinical competence, and gender. med educ. 2002;36:522-527. doi: 10.1046/j.1365-2923.2002.01234.x. 2. crump, wj. professional identity curriculum at the university of louisville trover campus: reflection and meaning in medical education. j ky acad fam physicians. 2017;winter:88:18. 3. hojat m, vergare mj, maxwell k, brainard g, herrine sk, isenberg ga, et al the devil is in the third year: a longitudinal study of erosion of empathy in medical school. acad med. 2009;84(9):1182-1191. doi: 10.1097/acm.0b013e3181b17e55. erratum in: acad med. 2009 nov;84(11):1616. 4. hojat m, louis dz, markham fw, wender r, rabinowitz c, gonnela js. physicians’ empathy and clinical outcomes for diabetic patients. acad med. 2011;86(3):359-364. doi: 10.1097/acm.0b013e3182086fe1. 5. del canale s, louis dz, maio v, et al. the relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in parma, italy. acad med. 2012;87(9):1243-1249. doi: 10.1097/acm.0b013e3182628fbf. 6. colliver ja, conlee mj, verhulst sj, dorsey jk. reports of the decline of empathy during medical education are greatly exaggerated: a reexamination of the research. acad med. 2010; 85:588-593. 7. bellini lm, baime m, shea ja. variation of mood and empathy during internship. jama 2002; 287:3143-3146. 8. bellini lm, shea ja. mood change and empathy decline persist during three years of internal medicine training. acad med. 2005; 80:164-167. 9. rosen im, gimotty pa, shea ja, bellini lm. evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burn out among interns. acad med. 2006; 81:82-85. 10. davis mh. measuring individual differences in empathy: evidence for a multidimensional approach. j of personality and social psychology. 1983; 44:113-126. doi: 10.1037/0022-3514.44.1.113. 11. hojat m, gonnella js. eleven years of data on the jefferson scale of empathy-medical student version (jse-s): proxy norm data and tentative cutoff scores. med princ pract. 2015;24(4):344-350. doi: 10.1159/000381954. epub 2015 apr 28. 12. hojat m, shannon sc, desantis j, speicher mr, bragan l, calabrese lh. does empathy decline in the clinical phase of medical education? a nationwide, multi-institutional, cross-sectional study of students at dogranting medical schools. acad med. 2020;95(6):911-918. doi: 10.1097/acm.0000000000003175. 13. mangione s, kane gc, caruso jw, gonnella js, nasca tj, hojat m. assessment of empathy in different years of internal medicine training. medical teacher. 2002;24(4):370-373. 14. foreback j, kusz h, lepisto bl, pawlaczyk b. empathy in internal medicine residents at community-based hospitals: a cross-sectional study. j med educ curric dev. 2018;5:1-4. 15. wolfshol ja, bradley k, bell c, bell s, et al. association between empathy and burn out among emergency medicine physicians. j clin med res. 2019; 11(7): 532-538. 16. crump wj, ziegler ch, fricker rs. a residency professional identity curriculum and a longitudinal measure of empathy in a community-based program. j reg med campuses. 2018;1(4). doi: 10.24926/jrmc.v1i4.1353 . 17. martin da. a short history of trover clinic with commentary. mcclanahan publishing house: kuttawa, kentucky, 1989. 18. crump wj, fricker rs, ziegler ch, wiegman dl. increasing the rural physician workforce: a potential role for small rural mmedical school campuses. j rural health. 2016 jun;32(3):2549. doi: 10.1111/jrh.12156. epub 2015 oct 30. 19. hafferty fw. beyond curriculum reform: confronting medicine's hidden curriculum. acad med.1998 73(4):403-407. 20. pezzullo jc. analysis of variance from summary data: statpages website. accessed february 3, 2021. https://statpages.info/anova1sm.html. journal of regional medical campuses, vol. 4, issue 4 original reports 21. wickham h. (2016). elegant graphics for data analysis ggplot website. new york, n.y.: springer-verlag; https://ggplot2.tidyverse.org. accessed february 3, 2021. 22. united states department of agriculture, economic research service. 2003 rural urban continuum codes. http://www.ers.usda.gov/data-products/ruralurban-continuum-codes.aspx last accessed september 17, 2020. 23. hojat m, mangione s, kane gc, gonnella js. relationships between scores of the jefferson scale of physician empathy (jspe) and the interpersonal reactivity index (iri). medical teacher. 2005;27(7):625-628. 24. shanafelt td, west c, zhao x, et al. relationship between increased personal well-being and enhanced empathy among internal medicine residents. j gen intern med. 2005;20(7): 177-183. 25. costa-drolon e, verneuli l, manolios e, revahlevy a, sibeoni j. medical students’ perspectives on empathy: a systematic review and metasynthesis. acad med. 2021;96:142154. 26. schwartz zh. commentary on an excerpt from daybreak: thoughts on the prejudices of morality. acad med. 2020;95 (9):1382-1383. 27. sulzer sh, feinstein nw, wendland cl. assessing empathy development in medical education: a systematic review. med educ. 2016;50:300-310. 28. spiro hm. empathy: an introduction and what is empathy and can it be taught? in empathy and the practice of medicine. spiro hg, curnen mgm, peschel e, st. james d, eds. yale university press, new haven and london, 1993, pp1-14. 29. glick sm. the empathetic physician: nature and nurture. in empathy and the practice of medicine. spiro hg, curnen mgm, peschel e, st. james d, eds. yale university press, new haven and london, 1993, pp 85-102. microsoft word changes in labor and delivery patterns article.docx published by university of minnesota libraries publishing changes in labor and delivery patterns and outcomes after rural obstetrical service closure jennifer pearson md, samantha friedrichsen mph, leif olson, ms2, mbs doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 1, issue 4 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc jennifer pearson, md; university of minnesota medical school, duluth campus, department of family medicine and biobehavioral health. samantha friedrichsen, mph; university of minnesota medical school, duluth campus, department of family medicine and biobehavioral health. leif olson, ms2, mbs; university of minnesota medical school, duluth campus, department of family medicine and biobehavioral health. corresponding author: jennifer pearson md, university of minnesota medical school, duluth campus, department of family medicine and biobehavioral health, 1035 university drive, smed 157, duluth, minnesota 55812-3031, usa. phone: (218) 726-7574 fax: (218) 726-7699 email: jpearso1@d.umn.edu all work in jrmc is licensed under cc by-nc volume 1, issue 4 (2018) journal of regional medical campuses original report changes in labor and delivery patterns and outcomes after rural obstetrical service closure jennifer pearson md, samantha friedrichsen mph, leif olson, ms2, mbs abstract the number of rural hospitals offering labor and delivery services has been declining across the united states for decades. as a part of this trend, labor and delivery services at cook county north shore hospital in grand marais, minnesota were discontinued in july 2015. the closure necessitates that patients now travel to duluth, 110 miles away, for hospital-based delivery services. partnership between duluth’s regional campus medical school and this rural community has grown to incorporate researching the effects of this closure on the cook country region including the community of grand marais. a prior study undertaken evaluated patients’ perspectives on this loss of local obstetrical services. the present study’s purpose was to characterize the utilization and clinical outcomes of obstetrical care for patients before and after local labor and delivery services were discontinued. retrospective chart review compared measures before and after delivery services were discontinued locally. although not statistically significant, patterns since closure include an increased percentage of inductions, home births, and cesarean deliveries for women in cook county. introduction there has been a significant decline over the past couple of decades in the number of rural communities providing obstetrical services throughout the united states, canada, and elsewhere.1–4 according to the united states census bureau statistics from 2010, nearly 18 million reproductiveaged women live in rural counties. up to 40% of counties housing these rural women lack a qualified healthcare provider.5 it has also become increasingly clear that there is an association between loss of hospital-based obstetrical services and birth outcomes in rural counties.6–8 one of the limitations discussed in kozhimannil et al’s 2016 national analysis is that county data is the only available unit of analysis, but that counties vary considerably. it was suggested that future work assess the associations between obstetrical service loss and individual outcomes. our study focuses on patients seen at the sawtooth mountain clinic (smc) in grand marais, minnesota. grand marais has a population of 1,351 and is the county seat of cook county. cook county has a median household income of $51,793, a poverty rate of 10.1%, a population of foreignborn residents of 4.7%, and a percentage of the population over 25 years of age with a bachelor’s degree or higher of 39.6%.9 in addition to patients in cook county and surrounding areas, smc also partners with the grand portage band of lake superior chippewa health services to provide some services for band members in cook county and on the grand portage indian reservation. cook county north shore hospital (ccnh) in grand marais discontinued local obstetrical services in july of 2015. for decades prior to this closure, ccnh did not have epidural or surgical capabilities. local providers would assess women during prenatal care and determine whether they were low-risk, thus candidates for local delivery. surgical or higher risk patients were referred to regional providers for collaborative prenatal care between local and regional providers, with deliveries planned for a regional hospital. no regular home birth providers practiced in the area, so these patients did not have care coordinated by smc providers either prior to or post closure. since the closure of local obstetrical services, hospital management of labor and delivery now requires travel to a regional hospital in duluth, minnesota, 110 miles away. st. mary’s and st. luke’s hospitals are located within a mile of each other on the same central hillside in duluth, making the slight difference to each of them from ccnh insignificant. only emergent deliveries are currently done at ccnh. grand marais serves as one of the longitudinal rural medical scholars program (rmsp) preceptorship sites for medical students from the university of minnesota medical school’s duluth campus. given the campus’s mission to improve healthcare outcomes in rural minnesota and american indian communities by educating medical students, creating strong regional partnerships, and fostering research, a closer look at the local effects of obstetrical service closure was felt to be relevant not only to the affected community, but to the doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original report future providers of rural communities elsewhere facing similar issues. a prior study, which also grew out of the rmsp preceptorship in grand marais, looked at patients’ perspectives as a result of the loss of local obstetrical care.10 the present study’s purpose is to add to the initial study by characterizing obstetrical care utilization and obstetrical care clinical outcomes for patients before and after local labor and delivery service discontinuation. by taking a unique opportunity to observe these characteristics in one rural community before and after local obstetrical unit closure, we aim to better understand the changes resulting from local closure and whether prior patient concerns voiced are being actualized. this individual community study contributes a better understanding of the effects of local obstetrical care service closure on rural-dwelling parturient women. methods data collection a retrospective chart review was conducted on patients at smc in grand marais, comparing pregnancy and delivery outcomes before and after local delivery service discontinuation. this study included patients who received prenatal care at smc for singleton pregnancies with deliveries occurring at 24 weeks gestation or longer between january 1, 2013 and may 15, 2017, the maximum possible duration for available chart review time and resources. the time period for deliveries before the discontinuation of obstetrical services is from january 1, 2013 to june 30, 2015 when data collection began (2 years and 6 months duration); while the time period after the discontinuation is from july 1, 2015 may 15, 2017 (1 year and 10.5 months duration). data from the charts was entered into a redcap database by trained study investigators.11 the study was conducted in compliance with the university of minnesota’s institutional review board requirements for human research protection. statistical methods demographics and characteristics of the patients and pregnancies were summarized overall, and before/after discontinuation of local labor and delivery services using descriptive statistics. delivery patterns and birth outcomes were summarized by year using descriptive statistics (mother’s age, gravidity/parity, gestation at delivery, delivery site, type of delivery, inductions, baby sex, baby weight, baby apgar scores, etc.). due to the correlated nature of the data (multiple deliveries per mother), generalized estimating equations (gee) with a repeated measures statement for mother were used to test for differences in the rates of interest listed above from before to after the discontinuation of services, using an independent working correlation structure. for binary outcomes (i.e. inductions, assisted deliveries, and c-sections), a binary distribution and logit link were used in the gee, and for continuous outcomes (i.e. gestation, baby weight, and apgar scores), a normal distribution and identity link were used in the gee. results are reported as regression point estimates β and standard errors (se), as well as odds ratios and 95% confidence intervals (for binary outcomes only). pvalues <0.05 were considered statistically significant, and sas v.9.4 (sas institute, cary, nc) was used for analysis. results sample our sample size for analysis was 160 deliveries at 24 weeks gestation or longer, resulting from singleton pregnancies for 137 women. in addition to data on delivery characteristics, we extracted data on a subset of the babies resulting from these deliveries (n=110). data was unavailable for babies from the remaining 50 deliveries due to incomplete records from out-of-county providers available in smc medical records. all 160 deliveries were live births. about half of the deliveries (n=78, 49%) were from before the discontinuation of labor and delivery services, and the other half were from after (n=82, 51%). most women had only one delivery in the dataset (n=115/137, 84%), while a small number had 2 deliveries (n=21, 15%), and only one had 3 deliveries (1%). a small group of mothers (14%, n=19/137) had at least one delivery in both time periods. there were no statistically significant differences in mother age, mother gravidity, or baby sex between deliveries before and after discontinuation of delivery services in grand marais (table 1). outcomes as expected, significantly fewer deliveries occurred at ccnh after delivery services were discontinued. deliveries at st. mary’s hospital in duluth became more common, increasing from 33.3% to 51.2%, but there was no statistically significant change in the deliveries at st. luke’s hospital in duluth (41% vs. 38%) or deliveries at a hospital other than those listed (1.3% vs. 3.7%). the proportion of home births trended up (1.3% vs. 4.9%), but statistical significance was not achieved. there were no statistically significant changes in the gestational age at delivery, nicu transfers, baby weight, or baby apgar scores when comparing deliveries before and after the discontinuation of delivery services. both induction rates and cesarean section rates trended up (23.1% to 29.3% and 25.6% to 28% respectively) after local delivery services were discontinued, however these changes were not statistically significant. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original report discussion population-based studies have shown that the need for rural women to travel to access intrapartum maternity services is associated with adverse outcomes for newborns and mothers and increased interventions.6,12 these findings include increased rates of inductions and unplanned out of hospital deliveries.1,12–14 this project’s aim to characterize utilization and clinical outcomes of obstetrical care for patients in one specific community before and after local labor and delivery service discontinuation shows consistency with what has been documented in these population-based studies. the patterns seen in grand marais and cook county including increasing induction rate, cesarean delivery rate, and percentage of home births may have resulted from loss of local obstetrical services. given our lack of statistically significant findings, however, larger studies are needed to confirm these trends, but patterns should continue to be monitored. others have discussed the changing risk and cost to communities and individual parturient patients when local delivery is no longer an option.1,3,10,15–19 the risks and costs to an individual community such as grand marais can thus start to be more easily articulated and calculated if these trends continue. the local change in services produced ripple effects observed at a regional level as birth location shifted to hospitals in duluth. interestingly, one duluth hospital experienced an increase percentage of deliveries while the other experienced a decrease in deliveries to mothers from cook county. explanation for this trend is beyond the scope of this study, but likely results from patient preferences, insurance coverage, and/or availability of neonatal services at each. further evaluation of this trend may be of interest to regional hospitals desiring to attract out-of-region patients. there are some limitations to keep in mind when interpreting the findings of this study. first, the sample size is small, and the analyses are likely under powered, increasing the risk of type ii error. continuing to follow trends, and ultimately looking at an expanded time frame before and after the service change would improve sample size. second, we were not able to extract all the data for the babies, as previously addressed, which may bias the baby-level outcomes. lastly, these results are from a small rural town in minnesota and may not be fully generalizable to areas of the country with different demographics or pregnancy characteristics. additionally, the pregnancies in this sample are mostly lowrisk with only a small number of pregnancy complications reported. the discontinuation of delivery services may have a stronger impact on more complicated pregnancies than the deliveries in our sample, but unfortunately, we do not have the sample size to explore this possibility. conclusion after discontinuation of local hospital delivery services in grand marais, minnesota, the proportion of deliveries decreased at cook county north shore hospital and increased in duluth as expected. our data do not provide enough evidence to conclude that rural pregnancy outcomes changed after the discontinuation of the local hospital delivery services. nevertheless, patterns in this dataset are consistent with population-based studies and warrant further investigation: increasing rates of home births, inductions, and caesarian deliveries. with loss of local obstetrical services, each of these variables trended upward. the results of our study can be used to help design larger studies of rural pregnancy outcomes at the individual level in communities with comparable demographic characteristics facing potential changes to local service availability. comparison could also be made to trends being seen in communities with contrasting demographic profiles. further refinement of the patterns highlighted in our study could allow rural communities to better understand the local effects of loss of obstetrical services, and the risks and costs associated. this understanding can allow communities to better respond to the specific healthcare needs and concerns of their rural parturient women. references 1. kornelsen j, grzybowski s. the reality of resistance: the experiences of rural parturient women. j midwifery womens health. 2006;51(4):260-265. 2. kozhimannil kb, casey mm, hung p, han x, prasad s, moscovice is. the rural obstetric workforce in us hospitals: challenges and opportunities. j rural health off j am rural health assoc natl rural health care assoc. 2015;31(4):365-372. doi:10.1111/jrh.12112 3. hutten-czapski p. the state of rural health care presentation to the standing senate committee on social affairs, science and technology. presented at the: may 31, 2001. https://www.srpc.ca/pdf/staterural-healthcare.pdf. accessed may 25, 2017. 4. rourke jt. trends in small hospital obstetric services in ontario. can fam physician. 1998;44:2117-2124. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original report 5. kozhimannil kb, henning-smith c, hung p, casey mm, prasad s. ensuring access to high-quality maternity care in rural america. womens health issues off publ jacobs inst womens health. 2016;26(3):247-250. doi:10.1016/j.whi.2016.02.001 6. kozhimannil kb, hung p, henning-smith c, casey mm, prasad s. association between loss of hospitalbased obstetric services and birth outcomes in rural counties in the united states. jama. 2018;319(12):1239-1247. doi:10.1001/jama.2018.1830 7. lisonkova s, sheps sb, janssen pa, lee sk, dahlgren l, macnab yc. birth outcomes among older mothers in rural versus urban areas: a residence-based approach. j rural health off j am rural health assoc natl rural health care assoc. 2011;27(2):211-219. doi:10.1111/j.1748-0361.2010.00332.x 8. grzybowski sc, cadesky as, hogg we. rural obstetrics: a 5-year prospective study of the outcomes of all pregnancies in a remote northern community. cmaj can med assoc j j assoc medicale can. 1991;144(8):987-994. 9. united states census bureau: american fact finder; 2010. https://factfinder.census.gov/faces/tableservices/jsf /pages/productview.xhtml?src=cf. accessed june 19, 2018. https://www.census.gov/quickfacts/fact/table/cook countyminnesota/edu635216?#viewtop 10. pearson j, siebert k, carlson s, ratner n. patient perspectives on loss of local obstetrical services in rural northern minnesota. birth berkeley calif. december 2017. doi:10.1111/birt.12325 11. harris pa, taylor r, thielke r, payne j, gonzalez n, conde jg. research electronic data capture (redcap)--a metadata-driven methodology and workflow process for providing translational research informatics support. j biomed inform. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010 12. grzybowski s, stoll k, kornelsen j. distance matters: a population based study examining access to maternity services for rural women. bmc health serv res. 2011;11:147. doi:10.1186/1472-6963-11-147 13. kornelsen j, moola s, grzybowski s. does distance matter? increased induction rates for rural women who have to travel for intrapartum care. j obstet gynaecol can jogc j obstet gynecol can jogc. 2009;31(1):21-27. 14. iglesias s, bott n, ellehoj e, et al. outcomes of maternity care services in alberta, 1999 and 2000: a population-based analysis. j obstet gynaecol can jogc j obstet gynecol can jogc. 2005;27(9):855863. microsoft word learning during covid-19 article.docx published by university of minnesota libraries publishing learning during covid-19: rapid e-learning transition at a regional medical school campus ramey moore; rachel s. purvis; cari bogulski; tina maddox; lauren k. haggard-duff; tom k. schulz; scott warmack; angel holland; pearl a. mcelfish doi: https://doi.org/10.24926/jrmc.v4i2.3645 journal of regional medical campuses, vol. 4, issue 2 (2021) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc ramey moore; college of medicine, university of arkansas for medical sciences northwest, fayetteville, arkansas, 72703, usa rachel s. purvis; college of medicine, university of arkansas for medical sciences northwest, fayetteville, arkansas, 72703, usa cari bogulski; office of community health and research, university of arkansas for medical sciences northwest, fayetteville, 72703, usa tina maddox; college of health professions, university of arkansas for medical sciences northwest, fayetteville, arkansas, 72703, usa lauren k. haggard-duff; college of nursing, university of arkansas for medical sciences northwest, fayetteville, arkansas, 72703, usa tom k. schulz; department of internal medicine, university of arkansas for medical sciences northwest, fayetteville, arkansas, 72703 scott warmack; college of pharmacy, university of arkansas for medical sciences northwest, fayetteville, arkansas, 72703 angel holland; college of health professions, university of arkansas for medical sciences northwest, fayetteville, arkansas, 72703, usa pearl a. mcelfish; college of medicine, university of arkansas for medical sciences northwest, fayetteville, arkansas, 72703, usa corresponding author: pearl a. mcelfish 1125 n college ave, fayetteville, ar 72703; phone: (479) 713-8680; email: pamcelfish@uams.edu; fax: (479) 713-8670 all work in jrmc is licensed under cc by-nc volume 4, issue 2 (2021) journal of regional medical campuses original report learning during covid-19: rapid elearning transition at a regional medical school campus ramey moore; rachel s. purvis; cari bogulski; tina maddox; lauren k. haggard-duff; tom k. schulz; scott warmack; angel holland; pearl a. mcelfish abstract covid-19 has changed the day-to-day landscape of education for students, faculty, and staff worldwide, and this is especially true for students in health sciences and medical education programs. this paper explores the effects of the rapid shift to e-learning modalities for students at the university of arkansas for medical sciences northwest, a regional medical campus located in northwest arkansas. a survey and open-ended written interview questions was conducted with a total of 144 student respondents and in-depth follow up interviews were conducted with 29 of those students. utilizing descriptive statistics and qualitative descriptive analysis, the survey and interviews explored the effects of covid-19 on the lived experiences of students as part of the transition to e-learning. we found that 64.5% students reported satisfaction with the transition to e-learning as good or very good and the primary themes that influenced e-learning success for students were: communication, technology, pedagogy, and community. introduction e-learning has become an increasingly important area for content delivery, especially for technical and postgraduate education.1 e-learning for some educational programs has become routine, but for many students in medicine, pharmacy, and other health professions, elearning is still relatively novel.2 as of april 20, 2020, more than 1.5 billion students have been affected by covid-19-related closures across 191 countries.2,3 the effects of the covid-19 pandemic penetrate to nearly every aspect of the contemporary world and most colleges and universities moved to online instruction during the spring of 2020 as a way of protecting students, staff, instructors, administrators, and faculty from exposure to covid-19.2,4,5 prior studies demonstrate that a transition to e-learning in health sciences and medical curricula should be conducted with careful planning, and the skills that faculty need for e-learning contexts can be widely divergent from successful face-to-face pedagogies.6 the onset of a pandemic allowed for neither careful planning nor the careful training of faculty in e-learning pedagogies. it is important that researchers, administrators, and educators understand and evaluate the successes and failures of education systems and pedagogical practices during this rapid transition to elearning. there are more than 1 400 regional medical and health sciences campuses (rmc) across the united states.7 the liaison committee on medical education, which provides accreditation for medical education programs in the united states and canada, defines an rmc as “an instructional site that is distinct from the central/administrative campus of the medical school and at which some students spend one or more complete curricular years”.8 regional medical campuses do not often compare to the infrastructure and resources of an institution’s main campus; however, some regional journal of regional medical campuses, vol. 4, issue 2 original report campuses may more commonly implement online learning platforms.9,10 little is known about how regional medical campuses transition to e-learning. this article analyzes student experiences related to the transition to e-learning on a regional medical campus, presenting lived experiences of these students. this article indicates areas of concern for institutional responses to future pandemics or emergencies that may require such transitions in the future. the university of arkansas for medical sciences (uams) is the state’s only academic health center. uams northwest is a regional campus with 268 students in 4 colleges: health professions (genetic counseling, physical therapy, occupational therapy, and radiologic imaging sciences), medicine, nursing, and pharmacy. uams northwest also has primary and specialty clinical care clinics, residency programs, research, and community health education programs. educational programs varied in use of e-learning prior to covid-19. most health professions courses were taught with in-person faculty with a limited amount of interactive video courses. pharmacy and medicine students were already familiar with some in-person course and some interactive video classes that had been deployed to ensure consistent education across campuses. interactive video classes included several students sitting together in a classroom with a live faculty member in their classroom and second faculty member remotely teaching on the interactive video. some programs, such as graduate nursing programs, instruction almost exclusively relied on e-learning prior to covid-19. all programs had extensive clinical rotations at uams and partner health care institutions. the decision to cancel classes was communicated by email to all faculty, staff, students, and clinical partners on thursday, march 12th, 2020. for most programs, classes were canceled for one week, and leaders within each of the colleges managed the logistics of shifting course materials to online, to an e-learning system for course delivery and management, with attention to accreditation standards for each program. the college of health professions (genetic counseling, physical therapy, occupational therapy, and radiologic imaging sciences) made the transition over the weekend and began e-learning instruction on monday, march 16th, 2020. to protect student health, all students were removed from in-person clinical rotations at uams and partner health care institutions. some clinical education continued utilizing telemedicine technology. the amount of latitude in pedagogy and delivery technology for individual instructors or courses varied, but leaders from each college worked to harmonize approaches for delivery, testing, clinical/practical instruction, and lab and manual instruction to keep students on track. university library technology and academic affairs staff worked to make available new educational technology to further support the transition of all programs to e-learning platforms. communication with students was conducted at multiple institutional levels simultaneously. students received daily updates from the uams chancellor’s office related to covid-19, including local infection numbers, and numbers of patients in uams medical facilities. programs and colleges directly communicated with students regarding changing expectations and standards within each program’s curriculum. programs also conducted outreach and sought feedback from students regarding administrative issues, student health and wellbeing, and issues related to coursework. faculty met with students, one-on-one, and in small groups, using phone and video communication methods to provide support and instruction. methods uams northwest has conducted a yearly program evaluation survey to capture student experiences on the uams northwest campus. the 2020 version of this survey included questions on covid-19 and e-learning. all 268 students enrolled in programs on the uams northwest campus were sent an email with the evaluation survey. the qualitative interview respondents were recruited using a stratified (by academic unit) randomized list of survey respondents. the survey instrument captured students’ demographic information and included questions regarding their experience on the uams northwest campus. in may and june of 2020, covid-19-specific questions were included on the survey instrument. these questions included “please rate the transition from in-class learning to online learning” and “please indicate your level of satisfaction with uams about the support you are getting from uams to help you transition to taking your classes online” with likert scale answers along a 5-point scale. other questions focused on covid-specific experiences, such as “given the changes at uams caused by the spread of covid-19, how often do you worry about the following?” with a 4-point likert scale response across 4 dimensions including “doing well in classes now that many or all of your classes are online” and “accessing and successfully using the software journal of regional medical campuses, vol. 4, issue 2 original report needed for your online classes (e.g. blackboard, skype, zoom, etc.)”. open-ended survey questions and the semi-structured qualitative interview guide focused on the effects of covid-19 on students’ experiences and perceptions of the transition to e-learning, and their experiences related to the covid-19 pandemic. the open-ended questions and semi-structured qualitative interview guides students to speak in their own words about their lived experiences. surveys were captured using the surveymonkey platform. qualitative interviews were conducted by trained research staff, one male and one female, and were recorded using zoom teleconferencing software. interviews were recorded and viewed multiple times by the research team. quotes were transcribed verbatim from interview recordings. quantitative data are summarized to describe respondent characteristics and their self-reported rating of experiences. qualitative descriptive analysis was used to explore respondents’ experiences and perceptions what worked well and what did not work well during the transition to e-learning.11-13 this methodology focuses on the summary of respondent experiences and perceptions, while also emphasizing the meanings that are ascribed to their experiences.11-13 following data collection, the research team developed a codebook based on a combination of a priori and emergent themes using a template analysis methodology.14-16 the research team which consisted of one primary coder and 2 confirmation coders collaboratively discussed themes to ensure scientific rigor. results demographic characteristics of survey respondents are presented in table i. the survey and written interview responses had 144 respondents (53% response rate), with all academic programs at uams northwest represented. the majority of students reported that they were 18-30. most (81.3%) survey respondents reported non-hispanic white as their race or ethnicity, and 72.9% of respondents reported their gender as female. 29 of those students took part in the additional in-depth interview. table i. descriptive survey results (n = 144). journal of regional medical campuses, vol. 4, issue 2 original report table ii provides survey responses. most (84.5%) respondents stated that they were ‘satisfied’ or ‘very satisfied’ with their experience on the uams northwest. a majority of respondents rated the transition to online/e-learning as ‘good’ (43.4%) or ‘very good’ (41.1%). further, 77% of respondents rated their satisfaction with the support for transition to elearning/online learning as ‘very satisfied’ (30.1%) or ‘generally satisfied’ (46.9). when asked about agreement with the statement: “i received appropriate communication from uams about its ongoing responses to covid-19”, 97.3% of respondents stated that they ‘strongly agree’ or ‘agree’ with that statement. regarding students’ concerns about finding a job after graduation, 22.5% of respondents reported that they were concerned ‘to a great extent’, 31.5% concerned ‘somewhat’. almost half (41.4%) of respondents noted that they were ‘not at all’ concerned with working in health care professions because of covid-19, and only 8.1% of respondents noted being concerned ‘to a great extent’. table ii. survey responses (frequency and percentage of all valid responses) for academic consequences of covid-19 (n = 144). frequency percentage how satisfied are you with your overall northwest campus experience? very satisfied 53 41.1% satisfied 56 43.4% neutral 17 13.2% dissatisfied 3 2.3% very dissatisfied 0 0.0% prefer not to answer 0 0.0% missing 15 please rate the transition from in-class learning to online learning. very good 29 25.7% good 45 39.8% fair 32 28.3% poor 5 4.4% very poor 2 1.8% prefer not to answer 0 0.0% missing 31 please indicate your level of satisfaction with uams about the support you are getting from uams to help you transition to taking your classes online. very satisfied 34 30.1% generally satisfied 53 46.9% neither satisfied nor dis satisfied 18 15.9% generally dissatisfied 4 3.5% very dissatisfied 4 3.5% prefer not to answer 0 0.0% missing 31 please indicate your level of agreement with the following statement: i received appropriate communication from uams about its ongoing responses to covid-19. strongly agree 52 46.8% agree 45 40.5% neither agree or disagre e 8 7.2% disagree 3 2.7% strongly disagree 3 2.7% prefer not to answer 0 0.0% missing 33 because of covid-19, i am concerned about getting a job after graduation. to a great extent 25 22.5% somewhat 35 31.5% very little 24 21.6% not at all 27 24.3% don't know 0 0.0% prefer not to answer 0 0.0% missing 33 because of covid-19, i am concerned about working in the health care profession. to a great extent 9 8.1% somewhat 25 22.5% very little 31 27.9% not at all 46 41.4% don't know 0 0.0% prefer not to answer 0 0.0% missing 33 table iii describes responses related to student worries related to the covid-19 pandemic. only 19.5% of respondents reported that they worried ‘very often’. approximately one-third (31.9%) of students reporting that they ‘sometimes’ worried about their friendships or social connections, with an equal number of students (31.9%) reporting that they ‘never’ worried about it. students reported worrying about technology, with 18.6% reporting ‘very often’, 17.7% reporting ‘often’, or 35.4% reporting that they ‘sometimes’ worried about technology. related to technology, students were also asked about worries related to access and successfully using software for e-learning with only 10.6% reporting ‘very often’, and 15% reporting ‘often’. of those surveyed, 41.6% reported worrying about this issue. journal of regional medical campuses, vol. 4, issue 2 original report table iii. survey responses (frequency and percentage of all valid responses) for items addressing worries caused by covid-19 ("given the changes at uams caused by the spread of covid-19, how often do you worry about the following…?") four primary themes emerged during analysis: communication, technology, pedagogy, and community. seven secondary themes emerged across the 4 primary thematic categories. these secondary themes include: frequent and clear communication, software and hardware, instructor proficiency with technology, dialogic and adaptive teaching techniques, clinical skills and field experiences courses, studying and learning environments, sense of community, and transition to job market. primary and secondary themes are listed in table iv. table iv: primary and secondary themes frequent and clear communications respondents discussed that the clarity and frequency of official and unofficial communications were critical in easing the transition from in-person courses to a full elearning environment. respondents often integrated their assessment of communication regarding covid-19 generally with the communication about their courses. when asked about their experience, respondents stated that they appreciated the way that the administration “kept [students] informed of the discussions that administration was having regarding our return to journal of regional medical campuses, vol. 4, issue 2 original report school”. further, this respondent appreciated the way that instructors “checked in with our mental health and stresses regularly in class”. respondents stated that frequent and clear communications “kept class normal and routine while giving clear expectations was helpful”. respondents reported that clarity of expectations became increasing important as the ability to communicate in person with instructors decreased. software and hardware some e-learning technologies were identified as useful in facilitating learning and others were identified by students as impediment to learning. respondents often noted that video calling utility functionalities for “breakout rooms” for “smaller class discussion” enhanced their learning experiences. quiz and polling software, such as kahoot, was often noted as a technological solution to unidirectional communication where such tools facilitated active learning. another student noted that “the hurdles [faced by students] are technology and software” for her program, although some problems were avoided through program requirements for “specific hardware” so “everyone in the program had the same setup”. instructor proficiency with technology students’ experiences were influenced by the faculty members’ proficiency or lack of proficiency with new technological tools. students reported that some faculty were “already comfortable with the technology and structure” of e-learning. however, respondent discussed concerns with “first time instructors [who were] unfamiliar with technology”. respondents said they recognized that the transition was difficult for instructors who had to adjust delivery methods mid-course, stating “transition was hard for everyone, even for professors who were used to submitting on one platform”. students described that when their faculty were not as experienced in the technology that resulted in ineffective teaching and often resulted in courses beginning significantly later than scheduled. respondents also noted that faculty’s lack of experience with technology resulted in classes that did not always “start on time”. respondents also stated that “classes went over”. one respondent stated that “a couple [of my classes] went hours over, one [class] went an hour over” which resulted in “mental fatigue”. dialogic and adaptive teaching techniques faculty who utilized dialogic and adaptive teaching techniques were identified as dramatically improving student experience with e-learning. respondents stated that being asked about preferences, needs, and issues related to learning, and then having their responses incorporated into the course, was essential for a smooth transition with minimal disruption for learning. respondents stated that the courses that worked best “adapted to the changing circumstances” and with adjustments that fit “online learning needs”. respondents noted that pedagogical methods that “fostered active student involvement in discussion” alongside “activities that students could work through with guidance” were the most effective for their courses. clinical skills and field experience courses. respondents reported that e-learning delivered health sciences and medical education works for some courses but noted that the experience of shifting to e-learning did not work as well for hands on clinical skills and field experience courses. respondents frequently noted that clinical skills courses became impossible or lost most educational value. respondents noted that “practicing these hands-on skills was something i was looking forward to, which we didn’t really have a great way to do this online”. another respondent echoed this sentiment stating that “it’s hard to watch your professor on a computer screen…practicing on a dummy or their child” and that “you’re making the best of it, but there may not be time when you resume normal classwork to…practice those skills”. respondents reported being anxious about the quality of their education compared to past courses where hands-on clinical skills instruction methods could be observed, critiqued, and corrected. respondents described changes in public health field experience as well, stating “because of covid we had to go online and we couldn’t go out and meet people” and this “class had to dramatically change...but, it felt like our learning experience was hindered because of that”. respondents noted the inevitability of changes to classes due to the pandemic and discussed anxiety about educational quality especially for clinical and field experience courses. studying and learning environments several respondents noted that prior to covid-19 they had relied on quiet study spaces on campus, including the uams northwest library, empty classrooms, or lounge areas. losing access to quiet, uncluttered learning environments for class time, group activities, or for studying was identified as a major concern with the rapid transition to fully online courses. some journal of regional medical campuses, vol. 4, issue 2 original report respondents noted that their home environments were often shared with family or with roommates or were otherwise not conducive to class time or to study time. respondents identified that “studying at home was not beneficial to me and made it harder to get schoolwork done”, and others described that it was “easy to get distracted” while studying at home. one respondent summarized their experiences with studying and learning at home, stating that “for me, what made [studying and learning at home] harder was not having…places to study [and] trying to make myself study at home, where there are the most distractions”. respondents also linked pedagogical practice with their problems with a home studying environment and described that “being at home, there are many more distractions and it’s hard to focus when someone is just reading/lecturing to me”. some students also experienced issues with their home technology and internet connectivity noting that “internet connection was a big problem for me. my internet would go out during a test or a quiz. i tried multiple places and the internet was never reliable”. sense of community. students often described missing face-to-face interaction with fellow students and missing these contacts as part of the shift to online learning. respondents linked their sense of community to the nature of the smaller campus noting that they chose to come to uams northwest because “i like how personal it feels on campus, and especially within each college. not a whole lot of people, and it’s easier to connect. you get a lot of one-on-one time; you aren’t fighting for attention”. respondents stated that the uams northwest campus was “much closer knit”. this was echoed by a respondent who noted that the uams northwest campus “is more like a community than what my classmates are feeling at the main campus”. the switch to online learning was identified as challenging the close-knit community that students had experienced, noting that “not being on campus for studying, events, etc. made me feel separated and distant”. other respondents noted that “classrooms [help] maintain connections with the professors and other students”. however, students also noted that even with online learning that the group worked to maintain their closeknit community, recounting that “other students sent out reminders and group me notifications” to keep each other accountable and completing necessary coursework. transition to job market several respondents discussed anxieties about how covid-19 and changes in instruction would translate to their capabilities as professionals entering the job market. respondents identified that they were “worried about how covid will affect the future” and especially how it would affect her licensure process and especially the job market for her profession. respondents noted that their biggest concern was “not finding a job/being able to take the boards” and “ability to take the naplex and get a job…is stressing me out”. respondent discussed that “our professors seem to be very optimistic about us finding jobs, which is fine, it’s great to hear that they are optimistic, i’m not sure, i know people…in my profession who have lost their jobs…and nobody knows when there is going to be an upswing”. some respondents stated that they were anxious about “having a job on finishing school, since hospitals have been cutting positions” and others discussed their worry that “there’s no way to plan, the timeline has been changed, and the job market itself has dramatically changed”. discussion this study used primarily qualitative methods to examine the rapid transition to e-learning for students on an rmc. this study found frequent and clear communication, software and hardware, instructor proficiency with technology, dialogic and adaptive teaching techniques, clinical skills and field experiences courses, studying and learning environments, sense of community, and transition to job market were key factors in the transition. frequent and clear communication was identified as a critical need for students. students desired clear communication about institutional action, and also noted that clarity of expectations in courses and for clinical curricula was a major concern. this finding is consistent with prior research which highlights the role of clarity of communication in online learning environments, including clear guidelines, timely feedback, and virtual face-to-face elements.17 students were also concerned with technology related to course delivery, with 2 related themes arising out of general issues related to software and hardware, and with instructor proficiency with technology. respondents noted that teleconferencing programs that allowed for more personal connection with instructors and peers were appreciated, while instructor proficiencies, or lack thereof, tended to exacerbate issues for students and created adverse conditions for learning. the rapid journal of regional medical campuses, vol. 4, issue 2 original report transition to e-learning that is discussed here highlighted issues that had been identified in the literature on elearning in healthcare fields, such as issues with technology, behavioral expectations, student mentoring, and communication.18 pedagogical issues, including dialogic and adaptive teaching techniques, clinical skills and field experience courses, and the studying and learning environments, were noted by respondents. respondents noted that when instructors sought feedback from students, and then adjusted courses appropriately to that feedback, were the most effective for learning. students drew parallels between at-home elearning and difficulties in the social context of course delivery, where losing access to campus resources was considered the direct result of covid-19 restrictions and the e-learning modalities. students also identified community as a key primary theme in this study. contrasting the sense of community felt by students precovid-19 pandemic with difficulties in feeling connected to the community, students noted that elearning modalities did not carry an inherent affective connection to other students. this is consistent with prior research that shows students look for interdependence with peers, which indicates a desire to have a connection in an academic setting with a peer group as part of their educational experience.19,20 the findings of this study show that the rapid transition to elearning modalities did not necessarily foster the same peer group environments which students found to be valuable prior to the covid-19 pandemic. as a corollary to concerns related to community, students identified concerns related to networking and transition from their coursework to the job market. this is a novel finding and merits further research to explore the impacts of such a rapid transition to e-learning on these students when they enter the job market. overall, the findings are consistent with prior research which has demonstrated that the online delivery of course content and e-learning modalities present challenges for both instructors 21 and students.22 this research provides new and important insights because most prior literature regarding the effects of covid-19 on education have focused on higher education as a unit of analysis, which often assumes some amount of homogeneity across educational programs.23-37 some studies have focused specifically on health sciences and medical education transition to e-learning during covid-19.2,38-41 and this is the first study to focus on that transition at a regional medical campus. the study offers new insights into the unique challenges faced by students in health professions, medicine, nursing, and pharmacy at a regional medical campus. this study and others will be of particular benefit for institutional planning to conduct fine-grained experiential and longitudinal studies that link institutional and pedagogical techniques to student outcomes within and across different health sciences and medical educational contexts. there are some limitations to the study. while the sample of 144 was large for a qualitative study, all students were from one regional medical campus. the sample size and location along with the homogeneity of the sample in terms of race and ethnicity reduces the generalizability of the study. additionally, these findings may not be representative of health sciences students at other campuses. follow-up studies will be necessary to understand changes in teaching and the perceptions of students over time. conclusion the examination of students’ experiences can help us better understand the importance of communication, technology, pedagogy, and community as we determine the future of health sciences and medical education during the transitions to e-learning. it is important that institutions be prepared for deploying technological resources and that faculty be trained on those resources in advance. the most important finding of this study relates to 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nm, et al. practical techniques to adapt surgical resident education to the covid-19 era. annals of surgery. 2020 2020; microsoft word regional medical campusus in canada article.docx published by university of minnesota libraries publishing regional medical campuses in canada and the united states: a systematic review trina m. fyfe, mist, phd; ralitsa akins, md, phd; pierre gagné, md, msc, frcp(c); craig cheifetz; sarina petrocelly; geoffrey w. payne, phd doi: https://doi.org/10.24926/jrmc.v1i3.1158 journal of regional medical campuses, vol. 1 issue 3 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc trina m. fyfe, mist, phd, trina.fyfe@unbc.ca, is the health sciences librarian, northern medical program, faculty of medicine, university of northern british columbia, 3333 university way, prince george, british columbia, v2n 4z9 canada, tel: 250-960-5195 ralitsa akins, md, phd, ralitsa_akins@yahoo.com, is the associate dean of faculty affairs at the washington state university elson s. floyd college of medicine, spokane health sciences campus, tel: 915-204-2496 pierre gagné, md, msc, frcp(c), pe.gagne@gmail.com, is professor and senior advisor on regional medical campus development, campus de l’université de montreal en maricie, faculté de médecine de l’université de montreal, and past chair of the aamc group on regional medical campuses, 1991, boulevard du carmel, trois-rivières, québec, g8z 3r9 canada, tel: 819-692-9570 craig cheifetz, craig.cheifetz@inova.org, md is regional dean, virginia commonwealth university school of medicine inova campus, and past chair of the aamc group on regional medical campuses, 3300 gallows road, falls church, virginia, 22042, tel: 703-776-3720 sarina petrocelly, sarina.petrocelly@inova.org, is faculty affairs and academic research coordinator, virginia commonwealth university school of medicine inova campus, 3300 gallows road, falls church, virginia, 22042, tel: 703.776.4485 geoffrey w. payne, phd, geoff.payne@unbc.ca, is vice president of research and professor, university of northern british columbia, and past chair of the aamc group on regional medical campuses, 3333 university way, prince george, british columbia, v2n 4z9 canada, tel: 250-960-6110 corresponding author: trina m. fyfe, mist, phd, trina.fyfe@unbc.ca, is the health sciences librarian, northern medical program, faculty of medicine, university of northern british columbia, 3333 university way, prince george, british columbia, v2n 4z9 canada, tel: 250-960-5195 all work in jrmc is licensed under cc by-nc volume 1, issue 3 (2018) journal of regional medical campuses original report regional medical campuses in canada and the united states: a systematic review trina m. fyfe, mist, phd; ralitsa akins, md, phd; pierre gagné, md, msc, frcp(c); craig cheifetz; sarina petrocelly; geoffrey w. payne, phd abstract introduction the development of regional medical campuses (rmcs) in canada and the united states (us) has been a response to increase undergraduate medical student enrollment and meet the societal needs of healthcare access by addressing physician shortages in underserved and rural areas. we systematically reviewed the literature on undergraduate rmcs in canada and the us to identify types of studies and leading themes. methods literature searches were performed within the following databases: medline ovidsp, evidence-based medicine reviews ovidsp, cinahl ebsco, eric ebsco, psycinfo ebsco, and web of science isi. articles were included in the review if they discussed undergraduate medical education in allopathic schools in canada and the us, were written in english and related to rmcs. each article was reviewed and assessed by two of the authors, and information extracted from the literature was thematically analyzed. all selected articles fit the definition of rmc developed by the association of american medical colleges’ group on regional medical campuses (grmc). the grmc has defined that rmcs could be of four distinct types: basic science campuses, where students study pre-clinical (basic sciences) courses; clinical campuses, where clerkship training is completed; longitudinal model (for example, longitudinal integrated clerkships) and, usually 4-year campuses, where both pre-clinical and clinical curriculum is delivered. results fifty (50) articles were selected for inclusion in the final review. thirty-six (36) of the reviewed articles (72%) specifically stated that the development of rmcs was in response to the physician shortage and limited access to healthcare in rural areas. twenty-five (25) articles discussed program models that spanned both basic science and clinical curricula. of the 50 articles that were included in the final review, 15 (30%) utilized descriptive methodology, and 35 (70%) involved quantitative, qualitative or mixed methods research, with some being considered “program evaluations.” four major themes emerged from the reviewed articles: workforce, social accountability, distributed medical education, and regional versus main campus settings. conclusion this study is the first systematic review of published literature on rmcs and providing a benchmark and direction for future research on rmc development and impact. introduction journal of regional medical campuses, vol. 1, issue 3 original report the creation of regional medical campuses (rmcs) has become an international phenomenon, with rmcs sprouting up in many countries, such as the united kingdom, australia, the united states and canada.1 rmcs have existed as far back as the 1960s, but it was not until the publication of minimed: the role of regional campuses in u.s. medical education and the 2006 call by the association of american medical colleges (aamc) for increasing the number of physicians, that any true national attention was focused on rmcs.1,2 medical schools have traditionally been located in urban centers and associated with large universities. the creation of new medical schools and the development of new or expanded rmcs has been prompted by the need to respond to physician shortages and limited access to healthcare in underserved and rural areas. the exapansions of schools and campuses has led to increased enrollment and medical school admissions. it is important to ensure that training more students would not perpetuate the maldistribution of physicians, with the majority concentrated in large urban areas. one of the most efficient ways to attract and retain physicians in an area is to train them locally. thus, being socially accountable to the underserved and rural areas and training medical students locally has proven to be of paramount importance.1 rmcs, by definition, extend undergraduate medical education beyond the main (usually urban) campus. rmcs are deemed more efficient than implementing new self-standing medical schools, since curriculum can be delivered across campuses via technology, at a distance. the number of rmcs in canada and the us has increased significantly since the 1970s.3,4 medical schools that created new or expanded existing rmcs did it independently, without national coordination, and there was a lack of agreement on the vernacular surrounding regional campuses. therefore, for many decades the impact of rmcs on medical education, workforce sustainability and local economies remained unclear. doi: https://doi.org/10.24926/jrmc.v1i3.1158 with the continued development of rmcs in canada and the us, it is imperative to synthesize the literature on rmc impact, such as, but not limited to: medical education outside of the traditional medical school and/or the big university-based teaching hospital can be as good as the traditional approach, and if students graduating from regional programs resolve the maldistribution of physicians and provide medical care to all communities. the purpose of this review is to identify and categorize themes from the existing body of literature on the development and evaluation of undergraduate rmcs in canadian and us medical schools. methods we completed a systematic review of the published literature on rmcs in canada and the us. a librarian performed a comprehensive search of the following databases: medline ovidsp, evidence-based medicine reviews ovidsp, cinahl ebsco, eric ebsco, psycinfo ebsco, and web of science isi. in an initial pilot review, the search included the campbell collaboration; this initial search yielded zero results and therefore was excluded from the search process. to ensure the literature search was comprehensive and effective, it was peer-reviewed by an independent medical education librarian. in addition, three of the leading medical education journals were handsearched: academic medicine (including the special collection on regional medical education, rural medical education, and care for the underserved), medical education and medical teacher. this review did not involve human subjects and ethics approval was not sought. the following search terms were used: medical education, undergraduate; schools, medical, regional campus, site, center or program; distributed campus or site or center or program; satellite campus, site, center or program; dispersed campus, site, center or program; branch campus, site, center or program; basic science model; clinical model; longitudinal model; distributed model; combined model; integrated clerkship; longitudinal clerkship; and geographically isolated journal of regional medical campuses, vol. 1, issue 3 original report campus. searches were limited to englishlanguage, canada and us articles only. as an example of our systematic approach, table 1 presents the search strategy for the medline ovidsp search. the selected key words used to search the databases appeared to be sensitive enough to provide for a broad, yet targeted, set of results. it must be noted that the language used to describe rmcs varies considerably in the literature.4 a large variation and subjectivity in rmc classification exists. what constitutes a rmc has been judged and redefined over time by different authors and agencies. for example, the liaison committee on medical education (lcme) considers as a regional campus any location separated from the main campus, where a minimum of one student spends 6 or more months of their training.5 terms have been used interchangeably for community-based or rural-based continuous medical education, postgraduate medical education, nursing education and other healthallied education. according to the grmc, an rmc involves “a significant portion of the medical educational program (e.g., all of the required preclinical and/or clinical clerkships) at a site geographically distant from the medical school”.6 the grmc has defined rmcs to be of four distinct types: basic science campuses, where students study pre-clinical (basic sciences) courses; clinical campuses, where clerkship training is completed; longitudinal model (for example, longitudinal integrated clerkships) and, usually 4-year campuses, where both pre-clinical and clinical curriculum is delivered (integrated, mixed model).4 this categorical system provided the common denominator for rmcs across the us and canada and for the purposes of our review, we adopted the grmc classification system for rmcs in undergraduate medical education. articles were included if they met one of the four criteria outlined by the grmc. each database search concluded with developing a data set to be reviewed for inclusion. after combining the final search sets from each database and the hand-searching process, and after removal doi: https://doi.org/10.24926/jrmc.v1i3.1158 of duplications, 950 potential articles remained, of which a set of 289 articles was selected for further review. articles about allopathic undergraduate medical education in canada and us medical schools that could be aligned with the categories of the grmc’s definition of rmcs were included. after the review process iterations were complete, the researchers identified 50 articles meeting all inclusion criteria. two researchers independently reviewed each of the 289 articles. if discrepancy between the reviewers regarding inclusion or exclusion existed, a third reviewer read the article and weighed for a final decision. twenty-two articles had to be reviewed by a third reviewer. the inclusion and exclusion criteria used in the determination of the final article review set are presented in figure 1. a qualitative thematic analysis of the included articles was conducted. the intent of the systematic review was to identify and categorize the results, and not to critically appraise the quality of the study design of the included articles. therefore, the articles were analyzed using open and axial coding. this process involved coding the articles for major categories (open coding) and then focusing on each category specifically to identify further relationships (axial coding) and thread themes.7 results thirty-six (36) of the reviewed articles (72%) specifically stated that the development of rmcs was in response to physician shortage and limited access to healthcare in underserved and rural areas. twenty-five (25) articles (50%) discussed program models that spanned both basic science and clinical curricula. of the 50 articles that were included in the final review, 15 (30%) utilized descriptive methodology, describing program implementation, challenges and successes. thirtyfive (70%) articles involved quantitative, qualitative or mixed methods research, with some being labeled “program evaluations.” the articles included in the review fit the definition and categories provided by the grmc. table 2 presents the types of rmcs according to the grmc journal of regional medical campuses, vol. 1, issue 3 original report classification system as found in the literature. table 3 presents the study methodology utilized in the included articles. thirty-four (34) of the 50 articles (68%) were published in medical education journals. the remaining 16 articles (32%) were published in general education, medical specialty, rural health, and other journals. discussion four major themes emerged from the included articles: workforce, social accountability, rural medical education, and rural versus urban setting.1,8-56 table 4 presents the codes within each of the four major topic categories, and table 5 presents the complete bibliographic information for the fifty articles included in our analysis. workforce: twenty-two of the articles stated that rmcs were developed as a response to physician shortage and maldistribution, often with a specific focus on underserved areas and rural geographies. medical schools were challenged to increase enrollment and admissions to their undergraduate medical programs without funding for developing new schools. the existing medical schools were tasked with producing more physicians to meet the shortage and maldistribution issues plaguing both canada and the us.2,57 physician workforce distribution across underserved and rural areas in canada and the us has been problematic, leaving these populations without adequate or equitable access to health care. the earliest articles on the topic came out of the washington, wyoming, alaska, montana and idaho (wwami) program, which began in 1970.8 multiple articles about wwami focused on the workforce and provided historical background, benchmarking for rmcs that have since developed as well as evidence that rmcs do have an impact on the physician workforce. the national residency matching program (nrmp) data do not identify graduates of rmcs separately, thus making it more difficult to assess the association between training students in rmcs and acceptance to primary care residency programs. individual campuses or medical schools track and doi: https://doi.org/10.24926/jrmc.v1i3.1158 report on the career choices of their rmc graduates. small rmcs are disadvantaged in reporting numbers because of smaller enrollments and limited resources devoted to graduate tracking and impact research.4 the wwami program is one of the longest existing regional programs and provides longitudinal data about the effectiveness of regional programs in retaining physicians. for example, after completing the wwami program, many students have returned to their areas of training to practice medicine, even though the students may not have been originally from that specific area; in idaho, 71% of the students returned to the state to practice medicine.48 social accountability: medical schools have a social responsibility to produce graduates that will serve all patient populations, including underserved and rural areas.1 the literature described the roles of physicians in community partnerships and community leadership. few studies focused on the evaluation of the rmcs at the community level, and only a few articles explored rmc’s effects on community stakeholders. three studies originating from the university of british columbia (ubc) program described the community influences of rmcs. in 2004, ubc’s undergraduate medical program created two campuses at considerable distances from the main campus in vancouver; one campus was located in a small urban city, victoria, and the other in a northern rural area, prince george. the prince george northern medical program collaborated with the university of northern british columbia to conduct a study with local community stakeholders. hanlon, et al. conducted interviews with local physicians about their involvement and perception of the medical program in regards to their practice and the community in general.30 another publication focused on the rmc’s impact on its community stakeholders: local business, economy, education, health and political sectors in the community. that qualitative study found that community stakeholders felt pride and an increased sense of status, developed new partnerships, a new found journal of regional medical campuses, vol. 1, issue 3 original report sense of community self-efficacy, and perceived positive change at the local community level.37 another study also found that the rmc benefited the community education, health services, and the local economy, with major impact on health services and improving healthcare access in a medically underserved community.54 distributed medical education: the development of rmcs brought about educational innovation and renewed pedagogy. new curriculum delivery strategies were developed in order to provide medical education to rmcs at distant locations, such as use of technology and videoconferencing. one of the earliest innovation articles regarding rmcs described the use of satellite in the wwami program as a tool to communicate between the various rmc locations.22 since the early days of the rmcs, the use of technology has evolved and increased in the delivery of curriculum. lectures can be distributed using videoconference technology, students can interact with each other online and curriculum is becoming more flexible because of advances in technology. an example is the use of technology to deliver pathology curriculum within a distributed program; to evaluate the effectiveness of the technology in the delivery of the curriculum, a study compared student examination scores across multiple rmcs and surveyed student opinions about the material delivery.28 based on the geographically distributed nature of the regional campuses, it is critical that educational innovation is encouraged and fostered, to ensure the success of the rmcs. an integral part of the successful implementation of rmcs is successful faculty recruitment, and this is most evident in the implementation of longitudinal integrated clerkships (lics), where students participate in the continuous care of patient panels across disciplines and healthcare settings.24 a great deal of research has been done to evaluate the value of lics on student performance, future career selection and learning perception. lics implemented in the rmc setting have proven to be academically successful and doi: https://doi.org/10.24926/jrmc.v1i3.1158 have had positive impacts on relieving the shortage of physicians in rural communities. regional versus main campus: to evaluate rmcs, medical education researchers study rmcs from the aspect of comparable national examination scores, various student outcomes (e.g., grades distribution), and perceptions focused on equitable experiences (e.g., student satisfaction with curriculum and services). program evaluation is an important component of rmc implementation and sustainability. twentythree articles described and compared programs by analysis of exam scores, student and faculty surveys, and data from focus groups. the program evaluations customarily compared the regional campus to the main campus in regards to student success and satisfaction. the comparative studies proved that students at regional campuses score comparably with students at main campuses. these types of studies continue to be critical for the sustainability and continued development of rmcs across canada and the us and are of the utmost importance for regional programs, validating the quality of medical education in distributed regions. another way of evaluating the rmcs’ impact has been through an economic lens. articles discussed the financial benefits of developing rmcs over implementing new stand-alone medical schools. for example, an article from the 1960s, was the first to discuss the local economic impact of regional campuses stating that developing regional sites would be less expensive than creating new medical programs.15 study limitations this review provides categorization of articles qualified by inclusion criteria and critical analysis of the study design of the included articles was not intended. deployment of conclusions is limited to institutions with existing rmcs, as defined by grmc. translating the findings of this study to new and developing rmcs need to be done with caution. journal of regional medical campuses, vol. 1, issue 3 original report future direction although rmcs have been in place for over 50 years, the majority of rmcs have been established recently, making it difficult to obtain longitudinal data. however, there has been program evaluation and descriptive work that provides potential new rmcs with initial benchmarking and implementation data. rmc programs need to consider establishing research agendas, as early as the planning phases for creating new campuses, to ensure that this is part of the rmc’s mandate and can be reasonably done with available resources. comparative studies remain an integral part of rmc research, in establishing evidence that the educational outcomes of students at the regional campuses are comparable to those at the main campus. without strict language, searching for rmc articles in a database will continue to be challenging. we recommend that future rmc publications should consider utilizing grmc language and categorization of their programs. there are opportunities for rmcs to research social accountability. existing research demonstrates that value exists outside of increasing the physician workforce to address physician shortage and maldistribution, with boosts in local economy and improved healthcare access and delivery. one important aspect of the rmc literature discussed financial accountability. based on the articles included in this study, rmcs are thought to provide an economically viable alternative to producing more md graduates and responding to the need to offset the predicted physician shortage.8,15,20,47,49 more research needs to be done on the financial and local economic aspects of rmc impact. the paucity of research on rmcs, and the continued increase in the number of rmcs, suggest that future studies on the impact of rmcs – educationally and within the local community – are critical. anecdotally, rmc regional deans, faculty, and senior leadership share success across institutions. in addition, until recently, there was a lack of a systematic way to categorize rmc campuses, thus research and publication about such findings proved quite difficult. since the doi: https://doi.org/10.24926/jrmc.v1i3.1158 number of medical students per campus are traditionally low, it might be difficult to draw statistically significant conclusions by using individual, isolated campuses as basis for research. such approach would translate in unacceptable delays before reaching conclusions. we recommend that future rmc studies involve multiinstitutional, multi-campus research, where results could be widely deployable. conclusion this study is the first systematic review of the published literature on rmcs. this review provides a benchmark and direction for future research in this area of rmc development and impact. this systematic review suggests it would be beneficial to explore the impacts of rmcs on workforce, social accountability, distributed medical education and regional versus main campus settings. abbreviations: aamc – association of american medical colleges grmc – group on regional medical campuses nrmp – national resident matching program rmc regional medical campuses us – united states competing interests: the authors declare that they have no competing interests. authors’ contributions: gp conceived of the review. tf carried out the searches, coordinated the review process, and wrote the draft manuscript. ra, pg, sp, gp, and tf participated in the development of the design of the review, reviewed articles, and helped to draft the manuscript. cc helped to draft the manuscript. all authors read and approved the final manuscript. acknowledgments: the authors would like to thank the members of the group on regional medical campuses (grmc), grmc steering committee and the staff at the association of american medical colleges (aamc). the 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barbara; hunt, daniel. longitudinal integrated clerkships for medical students: an innovation adopted by medical schools in australia, canada, south africa, and the united states. academic medicine. 2009;84(7):902-907. 43. penn cl. more physicians coming soon. uams continues plans for northwest arkansas satellite campus. journal of the arkansas medical society. 2007;104(5):104-107. 44. phillips wrea. clinical content of the wami community clerkship in family medicine. journal of medical education. 1982;57(8):615-620. 45. pinder kef, jason c.; ovalle, william k. a new paradigm for teaching histology laboratories in canada's first distributed medical school. anatomical sciences education. 2008;1(3):95-101. 46. poncelet ab, seth; calton, brook; hauer, karen e.; kirsch, heidi; jones, tracey; lai, cindy j.; mazotti, lindsay; shore, william; teherani, arianne; tong, lowell; wamsley, maria; robertson, patricia. development of a longitudinal integrated clerkship at an academic medical center. medical education online. 2011;16. 47. rackleff lzoc, mark t.; warren, dwight w.; friedland, michael l. establishing a regional medical campus in southeast florida: successes and challenges. academic medicine. 2007;82(4):383389. 48. ramsey pgc, j. b.; hunt, d. d.; marshall, s. g.; wenrich, m. d. from concept to culture: the wwami program at the university of washington school of medicine. academic medicine. 2001;76(8):765-775. 49. robertson je, jr.; boyd, jennifer; hedges, jerris r.; keenan, edward j. strategies for increasing the physician workforce: the oregon model for expansion. academic medicine. 2007;82(12):1158-1162. 50. sadoski mc, christopher c. the texas a&m experience with class size and campus expansion: evaluation of first year using distance learning and on-site curriculum delivery. teaching & learning in medicine. 2010;22(4):262-267. 51. smego ra, jr.; d'alessandri, robert m.; linger, barry; hunt, virginia a.; ryan, james; monnier, john; litwack, gerald; katz, paul; thompson, wayne. anatomy of a new u.s. medical school: the commonwealth medical college. academic medicine. 2010;85(5):881-888. 52. snadden db, joanna; u. b. c. associate deans of md undergraduate education. expanding undergraduate medical education in british columbia: a distributed campus model. cmaj canadian medical association journal. 2005;173(6):589-590. 53. spencer dlde, gabrielle. the effect of regional medical education on physician distribution in illinois. journal of medical education. 1983;58(4):309-315. 54. toomey p, lovato cy, hanlon n, poole g, bates j. impact of a regional distributed medical education program on an underserved community: perceptions of community leaders. academic medicine. 2013;88(6):811-818. 55. veerapen km, sean. students' perception of the learning environment in a distributed medical programme. medical education online. 2010;15. 56. woloschuk w, myhre d, jackson w, mclaughlin k, wright b. comparing the performance in family medicine residencies of graduates from longitudinal integrated clerkships and rotation-based clerkships. academic medicine. 2014;89(2):296-300. 57. association of american medical colleges. aamc calls for 30 percent increase in medical school enrollment. 2006; https://www.aamc.org/newsroom/newsreleases/2 006/82904/060619.html. accessed november 24, 2014. doi: https://doi.org/10.24926/jrmc.v1i3.1158 journal of regional medical campuses, vol. 1, issue 3 original report table 1 medline ovid search strategy database(s): ovid medline(r) in-process & other non-indexed citations and ovid medline(r) 1946 to present search strategy: # searches 1 education, medical, undergraduate/ 2 schools, medical/ 3 students, medical/ 4 clinical clerkship/ 5 (undergraduate adj3 medical adj3 (school* or education or student*)).tw. 6 1 or 2 or 3 or 4 or 5 7 (regional adj3 (campus* or site* or center or centre or program*)).tw. 8 (distribut* adj3 (campus* or site* or center or centre or program*)).tw. 9 (satellite adj3 (campus* or site* or center or centre or program*)).tw. 10 (dispersed adj3 (campus* or site* or center or centre or program*)).tw. 11 (branch adj3 (campus* or site* or centre or centre or program*)).tw. 12 ((basic science or clinical or longitudinal or distribut* or combined) adj3 model).tw. 13 ((integrated or longitudinal) adj3 clerkship*).tw. 14 (geographically adj3 campus*).tw. 15 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 16 6 and 15 17 exp canada/ 18 exp united states/ 19 17 or 18 20 16 and 19 21 limit 20 to english language doi: https://doi.org/10.24926/jrmc.v1i3.1158 journal of regional medical campuses, vol. 1, issue 3 original report fig. 1 inclusion and exclusion criteria and literature review flow chart inclusion criteria exclusion criteria • undergraduate medical education programs • english literature • setting fits into one of the grmc’s categories: o basic science model o clinical model o longitudinal/distributed model o combined model • graduate medical education, continuing medical education, nursing or other health professional programs • commentaries, opinion pieces, letters • reports, books, theses/dissertations • programs located outside canada and the us databases: ebm reviews (ovidsp); medline (ovidsp); cinahl (ebsco); eric (ebsco); psycinfo (ebsco); web of science (isi) hand searching: academic medicine (plus special collection); medical education; medical teacher potentially relevant articles n = 950 total number of articles after screening n = 289 total number of articles included after review n = 50 total number of articles removed after screening n = 661 total number of articles excluded after review n = 239 journal of regional medical campuses, vol. 1, issue 3 original report table 2. type of rmcs type of rmc number basic science model 1 clinical model 8 combined model 25 distributed model 10 clinical & distributed model 2 all models 4 total 50 table 3. research approaches utilized in the included articles approach number percentage descriptive 15 30% mixed methods 1 2% qualitative 6 12% quantitative 23 46% review 5 10% total 50 100% doi: https://doi.org/10.24926/jrmc.v1i3.1158 doi: https://doi.org/10.24926/jrmc.v1i3.1158 journal of regional medical campuses, vol. 1, issue 3 original report theme code sub-code regional versus main campus the comparison amongst rmcs within an undergraduate medical school regarding grades and other outcome measures (i.e. research). equity program evaluation satisfaction examination scores social accountability the role of the community in the development of rmcs and/or the rmcs impact on community for which it is situated outside (of workforce). partnership community physicians distributed medical education educational approach is changed/renewed as an impetus of, or result of, the development of rmcs. cost technology accreditation faculty recruitment workforce addresses physician shortage or mal distribution of physicians in specific geographic areas. admissions enrollment increase distribution of physicians shortage of physicians academic qualifications site selection table 4. emergent themes and codes doi: https://doi.org/10.24926/jrmc.v1i3.1158 journal of regional medical campuses, vol. 1, issue 3 original report table 5. fifty articles included after review author & year school type of rmc approach methodology themes atkin et al. 1987 wwami combined model quantitative longitudinal study distributed medical education regional versus main campus bianchi et al. 2008 mcmaster distributed model quantitative comparative study regional versus main campus bing-you et al. 2010 tufts combined model descriptive descriptive study workforce distributed medical education social accountability bland et al. 1995 n/a n/a review synthesis workforce bradley et al. 2012 florida state university college of medicine combined model quantitative comparative study regional versus main campus carney et al. 1999 clinical model quantitative comparative study distributed medical education cigarroa 2008 university of texas health science center at san antonio clinical model descriptive descriptive study workforce regional versus main campus clark 1966 n/a n/a qualitative interviews distributed medical education social accountability couper et al. 2011 northern ontario school of medicine clinical model qualitative cross-sectional descriptive regional versus main campus crump et al. 2004 university of louisville school of medicine clinical model quantitative survey workforce crump et al. 2010 university of louisville school of medicine clinical model quantitative survey workforce distributed medical education crump et al. 2013 university of louisville school of medicine clinical model quantitative comparative study regional versus main campus workforce cullen et al. 1976 wwami combined model quantitative comparative study workforce social accountability doi: https://doi.org/10.24926/jrmc.v1i3.1158 journal of regional medical campuses, vol. 1, issue 3 original report regional versus main campus cullen et al. 1981 wwami combined model quantitative comparative study workforce regional versus main campus dohner 1985 wwami combined model quantitative survey distributed medical education donnon et al. 2009 university of calgary clinical model quantitative survey workforce distributed medical education ellaway et al. 2013 northern ontario school of medicine; university of calgary; mcgill university clinical model review synthesis distributed medical education regional versus main campus essex and sorlie 1982 university of illinois basic science model quantitative comparative study regional versus main campus farnsworth et al. 2012 n/a n/a review synthesis workforce distributed medical education fogarty et al. 2012 florida state university clinical model descriptive descriptive distributed medical education regional versus main campus ford et al. 2008 university of british columbia combined model quantitative comparative study regional versus main campus distributed medical education fyfe et al. 2009 university of british columbia combined model descriptive descriptive distributed medical education hanlon et al. 2010 northern medical program (nmp) – ubc combined model qualitative interviews social accountability heck et al. 2014 university of north carolina clinical model descriptive descriptive distributed medical education regional versus main campus hirsh et al. 2012 harvard medical school – cambridge clinical model quantitative comparative study distributed medical education doi: https://doi.org/10.24926/jrmc.v1i3.1158 journal of regional medical campuses, vol. 1, issue 3 original report integrated clerkship regional versus main campus hoag et al. 2013 university of british columbia combined model quantitative survey distributed medical education regional versus main campus hurt and harris 2005 florida state university clinical model descriptive descriptive workforce distributed medical education lau and bates 2004 university of british columbia combined model review synthesis distributed medical education lorenzetti et al. 2011 west virginia university school of medicine clinical model descriptive descriptive distributed medical education lovato et al. 2009 ubc combined model qualitative interviews social accountability mazotti et al. 2011 university of california, san francisco clinical model quantitative survey regional versus main campus mclaughlin et al. 2011 universities of alberta, british columbia and calgary clinical model quantitative comparative study regional versus main campus distributed medical education mihalynuk et al. 2008 ubc combined model qualitative interviews workforce norris et al. 2006 wwami combined model descriptive descriptive workforce distributed medical education norris et al. 2009 16 schools in australia, canada, south africa and us clinical model quantitative survey distributed medical education penn 2007 university of arkansas medical school clinical model descriptive descriptive workforce phillips et al. 1982 wwami combined model quantitative comparative study regional versus main campus distributed medical education pinder et al. 2008 ubc combined model quantitative survey distributed medical education doi: https://doi.org/10.24926/jrmc.v1i3.1158 journal of regional medical campuses, vol. 1, issue 3 original report regional versus main campus poncelet et al. 2011 university of california, san francisco clinical model mixed methods surveys; focus groups distributed medical education regional versus main campus rackleff et al. 2007 florida atlantic university university of miami miller school of medicine combined model descriptive descriptive workforce social accountability distributed medical education ramsey et al. 2001 wwami combined model descriptive descriptive workforce social accountability distributed medical education robertson et al. 2007 oregon health & science university school of medicine combined model descriptive descriptive workforce social accountability distributed medical education sadoski and colenda 2010 texas a&m health science center college of medicine combined model quantitative survey, comparative study workforce regional versus main campus smego et al. 2010 the commonwealth medical college combined model descriptive descriptive workforce distributed medical education snadden and bates 2005 ubc combined model descriptive descriptive workforce distributed medical education snadden et al. 2011 n/a n/a review synthesis distributed medical education workforce social accountability spencer et al. 1983 university of illinois combined model descriptive descriptive workforce toomey et al. 2013 university of british columbia combined model qualitative interviews social accountability veerapen et al. 2010 university of british columbia combined model quantitative survey regional versus main campus doi: https://doi.org/10.24926/jrmc.v1i3.1158 journal of regional medical campuses, vol. 1, issue 3 original report woloschuk et al. 2014 university of calgary clinical model quantitative comparative study regional versus main campus microsoft word videoconferencingarticle.docx published by university of minnesota libraries publishing teaching and learning with videoconferencing at regional medical campuses: lessons from an ethnographic study macleod, a (phd), cameron, p (phd) kits, olga (ma), power, g (cpa, cma), tummons, j (phd) doi: https://doi.org/10.24926/jrmc.v2i1.1559 journal of regional medical campuses, vol. 2, issue 2 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc macleod, a (phd) cameron, p (phd) kits, olga (ma) power, g (cpa, cma) tummons, j (phd) all work in jrmc is licensed under cc by-nc volume 1, issue 6 (2019) journal of regional medical campuses original reports teaching and learning with videoconferencing at regional medical campuses: lessons from an ethnographic study macleod, a (phd), cameron, p (phd) kits, olga (ma), power, g (cpa, cma), tummons, j (phd) abstract distributed medical education and instruction at regional medical campuses is becoming more prevalent. with its focus on connecting learners in multiple environments outside of traditional classroom or clinical environments, the role of technology is central to its success. in many distributed medical education settings, videoconferencing plays a key role. over the course of a 3-year ethnographic study, we learned that videoconference technologies are more than the background for learning, but rather play an active role. we describe herein a series of practical tips for those working in the context of a videoconferenced distributed medical education program. rather than treating videoconferencing technologies as something we can ignore, predict, or control, we hope that the tips help educators at regional medical campuses think critically about the realities of teaching and learning in a videoconferenced distributed context. distributed medical education (dme) programs, defined as “educational events and activities in multiple locations and learning environments outside of the traditional classroom or teaching hospital settings”1 have become well established over the past decade.2–6 the rationale for dme programs¾which are embedded in regional medical campuses¾are multiple, including addressing the health needs of rural populations,7 promoting primary care,8 political influence;9 and prioritization of self-directed learning.10 being able to connect regional campuses has been made possible through the affordances of technologies, like videoconferencing.3,11 these factors, when combined with a shortage of medical graduates,12 particularly in rural areas,5 has meant that dme is more than a passing fad. dme programs have required a degree of creativity with respect to curriculum design and delivery.13,14 they must ensure a comparable educational experience, which is an important accreditation requirement.3 one of the most common ways that dme programs have attempted to ensure this comparability is through the use of videoconferencing technologies that connect groups at multiple sites and allow them to share in real-time instruction.15 as educators and researchers working within the context of a videoconferenced distributed medical education (vdme) program, we have had the opportunity to watch videoconferencing in action on many occasions. while we were impressed by the scope and affordances of the videoconferencing system, we were struck by the fact that the technologies, themselves, which include cameras, screens, microphones, speakers, monitors, and more, played a central role in the classroom. we began to wonder about how these technologies influenced experiences of medical education for learners, teachers, and others at regional medical campuses. we conducted an ethnographic study from 2013 to 2016 that included the following: critical analysis of institutional documents, policies, and videos; more than 100 hours of observing vdme classrooms; and 33 interviews with a range of stakeholders, including medical students, faculty members, administrators, and audiovisual professionals. team members conducted document analysis of 65 dmerelated institutional documents, policies, and videos between january and december 2013. a minimum of 2 research team members analyzed each document. a structured guide was used that was focused on how these documents construct the intended dme curriculum, and the ways the curriculum actually unfolds as constructed through our fieldwork. between january and november of 2013, a smaller team of researchers participated in in-person observations (108 hours) of meetings, lectures and other videoconferenced activities in lecture halls, meeting rooms, and audiovisual control rooms. field notes were guided by a framework by james p. spradley and focused on the following: spaces where observations took place; actors, activities, and objects involved; time; inferred goals behind the actions; and inferred feelings of those involved.16 we took 136 photographs of rooms used for videoconferencing lectures, meetings, and other activities during field visits between january 2013 and 2014. core team members conducted semi-structured interviews with 15 students and 18 academic, administrative, and audiovisual staff members. interviews focused on elucidating material tools and technologies as key actors in dme programs.3,17–19 seven faculty interviews focused on teaching doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports with videoconferencing technologies. five interviews with administrative staff focused on videoconferencing coordination. six av professional interviews explored the videoconferencing system and its operation. the 15 student interviews explored learner experiences of lectures in the videoconferenced classroom; these included 7 interviews with host site students and 8 interviews with students from the newer campus. we constructed and analyzed these data iteratively, as insights gleaned in the field were continually interpreted and re-interpreted during data collection. we used qualitative data analysis software (atlas.ti version 7.0) for coding, sharing, and managing data.20,21 as we collected and analyzed our data, we noted many coexisting activities and actors working together to constitute the lecture. for example, we observed audiovisual professionals as central, yet often invisible, human actors centrally involved in the dme curriculum,2 and noted that the videoconferencing system often involved unintended audio, visual, and curricular exposures for staff and students involved in dme.22 furthermore, we were struck that student questioning-asking seldom occurred during dme lectures, and when it did, it unfolded in unintended ways using various strategies aimed at circumventing or mediating the material effects of the dme system.23 while we have published the results of this work in various locations,3,17–19,21,23 in the spirit of knowledge translation we wanted to synthesize our disparate findings into a set of practically-oriented, user friendly ‘tips’ for those who are working in the context of a vdme program. practical tips 1. recognize, and make visible, the human side of vdme where traditional classroom-based instruction focused mainly on the teacher-learner dyad, vdme programs, because of the function of connecting geographically separate sites through technologies, are much more complex. in the context of vdme, any given lecture has been arrived at through the work of the following: educational administrators working to set directions for the program; curriculum workers designing courses, objectives, and lectures; administrative professionals ensuring the multiple required tasks are attended to so that sessions can be distributed; teachers working to deliver materials through the vdme system; learners who are integrating materials received through vdme with other aspects of their medical education; and audiovisual (av) professionals who are ensuring the vdme system is optimized for instruction. many of these people are divided between multiple locations and may not have had the opportunity to meet one another yet alone work together. we learned, however, that making the human side of vdme visible—particularly audiovisual professionals and their work—went a long way toward encouraging successful vdme.17 we recommend that vdme programs highlight the key role of audiovisual professionals in delivering vdme curriculum, and encourage faculty teaching in vdme programs to consult regularly with these professionals to tailor their lecture delivery to the unique possibilities and limitations of vdme. 2. resist the urge to be tempted by the ‘latest and greatest’ technology videoconferencing technologies are evolving every day, with higher definition screens, faster connections, and clearer audio, all in continual development. with these ongoing technological advancements, it is tempting to assume that investing in the absolute newest models, complete with costly upgrades, means an improved educational experience. through our research, however, we learned that aiming for the experience of being in the same space together is an unrealistic, and probably unnecessary, goal for videoconferencing. rather than getting caught up in this cycle of trying to find ‘the best’ technology, we encourage those using vdme to carefully consider working creatively and collaboratively with the technologies they already have, in order to best serve their learners. while technology vendors, and even faculty and staff members who are technophiles, may advocate for acquiring the latest and greatest technology, we learned that other factors, like working collaboratively with av professionals/experts, are much more important to the success of vdme. 3. remember technology is not neutral despite the fact they are generally conceptualized as ‘backdrop’ in the context of medical education, our research found that videoconferencing technologies actually significantly change the learning environment. for example, we learned that students often avoided asking questions because they were hesitant to have their images projected on screen. similarly, lecturers described avoiding embedding a useful video in a powerpoint presentation in order to minimize the chances that something could ‘go wrong’. we saw firsthand that technologies do not simply do things ‘for’ us, but rather technologies also do things ‘to’ us; and, we encourage those using vdme to therefore think critically about the implications of choosing particular technologies. how might certain technological elements encourage learning and how, in turn, might they potentially discourage learning? a good example of such a consideration relates to the issue of question asking raised above. in this case, we would encourage the multiple stakeholders of vdme to explore critical questions, weighing pros and cons such as: is it necessary for question-askers to have their image projected on the screen? how would the experience be changed if questions were shared across sites by voice only? doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports 4. be flexible with policies in the early stages of developing a vdme program, it is tempting to try to anticipate all of the potential challenges that might occur and to proactively develop policies to preempt those challenges. for example, many of the people we interviewed described a local policy of submitting powerpoint files for lectures 2 weeks in advance of delivery so that slides could be tested and optimized for videoconferencing. this initial policy was developed to minimize operational risk and any real, or perceived, disadvantages for learners at regional campuses. while this policy made sense in theory, in practice, lecturers found it frustrating and an unrealistic timeline; and in some cases, resistance occurred. we suggest that administrators of vdme programs should be open to suggestion and responsive, developing authentic policies to deal with actual as opposed to predicted challenges. 5. allow students to connect using personal technologies most vdme technologies have some built in mechanism to connect learners at multiple sites. during our fieldwork, however, we noted that students frequently ‘worked around’ those mechanisms and connected using their own personal technologies, most frequently through sms messaging or facebook. in fact, the most authentic cross-site conversations that we learned about did not involve the formal vdme technologies at all. for example, students would send messages across sites through a facebook group in order to remind people at the opposite site to speak into the microphone, so they could hear them quickly. while some of the teachers and administrators we spoke with expressed frustration at students using personal devices during lectures, we found students were using these devices for educational purposes. we therefore encourage vdme programs to think critically about how to leverage these already available and widely used technologies in student-centered ways. 6. remember what videoconferencing technologies are designed to do the technologies of vdme are designed to optimize seeing and hearing—and they do so very efficiently! one of the challenges we learned about is that members of the vdme community become comfortable with, and complacent about, the technologies which can lead to unintended revelations.22 these situations can be embarrassing, professionally challenging, and ethically complex. we learned about several such examples, including a microphone left on accidentally in one site leading to everyone at another site overhearing what was intended to be a private conversation. we encourage the people of vdme programs to be mindful of the potential exposures that occur through these technologies, and to develop systems to remind users when technologies are ‘active’ or ‘live’. this may involve, for example, a red dot on the screen when the videoconferencing system is activated and being shared to other sites. 7. rethink faculty development people need to be prepared for teaching with vdme systems; however, many lecturers only use videoconferencing technologies for a few hours per year. traditional faculty development models, like hour-long workshops, may not be the solution. we encourage those investing in vdme systems to think carefully about how best to reach those who will be using the system, and to develop a multi-pronged approach. promising practices we witnessed include just-in-time meetings between av professionals and lecturers, and instructional videos that were accessible at any time. we believe simply allowing people the time and space to practice with new technologies in an environment in which they are not being judged by students or their peers could be especially helpful. in the context of vdme-related faculty development, there are many types of educational experts from whom we might learn. students, subject to the most instruction by vdme, are often overlooked with respect to their perspectives. providing opportunities for students to freely share their ideas and opinions would be very helpful. likewise, the av professionals who are working to produce lectures behind the scenes have almost constant access to the learning environment and are able to “see all.” through our research, we learned that these professionals often have very concrete and actionable ideas to share about how to optimize vdme teaching. yet, for a variety of reasons including their relative invisibility, academic and administrative divisions, issues of power, and others, they remain a largely underused resource. we believe av professionals are critical pedagogical partners who can provide feedback that might not otherwise be available, and we encourage members of vdme communities to reach out, ask for feedback, and build relationships with them to optimize teaching. 8. reconsider taken for granted pedagogical practices we often conceptualize teaching as an embodied practice, relying on strategies like eye contact to gage attention. we ask people to ‘call out answers’ in order to encourage engagement. we listen for whispering and restlessness to judge when it is time to wrap up a lecture. these tried and true pedagogical approaches, which become almost second nature to teachers, are for the most part, not appropriate in the context of videoconferenced teaching. they inevitably lead to focusing on the group of people who are in the same physical space as the teacher, to the detriment of those who are accessing the lecture through technology. another example of a taken for granted pedagogical practice that we frequently observed involved singling out learners at other sites and asking people to weigh in (i.e. “what do you think in doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports location x?; any thoughts from location y?”). while this was thought to be a strategy for being inclusive by those at the central site, we learned that people at other sites experienced it as uncomfortable, nerve-racking, and described feeling repeatedly “put on the spot.” clearly, there is a need to think through such practices and how they affect the sites differently when the interactions are mediated by technology. this again is an opportunity for thinking about the potential role of faculty development in helping teachers prepare for vdme instruction. 9. define success in terms other than ‘sameness’ we encourage vdme programs to think critically about what success means to them, and to explicitly name it. whether success is defined in terms of numbers of ‘dropped minutes’ (i.e. we only dropped 2 minutes of lectures in the entire term), student experience (i.e. mechanisms were in place to support question asking outside of given lecture time), learning outcomes (i.e. students at all sites performed comparably on assessments), or some combination thereof. whatever the given definition, we think it is very important to move away from the taken for granted position that ‘the same’ experience across sites is the gold standard, or even possible. rather, we encourage programs to think about the uniqueness of each distributed site and put systems in place to make vdme instruction work in the context of those realities. 10. try not to make assumptions about what is happening in other locations experiences of vdme across sites are technologically mediated. everything we hear, we hear through a network of microphones, cables, and speakers. everything we see, we see through a system of cameras, cables, and screens. spontaneous adjustments we would make in in-person interactions in order to optimize communication and understanding are not as easily available to us, or even available to us at all, through vdme. for example, through our observations we noted that students at a distant site could sometimes be seen to be chatting in the midst of a lecture. since we only observed this through a screen and muted microphone system, we initially assumed this chatting was a sign of disengagement. however, upon further investigation we learned that these students had developed an informal peer teaching system in which challenging concepts of the lecture were researched and discussed in real time. we encourage members of the vdme community to recognize the limitations of the technologies, and if something seems troubling, to further investigate rather than making assumptions. conclusions we present this series of ‘tips’ based on our ethnographic field work in the hopes that it might be useful for those who are currently working with, or considering integrating, videoconferencing technologies into their dme programs. vdme is a powerful tool that facilitates connection and sharing of information in real-time, and this is very important in the context of distributed medical education. rather than treating the technologies as something we can ignore, predict, or control, we hope that the tips help curriculum workers consider the realities of teaching and learning in a videoconferenced environment. references 1. solarsh g, lindley j, whyte g, fahey m, walker a. governance and assessment in a widely distributed medical education program in australia. acad med. 2012;87(6):807-814. doi:10.1097/acm.0b013e318253226a 2. macleod a, kits o, mann k, tummons j, wilson kw. the invisible work of distributed medical education: exploring the contributions of audiovisual professionals, administrative professionals and faculty teachers. adv heal sci educ. 2017;22(3):623-638. doi:10.1007/s10459016-9695-4 3. macleod a, kits o, whelan e, et al. sociomateriality. acad med. 2015;90(11):14511456. doi:10.1097/acm.0000000000000708 4. snadden d, bates j, ubc associate deans of md undergraduate education on behalf of the uad of mu. expanding undergraduate medical education in british columbia: a distributed campus model. cmaj. 2005;173(6):589-590. doi:10.1503/cmaj.050439 5. strasser rp, lanphear jh, mccready wg, topps mh, hunt dd, matte mc. canada’s new medical school: the northern ontario school of medicine: social accountability through distributed community engaged learning. acad med. 2009;84(10):1459-1464. doi:10.1097/acm.0b013e3181b6c5d7 6. mumford db. clinical academies: innovative school-health services partnerships to deliver clinical education. acad med. 2007;82(5):435-440. doi:10.1097/acm.0b013e31803ea8b4 doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 6 original reports 7. rourke j. how can medical schools contribute to the education, recruitment and retention of rural physicians in their region? bull world health organ. 2010;88(5):395-396. doi:10.2471/blt.09.073072 8. glasser m, hunsaker m, sweet k, macdowell m, meurer m. a comprehensive medical education program response to rural primary care needs. acad med. 2008;83(10):952961. doi:10.1097/acm.0b013e3181850a02 9. schofield a, bourgeois d. socially responsible medical education: innovations and challenges in a minority setting. med educ. 2010;44(3):263-271. doi:10.1111/j.13652923.2009.03573.x 10. murad mh, coto-yglesias f, varkey p, prokop lj, murad al. the effectiveness of selfdirected learning in health professions education: a systematic review. med educ. 2010;44(11):10571068. doi:10.1111/j.1365-2923.2010.03750.x 11. sargeant jm. medical education for rural areas: opportunities and challenges for information and communications technologies. j postgrad med. 51(4):301-307. http://www.ncbi.nlm.nih.gov/pubmed/16388173. accessed march 27, 2019. 12. chen l, evans t, anand s, et al. human resources for health: overcoming the crisis. lancet. 2004;364(9449):1984-1990. doi:10.1016/s01406736(04)17482-5 13. woollard b. many birds with one stone: opportunities in distributed education. med educ. 2010;44(3):222-224. doi:10.1111/j.13652923.2009.03609.x 14. worley p, esterman a, prideaux d. cohort study of examination performance of undergraduate medical students learning in community settings. bmj. 2004;328(7433):207209. doi:10.1136/bmj.328.7433.207 15. wong ry, chen l, dhadwal g, et al. twelve tips for teaching in a provincially distributed medical education program. med teach. 2012;34(2):116-122. doi:10.3109/0142159x.2011.588731 16. spradley jp. participant observation. new york: rinehart and winston; 1980. 17. macleod a, kits o, mann k, tummons j, wilson kw. the invisible work of distributed medical education: exploring the contributions of audiovisual professionals, administrative professionals and faculty teachers. adv heal sci educ. 2017;22(3):623-638. doi:10.1007/s10459016-9695-4 18. tummons j, fournier c, kits o, macleod a. using technology to accomplish comparability of provision in distributed medical education in canada: an actor–network theory ethnography. stud high educ. 2018;43(11):1912-1922. doi:10.1080/03075079.2017.1290063 19. tummons j, fournier c, kits o, macleod a. teaching without a blackboard and chalk: conflicting attitudes towards using icts in higher education teaching and learning. high educ res dev. 2016;35(4):829-840. doi:10.1080/07294360.2015.1137882 20. odena o. using software to tell a trustworthy, convincing and useful story. int j soc res methodol. 2013;16(5):355-372. doi:10.1080/13645579.2012.706019 21. tummons j. using software for qualitative data analysis: research outside paradigmatic boundaries. in: big data? qualitative approaches to digital research. vol 13. studies in qualitative methodology. emerald group publishing limited; 2014:155-177 se 8. doi:doi:10.1108/s1042319220140000013010 22. macleod a, cameron p, kits o, tummons j. technologies of exposure. acad med. november 2018:1. doi:10.1097/acm.0000000000002536 23. macleod apoc. pushing buttons: a sociomaterial exploration of the distributed lecture. int assoc dev inf soc. october 2017. https://eric.ed.gov/?id=ed579479. accessed march 27, 2019. microsoft word jrmc_4618.docx published by university of minnesota libraries publishing room 11 jane-frances aruma doi: https://doi.org/10.24926/jrmc.v6i1.4618 journal of regional medical campuses, vol. 6, issue 1 (2023) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc jane-frances aruma, penn state college of medicine, state college, pa all work in jrmc is licensed under cc by-nc volume 6, issue 1 (2023) journal of regional medical campuses perspective room 11 jane-frances aruma it felt like a whole new world on the other side of the exam rooms at this clinic. if i focused hard enough, i could probably smell all the knowledge and possibility emanating from behind the glass partition. it was here that physicians huddled, residents learned, patient care plans were discussed and solidified. i have not had much experience as a patient myself. but being at my small regional medical college offered me the opportunity to see even beyond the direct patient experience from as early as my first year. it was 2019 or was it 2020 (before the pandemic) and i had often wondered what doctors do between patients. between leaving one room and entering another, does nothing happen? do they carry information, emotion and whatever else from the previous patient unto the next? or is there some ritual, like taking a long, deep breath that represents reset a cleansing, a re-beginning, just like what i set out to do today. undeserving “what type of medical student doesn’t know how to count? i give you five minutes, and that’s all you get! have i made myself clear?” those words rang loudly in my ears, boldly threatening the certainty in my stride as i approached room 11. just last week, i had been careless enough to overstay my allotted time with a patient, inadvertently setting us a bit behind schedule. my preceptor had made it very clear that he was not pleased at all. which is why today, my second chance, just had to be different. today had to be better. having looked up my patient beforehand, i took time to learn all i could about his disease. i was armed to the teeth with knowledge about direct and indirect pathways, dopamine, and acetylcholine. i was ready as i’d ever be, to identify any item from the list of parkinson’s symptoms i memorized before i went to bed. my right hand on the door handle, i thought, this should be quick. i gave the heavy wooden door a push to open. hello patient n. yes, his day was good. yes, he was just here for a routine checkup. no, he had no specific concerns. yes, he was tolerating his medication. well, great! i left the room, and delivered a flawless presentation to my attending. all under 5 minutes! maybe medicine is for me after all. i gladly returned with the doctor to see our patient. all was well in the world again. *** room 11 looked different the second time around. the weight that had just lifted off me lent freedom to my eyes to caress the room in a way that they didn’t before. they first landed on the smiling face of viola davis plastered on the cover of the magazine in the display cabinet. and then, they fell on the adjacent wall where a lone yellow butterfly in flight had been wonderfully captured against a blurry green background, a drop of water on its right wing. the supply cabinet was slightly ajar above where my head had been, where my attending now sat speaking to the patient. our patient who had parkinson’s, but who also had bright blue eyes and hair that was thinning gracefully. our patient who had been a successful wrestler in his youth, a man of many stories and a healthy sense of humor. a man whose smile was easy to imagine even though his disease wouldn’t let me see it on his face. his face, the face of a man who had lived. where it had just been my patient and me with a table between, the room had since become dimensional. and so had patient n. have i really done well today? this experience will linger in my mind for weeks to come. i will think about room 11, the space in which i had been so focused yet so absent. i will consider the positions i occupied in this space one where i was the almost-doctor, the person with a job to do. and the other, where i was a student, free to learn, to observe, to think. and consequently, i will reflect on what it means to be a physician, a good physician the type i know i want to be. what makes a good doi: https://doi.org/10.24926/jrmc.v6i1.4618 journal of regional medical campuses, vol. 6, issue 1 perspective doctor? is it professionalism or humility? empathy or competence? i will reflect very carefully, critically. i will reflect through days spent shadowing and nights spent studying; through the multitude of errors i will make during my training; through the plethora of lessons i will learn every day. and eventually, i hope i will settle on the word “balance.” my practice, a sweet mix of intelligence and kindness, of efficiency and compassion. and then also, i will think about patient n. i will imagine the man in youthful exuberance. and will remember him fondly, as the man he is plus parkinson’s. for he has played a part in my story. and i will wait with gratitude, for certainly, there will be more patient ns to come. microsoft word novel clinical needs finding article.docx published by university of minnesota libraries publishing novel clinical needs finding course brings biomedical engineering students together with regional medical campus students, residents, and faculty to solve real-world problems hanna jensen, md phd; pearl mcelfish, phd; thomas schulz,md; raj r. rao phd doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 1, issue 4 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc dr. hanna jensen, md phd, is a clinical assistant professor in the department of biomedical engineering. she is the course instructor for the clinical needs finding course. dr. pearl mcelfish, phd, mba, ms is associate vice chancellor uams northwest arkansas region, director of the office of community health and research, and co-director of the center for pacific islander health. she co-leads the community engagement core for the uams translational research institute, and serves as chair of the research committee in the center for interprofessional education. dr. thomas schulz, md, is an associate professor of internal medicine in the division of hematology and medical oncology, and the program director of the uams northwest arkansas community internal medicine residency program at the university of arkansas for medical sciences. he serves as the co-director of the north street interprofessional student-led clinic on the uams northwest campus. dr. raj r. rao, ph.d., is professor and department head, biomedical engineering, and is the holder of the george m. and boyce w. billingsley endowed chair in engineering in the college of engineering, university of arkansas, fayetteville. corresponding author: dr. raj rao; professor and department head, biomedical engineering george m. and boyce w. billingsley endowed chair in engineering; university of arkansas, department of biomedical engineering 790 w dickson street fayetteville, ar 72701 e-mail: rajrao@uark.edu tel. 479-575-4667 all work in jrmc is licensed under cc by-nc volume 1, issue 4 (2018) journal of regional medical campuses original reports novel clinical needs finding course brings biomedical engineering students together with regional medical campus students, residents, and faculty to solve real-world problems hanna jensen, md phd; pearl mcelfish, phd; thomas schulz, md; raj r. rao, phd abstract biomedical engineering is the fastest growing engineering field in the united states, preparing a generation of skilled problem-solvers who, together with healthcare professionals, drive the momentum of novel technologies for the prevention, detection, treatment, and monitoring of disease. it is important to the education of biomedical engineers that the dialogue between healthcare professionals and schools of engineering is seamless, constant, and interactive. lack of sustainable discourse between those who produce technologies and those who use them could reduce the applicability and relevance of the biomedical engineering education1,2. reciprocally, for healthcare professionals to optimally harness the expertise of their engineering colleagues, a direct interaction is required. the department of biomedical engineering (bmeg) is one of the largest departments within the college of engineering at the university of arkansas, with approximately 70 students graduating annually. established in 2012 as the first and only biomedical engineering program in the state of arkansas, the department is establishing itself as one of the premier research departments on campus. the department prides itself in its commitment to diversity and has been successful in attracting diverse groups of students to enter the field of science and engineering. in spring of 2018, the bmeg undergraduate student body had the highest percentage of female and underrepresented minorities within the college of engineering: 53% female and 37% minority. the university of arkansas for medical sciences (uams) is the only allopathic medical school in the state of arkansas. in 2007, uams established uams-northwest as a regional campus in fayetteville. uams-northwest extends uams’ medical education, research, and clinical mission. uams-northwest has approximately 250 students in the colleges of medicine, nursing, pharmacy, and health professions, as well as 48 family medicine and internal medicine residents. uams-northwest is located more than 200 miles from the main uams campus in little rock but is only one mile from arkansas’ land grant university, the university of arkansas. the proximity of the regional medical campus to the land grant university provides opportunities for collaboration that can benefit the students of both institutions. this article provides an overview of the implementation and preliminary assessment of a novel clinical needs finding course that was recently instituted as a collaboration between the department of biomedical engineering and the university of arkansas for medical sciences– northwest campus. course background the “crown jewel” of any undergraduate engineering degree is a senior design capstone project that is carried out during the last year of the biomedical engineering education. during this two-semester course, engineering students work in small groups to produce a prototype of a medical device or process improvement. traditionally, most senior design capstone projects are faculty-led, with faculty presenting students with an array doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original report of projects to choose from. the department of biomedical engineering at the university of arkansas was committed to transforming the senior design project course to a student-led, real-world problemsolving, interactive course conducted under the mentorship of local healthcare professionals and biomedical engineering faculty. thus, the clinical needs finding course was instituted as a prerequisite to the senior design project, with the goal of fostering innovation and product development that is directly relevant to local healthcare professionals and patients. in spring of 2018, the biomedical engineering department at the university of arkansas, in collaboration with uams-northwest launched the clinical needs finding to junior level engineering students. this course provided a cohort of biomedical engineering students the opportunity to observe the operations of clinics on the regional medical campus while interacting with healthcare professionals and regional campus students and residents. the course also required engineering students to develop a project idea to improve patient care. this pilot course consisted of 16 students who participated in clinical observations and discussions on the regional campus. the clinical settings included physical and occupational therapy, family medicine, internal medicine, orthopedics, and a free clinic led by interprofessional students. student preparation prior to attending clinical observations, all students attended a health insurance portability and accountability act (hipaa) training administered by uams, signed a confidentiality agreement, and completed the course for human subject protection training of the collaborative institutional training initiative (citi) for biomedical research investigators. during the course, the students attended lectures that discussed the sustainability, bioethics, and healthcare economics behind innovations and technology. furthermore, the basics within medical device regulatory environment were covered. clinical observations partnering clinics included physical and occupational therapy, family medicine, internal medicine, orthopedics, and a free clinic led by interprofessional students. the pilot course consisted of 16 students who attended 47 observations (each four hours long). in clinics, engineering students shadowed regional campus students, residents, and faculty from the fields of medicine, nursing, pharmacy, and physical and occupational therapy. all engineering students wore photo-identification badges, and all patients were asked to verbally consent to having an engineering student present prior to any encounter. students were encouraged to interact with all professionals, patients, and caregivers in order to obtain a well-rounded understanding of the operation of the clinic from as many perspectives as possible. course deliverables as a course mid-term deliverable, each student presented a preliminary project idea based on their clinical observations and discussions with healthcare professionals. all ideas were vetted by engineering faculty and healthcare professionals at the regional medical campus. the most promising ideas were chosen to be developed further, and teams of 2 to 4 students were assigned to each idea. as a final course deliverable, student teams presented design briefs of each selected project. from the pilot course, 4 ideas were accepted as senior design projects for the 20182019 academic year: these included a grip-strength measuring pen and a mobile knee-block in collaboration with regional campus students and faculty from the college of health professions (occupational and in physical therapy); and an automatic pill dispenser and electrocardiogram signal filter in collaboration with regional campus students, residents, and faculty in the college of medicine and college of pharmacy. clinical collaborators were invited to all student presentations, and reviewed the materials students turned in as their course assignments. engineering student feedback at the end of the course, engineering students answered a survey about their experiences, and the vast majority provided extremely positive feedback (figure 1). some qualitative responses included: “my observations were both enlightening and educational. it allowed us to see the applications and uses behind the products that biomedical engineers make. this concept can be lost during one’s education, but this experience brought the purpose behind biomedical engineering to life.” “part of our job as biomedical engineers is to utilize our engineering skills in order to optimize healthcare delivery in clinical setting. to develop useful engineering products, clinical observation is important to find what physicians need to better do their jobs.” “my observations inspired me to include the first and most important value of this project: making the technologies available to the general population. many times, we forget that the people who are being charged extremely high prices are the ones who need help the most. i realized that the products developed for my project have to be relatively simple and inexpensive to make, available for a wide range of procedures, and provide an alternative to the preexisting methods.” “i think this course has been the most valuable biomedical engineering class i have taken thus far. i doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 4 original report loved being able to engage in my community and help them with their needs. all i would change is to make some more lectures about the design process.” figure 1. responses to student questionnaire about clinical needs finding and observations course in spring 2018 (bme = biomedical engineering) clinical students, residents, and faculty feedback at the end of the semester, students, residents, and faculty from uams-northwest clinics gave positive feedback about their experiences. engineering students were seen as professional, respectful, and unobtrusive to the flow of providing care in clinics. clinical students, residents, and faculty stated that the course “helped them think about possible engineering solutions to patients’ health problems.” clinical students, residents, and faculty also expressed a desire to continue to be involved with the projects as they progress through development and possible testing. future directions the clinical needs finding course has become a mandatory course for all biomedical engineering students at the university of arkansas. future implementations of the course will focus on patients who face significant barriers in healthcare due to cultural differences, financial limitations, or geographic distance to healthcare professionals. engineering students will be encouraged to work on projects that increase their understanding of ethical design and that have direct impact on local patients with a potential for global applications. the clinical needs finding course will focus on helping students become adaptive experts3, who possess an understanding about design and commercialization in an engineering context, but are sensitive to aspects beyond science, such as resourceconstraints or ethical challenges. the clinical needs finding course builds on studies which indicate that incorporating ethics and adaptive expertise instruction into biomedical engineering programs alongside new scientific content, could be the most beneficial modern addition to students4. as projects designs are completed, students, residents, and faculty from the regional medical campus will continue to work with engineering students and faculty to test the designs and publish results. conclusions the implementation of the clinical needs finding course is an example of how regional medical campuses can collaborate with universities in their geographic region for the benefit of learners in both universities and the community. both engineering and health care learners gained valuable understanding about the role of a biomedical engineer in a clinical care and built a network of peer learners and faculty support. ultimately, patients will benefit from biomedical engineering and health care programs working together to design real-world solutions to healthcare challenges. references 1. david j, johannes s, beng lc. everyday problem solving in engineering: lessons for engineering educators. journal of engineering education. 2006;95(2):139-151. 2. raman r, mitchell m, perez-pinera p, bashir r, destefano l. design and integration of a problem based biofabrication course into an undergraduate biomedical engineering curriculum. j. biol. eng. 2 016;10(1):10. 3. jp m. transfer of learning from a modern multidisciplinary perspective. charlotte, nc information age publishing; 2006. 4. rayne k, martin t, brophy s, kemp nj, hart jd, diller kr. the development of adaptive expertise in biomedical engineering ethics. journal of engineering education. 2006;95(2):165-173. microsoft word evidencebasedfacultyarticle.docx published by university of minnesota libraries publishing evidence-based faculty development programming for regional medical campuses and the bask framework ralitsa akins, md, phd doi: https://doi.org/10.24926/jrmc.v2i4.1304 journal of regional medical campuses, vol. 2, issue 4 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc ralitsa akins, md, phd; has served in academic leadership roles for over 15 years, including associate dean of academic affairs, senior associate dean, associate dean of faculty affairs, and is currently the provost at des moines university. corresponding author: ralitsa akins, md, phd email: ralitsa_akins@yahoo.com all work in jrmc is licensed under cc by-nc volume 2, issue 4 (2019) journal of regional medical campuses original reports evidence-based faculty development programming for regional medical campuses and the bask framework ralitsa akins, md, phd abstract medical schools’ regional campuses respond to vital needs in medical education. about one third of us medical schools have regional campuses. it is important to create and maintain, in all geographically separate locations, climate and culture conducive to effective teaching and learning. an evidence-based approach to designing and implementing faculty development programs for regional medical campuses is described, and the bask assessment framework is introduced, recognizing the interconnectedness between desired changes in behaviors, and learners’ attitudes, skills, and knowledge. irb approval was obtained for the completion of this study. introduction there is a paucity of publications on the topic of effective approaches in faculty development. traditionally, it has been difficult to reach to all faculty in geographically separate locations, and online tools have varied reports of success. a literature review was completed to identify best practices and evidence-supported successful approaches in implementing faculty development programs for regional campuses. an experienced outreach librarian supported a database search for articles on faculty development, with focus on approaches in distributed healthcare education. the articles from the initial search were reviewed by the author for relevance and an annotated bibliography was developed. based on the outcomes and topics within the articles, including lcme publications about most often cited deficiencies in medical schools, a faculty development program was developed and implemented in a new medical school with 4 regional campuses. a new framework for evidence-based faculty program assessment was developed: bask, based on behaviors, attitudes, skills and knowledge. findings from the literature faculty development is not a luxury, rather an imperative for every medical school. sustainable faculty development requires a medical education unit or department, staffed with respected faculty developers who are academic role models. the literature suggests the following: faculty development should be tailored to suit the needs of individuals, disciplines, and the institution, activities used in faculty development programs should encourage experiential learning and reflection (e.g. peer evaluation, portfolios), and that faculty development should strive for collaboration across medical disciplines, and where possible, across professions.10 leslie et al (2013) published a review exploring the nature and scope of faculty development in medical education, the quality of publications on faculty development, and identified meaningful areas for future research. the study found that most commonly used faculty development format was a longitudinal series of presentations for physicians only, and that the faculty development activities usually aimed to improve teaching, leadership, and scholarship. in studying faculty development programs, non-validated surveys were the most common data collection method, participants were the usual data source, and the commonly reported outcome was self-reported behavior changes. a gap was found in the current literature in exploring the impact of contextual/institutional factors in faculty development success and the need to implement more rigorous evaluation methods in faculty development assessment. focus groups have been often used to study the reasons for attendance and the deterrent factors for attending faculty development sessions, and how to make faculty development programs more pertinent to faculty’s needs. steinert et al (2010) suggested that faculty participated when they perceived that faculty development enabled personal and professional growth, they valued learning and selfimprovement, the workshop topics were viewed as relevant to teachers’ needs, the opportunity to network with colleagues was appreciated, and initial positive experiences promoted ongoing involvement. barriers against participation cited by non-attendees included volume of work, lack of time, and logistical factors. suggestions for increasing participation included introducing a ‘buddy system’ for junior faculty members, an orientation workshop for new staff, and increased role-modelling and mentorship.18 at mcgill university, an all-faculty development program was implemented, and the motivators and deterrents to participation in faculty development programs were studied, along with perceived barriers for involvement.11 it was determined that participants who regularly attended faculty development sessions perceived the topics as relevant to doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports their daily work and professional growth and valued the opportunities to network. non-attendees were deterred by inconvenient locations (e.g. program offered on central location only), inconvenient timing of sessions, lack of protected time, and lack of recognition and financial rewards for teaching. approaches in faculty development that were considered as effective included medical education presentations at grand rounds, site-specific workshops, and follow-up “booster sessions”. those involved in providing faculty development may be among only a few individuals for whom faculty development is an interest and priority within their work setting, and oftentimes funding to support faculty development is limited.15 graziano et al (2018) noted that concerns about clinical productivity, along with challenges in identifying physicians willing to teach were among the barriers to engaging community-based preceptors, and considered that faculty development could be a positive solution for both, assisting with improved teaching efficiency and sustained clinical productivity. it can be a challenge to recruit, train, and retain community preceptors. it is time-consuming to provide training, answer questions, maintain a connection, and ensure that preceptors are recognized for the role they play in educating the next generation of physicians. the society of teachers of family medicine has developed a resource for practitioners-preceptors and residency programs, available online. teachingphysician.org streamlines training, and includes topics on preparing a practice team for a student or resident, integrating a student into office routines, setting expectations teaching strategies, giving feedback, evaluating learners, billing issues; etc. community preceptors can log in to access tools and resources to help them teach the next generation of physicians to provide high-quality, patientcentered care.16 communicating faculty development news and information requires reaching faculty members in the multiple communities of practice. traditional strategies such as faceto-face programs and printed newsletters no longer have the audience or impact they once had. few schools use social media as tools to engage faculty. a faculty development blog, linked to the school’s medical education webpage, could offer customized, on-demand information about professional development topics, brief literature syntheses, and announcements of events and resources. blogging could be used for time-efficient information sharing,5 yet it has been empirically known that not all faculty embrace e-learning. reilly, vandenhouten and gallagher-lepak (2012) completed a literature review on faculty development and e-learning and described a multi-campus faculty development program using distance technology within a community of practice model in nursing. they concluded that evaluation of faculty development programs should be planned early in the design process, faculty development programs should build on previous activities, there should be opportunities to discuss classroom experiences with colleagues, ongoing professional communication of instructors with similar concerns should be encouraged, and faculty development for instructional technology must be focused on pedagogy, and not simply on technology skill acquisition. when preceptors in a required preceptorship program were offered traditional continuing medical education (cme), a preceptor listserv, an electronic clinical teaching discussion group, an orientation videotape, a cd-rom on teaching skills, and technology support, the preceptors agreed that the listserv and the electronic clinical teaching case discussion were most useful and that compared to the rest of electronic tools used, held the best promise for preceptor faculty development.1 on the other end of the spectrum from electronic communications, are the in-person sessions, where the instructor and the faculty-learners are in the same classroom – in a group or one-on-one setting. moser, dorsch and kellerman (2004) suggested using “academic detailing” as a method to deliver real-time faculty development to nearly all community preceptors, both rural and urban, using the raft technique (rapport-building, assessment, focused preceptor development, thanks/trinkets). the method could be expensive in terms of faculty time and might be difficult to schedule, yet could be a valuable, learner-centered method that reaches preceptors missed by traditional faculty development workshops. studies suggest that current faculty competencies may be lagging behind the expectations related to teaching and evaluation. holmboe et al. (2011) suggested that faculty development efforts should be focused on improving evaluation skills and developing life-long learning skills. the authors offered a 5-step model to improve assessment in medical education including 1) utilizing frame-of-reference training approach, 2) giving feedback to faculty about their performance as evaluators, 3) providing working knowledge of basic core psychometric concepts, 4) ensuring availability of web-based training modules for faculty development, and 5) learner active involvement, including completing selfassessment. nichols, kulaga and ross (2013) studied emergency medicine faculty’s skills in providing feedback and found that while preceptors provided good verbal feedback, skills were lacking in documentation/written feedback. one-on-one training was provided to preceptors, their skills in providing feedback were assessed using a 5-point scoring system, and part of the faculty also viewed a short video of a learner in the clinical setting, used for deliberate practice in writing feedback. a pre-post skills assessment revealed that if the deliberate practice (assessing a video) portion was not implemented, there was only a minimal improvement of preceptors’ skills, and therefore deliberate practice was considered a key step in changing behaviors in both, learners and teachers.13 steinert (2005) suggested that faculty development initiatives could bring about change at the individual and the organizational level and recommended that such sessions target diverse stakeholders, take place in a variety of settings, doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports use diverse formats and educational strategies and have deliberate educational design. while faculty development self-reported outcomes data, such as participant satisfaction or confidence, are easily obtained, it is more challenging to measure higher-level outcomes of a successful faculty development program. guglielmo et al. (2011) suggested that validated, reliable evaluation tools should be used in the assessment of faculty development, such as the kirkpatrick’s model. the kirkpatrick’s model measures the reaction of participants (i.e. participant satisfaction), learning (knowledge, skills, and attitudes), behavioral changes, and the impact on learners. furthermore, the optimal evaluation of any faculty development program should utilize both quantitative and qualitative measures, and should include a preand post-evaluation, and/or a delayed post-evaluation.3 faculty development has been effective in improving faculty perceptions about the value of teaching, increasing motivation and enthusiasm for teaching, increasing knowledge and behaviors, and in disseminating teaching skills. lancaster et al (2014) described 10 steps for building a successful faculty development program, to include: 1. build stakeholders by listening to all perspectives 2. ensure effective program leadership and management 3. emphasize faculty ownership 4. cultivate administrative commitment 5. develop guiding principles, clear goals, and assessment procedures 6. strategically place faculty development within the organizational structure 7. offer a range of opportunities, but lead with strengths 8. encourage collegiality and community 9. create collaborative systems of support 10. provide measures of recognition and awards langlois and thach (2003) described the lessons learned in developing, using, and disseminating a collection of preceptor development materials designed to be relevant to community-based faculty and easy to use. topics were oriented to meet community preceptors’ needs. there were 9 topics and 5 faculty development formats used. topics included setting expectations, evaluation, feedback, teaching and learning styles, one-minute preceptor, integrating learners into clinical offices, dealing with difficult situations, teaching at the bedside, and advanced training for experienced preceptors. the 5 formats included seminars, monographs, web modules, thumbnails (one-page handouts), and videos that could be downloaded and customized. lancaster et al (2014) also proposed specific topics for faculty development in teaching, learning, and assessment, to include syllabus/course design, writing objectives, constructing assessments, rubric design, grading strategies, student motivation, learning disabilities, classroom management, active learning, presentation and communication skills, self-reflection, and searching and evaluating evidence. hunt et al (2016) described the most common issues leading to severe accreditation actions against medical schools, such as probation, when judging schools’ compliance with the accreditation standards. a number of the issues they identified could be successfully addressed through faculty development activities, including curriculum management, comparability across instructional sites, systematic review and revision of the curriculum, career counseling, midcourse feedback, educational program objectives, student mistreatment, health care providers’ involvement in student assessment, and formative and summative assessment. in summary, faculty development needs to be systematic, involving planning, implementation and evaluation, and its outcomes should be realistic, task-oriented and measurable.10 in addition, faculty development should help the faculty and the institution to meet the medical program’s goals at all instructional sites. bask: an evidence-based faculty development assessment framework as demonstrated above, while various elements of what works in faculty development have been studied, faculty development literature does not offer a cohesive, overarching approach to faculty development. findings from the literature review were used to design a year-long faculty development program for a new medical school that started with the simultaneous development of 4 regional medical campuses and develop a new evidence-based framework for assessment of faculty development programming, bask, based on behaviors, attitudes, skills, and knowledge. program areas/topics, methods of delivery and instructional methodology that were identified as most effective in the literature were implemented. data from the attendee assessment forms from the faculty development sessions were analyzed. analyses were performed using ibm spss statistics v. 24 software. in addition, the faculty development program was designed following the principles of continued quality improvement, and the bask assessment framework was introduced. introducing the bask assessment framework traditionally, acquisition and attainment of knowledge and skills, and assessment of the attitudes of the learners have been considered as major outcomes in medical education, including student and faculty assessment. this triad of knowledge, skills, and attitudes has become a staple in doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports assessment and accreditation reviews. since the major goal of education and continued education is a positive impact on behaviors, and change in behaviors is brought about by participants’ attitudes, which are in turn supported by their knowledge and skills, the author suggests a new framework to reflect this interdependence in achieving incomes: the bask framework. bask stands for behaviors, attitudes, skills, and knowledge, and describes the outcomes dependence of all desired behaviors on learners’ attitudes in implementing and sustaining such improved behaviors, and in turn, learners’ attitudes’ dependence on their skills and knowledge acquisition, sustainment, and continued improvement. the acronym has a positive connotation and is easy to remember. quality improvement design of the faculty development program utilizing the bask assessment framework prior to the start of the faculty development program, a continued quality improvement model was embedded in its planned delivery, to include: • assessment using the bask framework: behaviors, attitudes, skills and knowledge • assessment of the satisfaction, learning and behavior elements of the kirkpatrick’s program assessment model, as reported by participants at each session • a preand post-test assessment format, to support the bask framework and the kirkpatrick’s elements assessment • yes/no questions to assess if participants gained new knowledge/learning • yes/no questions to assess if participants plan to change behaviors after session • “you said – we did” report to participants • session outcomes summary feedback to presenters institutional review board approval was sought to analyze the quality improvement data from the faculty development program upon completion of the 2016-2017 academic year, when the program was delivered, and exempt status of the study was granted under project irb #16228/2017. results from the implementation of the bask framework in academic year 2016-17, seventy-three faculty development sessions were delivered on the main campus and the 4 regional campuses of one new medical school. a majority of sessions offered videoand teleconferencing options for participants, all sessions amenable for video-recording were recorded, archived, and accessible (excluding sessions involving exclusively small-group discussions), and 12 sessions were delivered on-site at the campus locations. three hundred and three individual faculty attended one or more sessions, for a total number of session attendees of 1 125. on average, each session was attended by 15 individuals, ranging from 6 to 41. sessions designed for course directors had more limited attendance related to the target audience, and sessions on curriculum, assessment and hot topics in education attracted larger audiences. attendee satisfaction was measured at each session, and a pre-post-test design of assessment based on a 5-point likert scale was implemented for questions exploring: 1) participants’ self-reported intention to change behaviors, 2) change in attitudes, 3) gaining of new skills, and 4) gaining of new knowledge, as related to the faculty offered development sessions. in addition, at the end of the sessions, yes/no questions to assess if participants gained new knowledge/learning, and yes/no questions to assess if participants plan to change behaviors were asked. table 1 below presents the faculty development program topic distribution. table 1. faculty development topics distribution in percentages participant satisfaction (an element of the kirkpatrick’s program assessment model) was measured for each session, and the outcomes are presented in table 2. for the faculty development program, there we 11 male presenters who presented a total of 25 sessions, 10 female presenters who presented a total of 39 sessions, and 9 sessions were presented by teams of both genders. we asked the participants to measure their satisfaction with the sessions, with the perceived knowledge of the presenters, and the perceived communication skills of the presenters. as seen on table 2, team presentations yielded the least satisfaction. table 2. session satisfaction 7 30 12 12 10 29 0 10 20 30 40 assessment & evaluation curriculum design instructional methodology leadership research & scholarship multiple/mixed topics doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports paired two-tailed t-test was used to assess statisticallysignificant changes, and significance was reported at the 0.05 level. after the conclusion of 71% of the sessions, participants reported that they were planning to change behaviors based on what they learned during the faculty development sessions. thirty-two percent of the sessions impacted participants’ attitudes in the desired direction. participants perceived that their skills improved after 79% of the sessions, and that their knowledge improved after 82% of the sessions. in 5% of the sessions, there was no statistically significant change in attendees’ behaviors, attitudes, skills, or knowledge. ninety-five percent of the sessions yielded participant self-reports of positive change in at least one of the bask elements (behaviors, attitudes, skills and knowledge), and 26% of the sessions impacted all bask elements, i.e. there was a statistically-significant difference after the session in all bask elements. the results of the analyses are presented in table 3. table 3. pre-post assessment of the bask elements after the conclusion of the faculty development sessions, a summary report about the session outcomes and feedback from participants was sent to each presenter to aid future quality improvement of faculty development sessions. answers to questions raised during the sessions, and requested materials not available during the presentations were sent to the session participants in the fashion of “you said, we did” reports. feedback from attendees and presenters indicated such follow-up communication and reporting was helpful and much appreciated. study limitations the implementation of the evidence-based faculty development program included the 4 campuses of one medical school, and, therefore, considerations regarding local circumstances need be factored in when applying the principles utilized by this study to other medical schools and their regional campuses and geographically separate instructional sites. conclusion the evidence-based nature of this study, including a literature review about faculty development at regional campuses, utilizing data from the accreditation body for medical schools (lcme) regarding factors leading to severe accreditation session satisfaction (average, scale 1-5) assessment of presenter knowledge (average, scale 1-5) assessment of presenter communic ation skills (average, scale 1-5) male presenters (n=11, presented 25 sessions) 4.4 4.71 4.59 female presenters (n=10, presented 39 sessions) 4.48 4.71 4.67 team presentation (f, m) (presented 9 sessions) 3.91 4.28 4.07 4.4 4.71 4.59 4.48 4.71 4.67 3.91 4.28 4.07 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 male presenters (n=11, presented 25 sessions) female presenters (n=10, presented 39 sessions) team presentation (f, m) (presented 9 sessions) bask framework elements sessions with statistically significant difference pre-post b behaviors 71% a attitudes 32% s skills 79% k knowledge 82% no difference pre-post in any bask element – 5% of sessions at least one bask element affected – 95% of sessions all bask elements affected – 26% of sessions doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports decisions, as well as the quality improvement design of data collection and the pre-post testing model, suggest that the results of the study could inform the efforts of medical schools in building evidence-based faculty-development programs. additional studies on the topic of faculty development in medical schools, and regional medical campuses in particular, could lead to the development of a “core” faculty development series for those behaviors, attitudes, skills, and knowledge considered uniform across medical school settings, and in that way advance towards a national curriculum in “core” competencies for medical school faculty. such national curriculum could be informed by the bask framework, recognizing the pivotal importance of behaviors, attitudes, skills, and knowledge in designing evidence-based faculty development programs and implementing meaningful faculty development outcomes assessment. acknowledgements the author would like to acknowledge kathryn vela, mlis, ahip, health sciences outreach librarian with the spokane academic library at washington state university for her support in the literature review articles search. references 1. bramson r, vanlandingham a, heads a, paulman p, mygdal wi. (2007). reaching and teaching preceptors: limited success from a multifaceted faculty development program. fam med 39(6):386388. 2. graziano sc, mckenzie ml, abbott jf, buery-joyner sd, craig lb, dalrymple jl, forstein da, hampton bs, page-ramsey sm, pradhan a, wolf a & hopkins l (2018): barriers and strategies to engaging our community-based preceptors, teaching and learning in medicine, doi: 10.1080/10401334.2018.1444994 (accessed 4/7/18). 3. guglielmo bj, edwards dj, franks as, naughton ca, schonder ks, stamm p, thornton p, & popovich ng. a critical appraisal of and recommendations for faculty development. american journal of pharmaceutical education 2011; 75 (6) article 122. 4. holmboe es, ward ds, reznick rk, katsufrakis pj, leslie km, patel vl, ray dd, & nelson ea. (april, 2011). faculty development in assessment: the missing link in competency-based medical education. academic medicine 86(4): 460-467. 5. huggett k. (2015). a faculty development blog: curated and convenient. medical education, 49:1160-1161. 6. hunt d, migdal m, waechter dm, barzansky b & sabalis rf. (2016). the variables that lead to severe action decisions by the liaison committee on medical education. acad med. 91:87–93. 7. lancaster j, stein sm, maclean lg, van amburgh j, & persky am. (2014). faculty development program models to advance teaching and learning within health science programs. american journal of pharmaceutical education 2014; 78 (5) article 99. 8. langlois jp. & thach sb. (2003). bringing faculty development to community-based preceptors. academic medicine 78(2): 150-155. 9. leslie k, baker l, egan-lee e, esdaile m, & reeves s, phd. (july, 2013). advancing faculty development in medical education: a systematic review. academic medicine, 88(7): 1038-1045. 10. mclean m, cilliers f & van wyk jm. (2008). faculty development: yesterday, today and tomorrow. medical teacher, 30:555-584. 11. mcleod pj, steinert y, & boillat m. (2011). how faculty development research can inform practice. medical education, 45: 1150-1151. 12. moser se, dorsch jn, kellerman r. (2004). the raft approach to academic detailing with preceptors. fam med 36(5):316-8. 13. nichols d, kulaga a, & ross s. (2013). coaching the coaches: targeted faculty development for teaching. medical education, 47: 534-535. 14. reilly jr, vandenhouten c, gallagher-lepak s. (2012). faculty development for e-learning: a multicampus community of practice (cop) approach. journal of asynchronous learning networks, volume 16: issue 2, 99-110. 15. sicat bl, kreutzer k, gary j, ivey ck, marlowe ep, pellegrini jm, shuford vp & simons df. (2014). a collaboration among health sciences schools to enhance faculty development in teaching. american journal of pharmaceutical education; 78 (5) article 102. 16. society of teachers of family medicine (2012). new website helps departments and programs effectively train and support preceptors. ann fam med 10(1):82-83. 17. steinert y. (2005). learning together to teach together: interprofessional education and faculty development. journal of interprofessional care, (may 2005) supplement 1: 60-75. 18. steinert y, macdonald me, boillat m, elizov m, meterissian s, razack s, ouellet mn, & mcleod pj. (2010). faculty development: if you build it, they will come. medical education, 44: 900-907. microsoft word engaging native american articles.docx published by university of minnesota libraries publishing engaging native american students in research methodology mangan golden, ma; patricia conway, phd; catherine mccarty, phd; amy versnik nowak, phd; jessica hanson, phd; desbah begay; maliyan binette; linn birdchief; fred blaisdell; ginearosa carbone; seth culver; teague goodsky; zhaazhaa greensky; nizhoni greyeyes; joshua henry; quinton impson; cheyne littlesun; genevieve mcgeshick; dannah nephew; ty running fisher; michael spear; leah thompson; mary owen, md doi: https://doi.org/10.24926/jrmc.v5i1.4486 journal of regional medical campuses, vol. 5, issue 1 (2022) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc mangan golden, ma, research coordinator, center of american indian and minority health, university of minnesota medical school, duluth campus, duluth, minnesota patricia conway, phd, research scientist iii, essentia institute of rural health, duluth, minnesota amy versnik nowak, phd, associate professor, department of public health, university of minnesota-duluth, duluth, minnesota catherine mccarty, phd, associate dean of research, professor, department of family medicine and biobehavioral health, university of minnesota medical school, duluth campus, duluth, minnesota jessica hanson, phd, assistant professor, public health program coordinator, department of public health, university of minnesota-duluth, duluth, minnesota desbah begay, undergraduate student, university of new mexico, albuquerque, new mexico, native americans into medicine participant maliyan binette, undergraduate student, university of maine, orono, maine, native americans into medicine participant linn birdchief, bs, montana state university billings, billings, montana, native americans into medicine participant fred blaisdell, medical student, university of minnesota medical school, duluth campus, duluth, minnesota, native americans into medicine participant ginearosa carbone, medical student, university of minnesota medical school, duluth campus, duluth, minnesota, native americans into medicine participant seth culver, undergraduate student, fort lewis college, durango, colorado, native americans into medicine participant teague goodsky, postbaccalaureate student, university of minnesota-duluth, duluth, minnesota, native americans into medicine participant zhaazhaa greensky, undergraduate student, michigan technological university, houghton, michigan, native americans into medicine participant nizhoni greyeyes, undergraduate student, university of arizona, tucson, arizona, native americans into medicine participant joshua henry, undergraduate student, university of arizona, tucson, arizona, native americans into medicine participant quinton impson, undergraduate student, fort lewis college, durango, colorado, native americans into medicine participant cheyne littlesun, undergraduate student, salish kootenai college, pablo, montana, native americans into medicine participant genevieve mcgeshick, undergraduate student, university of minnesota-duluth, duluth, minnesota, native americans into medicine participant dannah nephew, undergraduate student, university of minnesota-duluth, duluth, minnesota, native americans into medicine participant ty running fisher, undergraduate student, stanford university, stanford, california, native americans into medicine participant michael spear, undergraduate student, stanford university, stanford, california, native americans into medicine participant leah thompson, undergraduate student, washington university, st. louis, missouri, native americans into medicine participant mary owen, md, director, center of american indian and minority health, assistant professor, department of family medicine and biobehavioral health, university of minnesota medical school, duluth campus, duluth, minnesota. corresponding author: mangan golden, ma research coordinator, center of american indian and minority health, university of minnesota medical school, duluth campus 1035 university dr. smed 182 duluth, minnesota, 55812 218-726-8303 goldenm@d.umn.edu all work in jrmc is licensed under cc by-nc volume 5, issue 1 (2022) journal of regional medical campuses original reports engaging native american students in research methodology mangan golden, ma; patricia conway, phd; catherine mccarty, phd; amy versnik nowak, phd; jessica hanson, phd; desbah begay; maliyan binette; linn birdchief; fred blaisdell; ginearosa carbone; seth culver; teague goodsky; zhaazhaa greensky; nizhoni greyeyes; joshua henry; quinton impson; cheyne littlesun; genevieve mcgeshick; dannah nephew; ty running fisher; michael spear; leah thompson; mary owen, md abstract the purpose of this project was to provide a learning experience for american indian/alaska native (aian) undergraduate students participating in a summer academic enrichment program, native americans into medicine (nam). through nam, operated by the center of american indian and minority health, students learned quantitative and qualitative research skills. they applied these skills through the development of a culturally relevant survey to measure commercial tobacco use in aian teens and analysis of the survey results. in phase/year 1, students learned qualitative research methods and interviewed participants of a regional tribal community powwow to inform the cultural adaptation of the national youth tobacco survey. in phase/year 2, students learned about quantitative research methods by conducting a cross-sectional study in which the survey was distributed to rural minnesota schools to assess tobacco attitudes, use, intent to use, and factors influencing tobacco use in aian youth. nam participants then analyzed the survey data. benchmarks for student success included developing a tool to assess tobacco use in aian youth, conducting the study, and disseminating results. at the pow wow in year 1, 26 youth (ages 12 to 18) who self-identified as aian were recruited to participate in cognitive interviews. student researchers reviewed each survey question for possible revision and inclusion in the final survey. in year 2, completed surveys were obtained from 281 (15% of eligible) students from 5 schools; 256 surveys were usable. thirty-one percent (n = 80) of students self-identified as aian; 56% were male. students’ mean age was 15.8 years. thirty-eight percent had tried cigarette smoking, even one or two puffs, or had vaped. as a cohort, students presented research results to health directors and providers at 2 tribal clinics. journal of regional medical campuses, vol. 5, issue 1 original reports this 2-year cohort approach to teaching qualitative and quantitative research skills to aian students was successful by internal benchmarks—namely, student researchers developed, implemented, and analyzed a survey appropriate for aian high school students, and all student researchers presented their research results at least once. background the university of minnesota medical school’s (umms) duluth campus was founded in 1972 to be a leader in educating physicians to practice in rural minnesota and american indian/alaska native (aian) communities. originally a stand-alone medical school for years 1 and 2, the duluth campus was merged to become a regional medical campus of the university of minnesota. as defined by the liaison committee on medical education, a regional medical campus (rmc) is “an instructional site that is distinct from the central/administrative campus of the medical school and at which some students spend one or more complete curricular years.”1 the number of rmcs in the united states has grown to meet the increased demand for physicians and to meet unique rmc research and education missions. scholarly activity is expected of faculty and students at rmcs. cathcartrake and robinson (2018) argued that scholarship should be more broadly defined to accommodate the unique mission-specific scholarship that is undertaken at rmcs.2 the center of american indian and minority health (caimh), housed in the umms located on the duluth campus, reinforces the school’s mission by recruiting aian medical students and supporting them academically and socially through their first 2 years of medical school. support includes academic tutoring if needed, advocating for student needs, providing referrals to different academic and health services, and offering a physical and emotional space for community building. caimh also develops and administers educational pathways to health profession programs. the oldest of the pathway programs, native americans into medicine (nam), is a 6-week summer academic enrichment program for aian college sophomores and juniors pursuing health-related careers. in the program, students learn and apply indigenous-based research practices while studying current issues in aian health. indigenous research methodologies model best practices for conducting research with aian communities and can challenge the colonial notions doi: https://doi.org/10.24926/jrmc.v5i1.4486 of knowledge systems and methodologies that have been prevalent in academia.3-5 historically, research conducted by academic investigators in tribal communities has lacked respect and relevance, furthering distrust similar to that seen in health care.3 through training in indigenous research methodologies, research faculty and students learn how to engage communities in a respectful and relationship-sustaining manner. centering indigenous approaches and knowledge to address community needs empowers students and builds tribal research capacity.3,5-7 another key element to this approach is the accountability of the researcher and the institution to the community. data and results are shared and controlled by the community, supporting sovereignty and self-governance.3-7 the goal of this article is to describe a tobacco research project initiated by nam with a cohort of aian students. one of the main aims of the tobacco research project was to teach nam students about indigenous research methodologies, then have them apply the methodologies within the community-informed project, with all data owned by the specific participating tribal communities. commercial tobacco in indian country tobacco use among youth was the primary focus of the nam research project. one of the first discussions with the nam cohort included an acknowledgment of the distinction between traditional and commercial tobacco for those who are unfamiliar with the role and influence in many aian communities. understanding the cultural significance of traditional tobacco and how it differs from commercial tobacco is essential to crafting a culturally appropriate evaluation tool and commercial tobacco cessation programs. a traditional tobacco is any tobacco used in a long-established, customary way that often maintains a spiritual aspect, especially in many aian cultures.8 these practices, as well as the plants used as tobacco, vary by region and cultural group.8 in journal of regional medical campuses, vol. 5, issue 1 original reports minnesota, asemaa (ojibwe) and cansasa (lakota) are both common words used for traditional tobacco. kinnikinnick is a mixture of tobacco with other plant materials, literally translating to “that which is mixed.”8 commercial tobacco is also occasionally used for ceremonies. traditional tobacco has great cultural and spiritual meaning to many of the investigators, while commercial tobacco is a catalyst for many of the disparities seen in aian communities. the significance of this distinction was at the heart of the motivation for conducting the project. in addition to understanding differences between traditional and commercial tobacco, the impact of commercial tobacco used and health disparities in general were important topics within the nam program. the life expectancy for aian individuals is 5 years less than the life expectancy of members of the overall population and is the lowest in the united states.9,10 higher rates of commercial tobacco use in the aian population contribute to increased rates of chronic lung disease, lung and other forms of cancer, and diabetes, all of which decrease the overall life expectancy for aian populations.11,12 the centers for disease control and prevention (cdc) reports that aian have higher rates of cigarette use than other ethnic and racial groups. reducing commercial tobacco use among aian offers the potential to reduce the amount of commercial tobacco–related deaths and to raise aian life expectancy.11 an understanding of aian youth commercial tobacco use and exposure could illuminate ways to encourage cessation earlier in life. while cigarette use remains a concern, electronic tobacco devices (i.e., vapes, juuls, mods, or other e-cigarettes) are now causing increased rates of tobacco use, primarily among adolescents and young adults. e-cigarettes, vaping, and juul use are forging a pathway for the renormalization of smoking and an increase in overall prevalence of tobacco use.13,14 the nam cohort was particularly interested in these new ways of consuming tobacco among aian youth. considering the cultural relevance of traditional tobacco, the high prevalence of commercial tobacco use among many aian communities, and the rise in e-cigarette use among youth in general, the nam cohort worked with faculty to develop a survey tool to better understand this health issue and potential outcomes in aian communities. within this research, the nam students were able to not only better doi: https://doi.org/10.24926/jrmc.v5i1.4486 understand a health disparity but also become more engaged as aian student researchers in a culturally significant and meaningful experience. methods this project is an example of a research product that was initiated and subsequently completed by a cohort of undergraduate aian students and that aligns with the unique mission of a regional campus at umms in duluth. the research project involved 17 student researchers who participated to increase their research knowledge and skills, develop an interest in research, and refine an instrument to assess traditional and commercial tobacco use among aian high school students. (a detailed description of the summer research program and the students is outlined in a complementary article titled “native americans into medicine: a program focused on developing representation and diversity in health care,” published in this same issue of journal of regional medical campuses.) the study was conducted in 2 phases over 2 summer sessions: (1) development of the method for the study, including refining the instrument, and (2) data collection and analysis of survey results. the project received approval through the university of minnesota institutional review board (irb); all students completed collaborative institutional training initiative (citi) training. one tribal community also required tribal irb approval of the project and the final manuscript of this article before submission. additionally, 7 tribal chairpersons received a letter explaining the project and were notified that they may have tribal members attending public schools where the survey was being implemented. phase 1: developing the study method refining the national youth tobacco survey and experiential learning in qualitative research method, summer 1 year 1 focused on learning basic research methods, with a focus on qualitative research. student researchers conducted a review of the literature regarding youth tobacco use and traditional and commercial tobacco use by aian and spoke with a tribal elder regarding traditional tobacco. the journal of regional medical campuses, vol. 5, issue 1 original reports research team selected the national youth tobacco survey (nyts),15 developed by the cdc to measure youth tobacco use and the impact of efforts to reduce tobacco use, as the basis for this study. they attempted to keep many of the questions and the format similar to the cdc and minnesota student survey (mss)16 to be able to compare results. student researchers developed a plan to refine the survey based on (1) a review of the literature and their own lived experiences, which led to a shortened version of the nyts; and (2) cognitive interviews with youth in a tribal community to ensure clarity and cultural sensitivity of items in the shortened version.15 student researchers created a semi-structured interview schedule to guide the cognitive interviews. they also completed training composed of roleplaying and didactic information about cognitive interviewing and qualitative data analysis. phase 1 sample cognitive interviews were conducted in one rural, tribal community during a pow wow. twenty-six youth ranging between 12 and 18 years of age who self-identified as aian were recruited to participate in the cognitive interviews. parents signed parental consent forms; verbal consent to participate was obtained from youth. phase 1 data collection three researchers conducted each interview, 2 of whom recorded youth responses; the third facilitated the interview, guided by the cognitive interview schedule. interviews were also audio recorded. the length of interviews varied widely, from 2 minutes to 17 minutes. each interview was coded so the taped interview and notes for each participant could be linked but still maintain anonymity. youth were thanked for their participation with a $25 gift certificate and prayer ties that nam student researchers dried and packaged from locally picked tobacco plants. data (recordings and notes) were stored electronically in a secure database and on password-protected devices. paper surveys were kept in a secured drawer in a secure office. phase 1 data analysis results of interviews were summarized to guide instrument development. all responses to each item were placed in a word document table. the doi: https://doi.org/10.24926/jrmc.v5i1.4486 comments were then coded by type of comment, youth appraisal of survey, information about the youth making the comment, and notes made by researchers during the process of summarizing student comments (see table 1). finally, as a group, student researchers reviewed each survey item and made a recommendation about revisions and whether to include the item in the final survey (survey available upon request). phase 2: cross-sectional survey with high school students the second phase of the project, a cross-sectional study focused on quantitative methods, surveyed youth in rural minnesota schools regarding tobacco attitudes, use, intent to use, and factors influencing tobacco use. based on the semi-structured interviews, changes were made to the existing nyts survey. changes made to the survey based on this input are considered minor and included removing questions not relevant to tobacco use (e.g., questions on marijuana) and demographic questions to fit with the mss. three questions were added about use of traditional tobacco, and one question specific to vaping was added. we also added a question about vaping by using just the juice, on the advice of the teen reviewer. phase 2 sample minnesota high schools whose student population included at least 15% aian students were identified, based on data from the minnesota department of education report card. twenty-four high schools were invited to participate. letters were sent to each school’s principal; research staff then contacted each school by phone. five schools located in minnesota agreed to participate; the communities were a mix of town and rural populations, which aligns with the mission of the duluth campus.16 phase 2 instrumentation and data collection university of minnesota faculty and student researchers created a work group to revise the nyts based on feedback from cognitive interviews and review by two groups of experts: (1) nam student researchers and (2) academic, public health, and medical professionals. finally, a high school student not previously affiliated with the study completed the survey to assess language clarity and relevance of journal of regional medical campuses, vol. 5, issue 1 original reports terminology. as a result, additional language regarding e-cigarettes was added regarding the frequency of using e-cigarette juice without the electronic devices. the 52-item survey was then programmed into qualtrics™ and piloted with 5 high school students located in an urban area in minnesota, resulting in minor grammatical changes to the survey. the link to the qualtrics survey was sent to each of the 5 participating schools for their review. nam faculty and staff administered the survey to students in the 5 schools during the academic year because student researchers were scattered across the country. in preparation for administering the survey, nam staff worked with each school to determine a date and time that would best fit their academic calendar. four schools chose to utilize the electronic version of the survey; one chose the paper format. surveys were completed during the school day in spring 2018. schools emailed passive permission forms to parents and guardians of students in grades 9 through 12, a common practice in minnesota high schools for gaining parental permission for youth to participate in similar surveys. schools and students received incentives for participating. schools were given a $500 stipend; participating students’ names were entered into drawings for door prizes such as ear buds and portable chargers, university water bottles and hats, and $10 gift cards. each school administered the survey; nam staff were on site to oversee the process, answer questions, and assist with any difficulties students may have had, such as clarifying the options for responses to the gender item. student assent was obtained prior to them completing the survey. students were informed that participation in the survey was voluntary and that they had the option to stop at any time, which some did. survey data were securely stored in qualtrics™ until they were downloaded for statistical analysis. downloaded data were stored on passwordprotected laptops. upon completion of the project, and to fulfill the requirements of the tribal irb, deidentified data were returned to one tribal community in compliance with their irb approval. paper versions of the survey were kept in a secure office by the principal investigator. phase 2 data analysis doi: https://doi.org/10.24926/jrmc.v5i1.4486 having access to data from the high school student surveys provided nam student researchers with the opportunity to learn about the following: ● creating a plan to analyze data, based on research questions ● cleaning survey data and using a log to track steps in analysis ● analyzing quantitative data from the survey using ibm spss statistics software ● determining which statistical test to employ to answer a research question ● disseminating results of the study for instance, students described the rate of tobacco use by students who were aian; the level of curiosity about using tobacco; and the relationship between income and tobacco use. they then disseminated information through posters presented at the conclusion of the second summer session. results approximately 1,900 students in the 5 schools were eligible to complete the survey; 281 (15%) completed the survey, and 256 surveys were usable. thirty-one percent (n = 80) self-identified as aian; 56% were male. students’ mean age was 15.8 years. thirty-eight percent had previously tried cigarette smoking, even one or two puffs, and had previously vaped. table 2 outlines the descriptive data of respondents’ use of vapes, juuls, mods, or other e-cigarettes in their entire lives. table 3 further describes commercial tobacco use in terms of amount (if any), and table 4 data are focused on participants’ self-reported curiosity to try tobacco products. students expressed more interest in trying vaping than any other method of using tobacco. the nam students worked with program faculty to run additional analyses with the small sample size; they found that participants who had tried cigarette smoking, even one or two puffs, were more likely to also receive free or reduced lunch (χ2 = 12.058[df = 1], p = .001). as shown in table 4, a high percentage of students were not interested in commercial tobacco in any of its forms. additionally, participants were asked to report on traditional tobacco use, as described earlier, regarding both their own and their family’s use of journal of regional medical campuses, vol. 5, issue 1 original reports traditional tobacco. fifty-one percent used traditional tobacco; 9% had used it previously. sixty-four percent reported that their family used traditional tobacco. discussion the aims of the nam summer 2018-summer 2019 research experience were met: student products (oral presentations, posters, and contributions to the manuscript define products) at the conclusion of the second summer indicated increased knowledge and capacity of aian undergraduate students to plan and conduct research. student researchers were given opportunities to present at regional and national conferences and also presented at tribal clinics. the study resulted in a survey with face validity to measure aian student tobacco use, curiosity about tobacco, and factors that influence both. long-range outcomes, including the influence of the research experience on students’ long-term career choices, will be assessed at a later date. data collected from this study are similar to other studies with aian youth. a national study that used the nyts survey found that aian youth were more likely than youth from other racial and ethnic groups to smoke19 and that most aian youth who used tobacco were using cigarettes rather than other methods of tobacco use.20 another study that used the u.s. youth risk behavior surveillance (yrbs) from 29 states found that although use of commercial tobacco and cigarette use was generally on the decline, aian youth were more likely than non-native youth to either ever use or currently use cigarettes, cigars, and smokeless tobacco.21 this disparity between aian youth and non-native youth holds true for aboriginal youth in canada.22,23 conclusion this 2-year cohort approach to teaching qualitative and quantitative research skills to aian students was successful by internal benchmarks—namely, student researchers developed, implemented, and analyzed a survey appropriate for aian high school students, and all student researchers presented their scholarship at least once. in addition to learning research methodology, student investigators learned about team formation. this is particularly important given that some students were not able to attend the doi: https://doi.org/10.24926/jrmc.v5i1.4486 program for year 2 and new students joined the team. as a result, faculty had to adjust teaching methods to orient the new students while reengaging the original cohort. while student retention and turnover may be a downside to a 2-year cohort program, the opportunity to build longitudinal relationships was seen as outweighing any negatives. limitations one limitation to this research case study was the small sample size. as a result, student researchers did not have a large dataset from which to learn. second, the survey instrument was modified from an existing survey. we attempted to keep many of the questions and answers similar to the cdc and mss as much as possible to allow comparison of results. item wording sometimes did not match the research question that student researchers wished to address. for instance, traditional tobacco use was not included in the original instrument. third, because the summer program is only 6 weeks long, time for learning and conducting research is attenuated. student researchers come from various universities across the nation, a recognized strength of the program, but this also means that students could not participate in work outside of those 6 weeks. as such, we had to balance a more in-depth research experience with what could be reasonably achieved during the program’s time frame. faculty continued the work outside of the summer experience with a commitment to maintaining the students’ project progression. an external factor influencing recruitment of schools came from the administration of another school survey, the mss, by the minnesota department of education during the same time period. this competing survey limited the number of schools that could logistically participate in our project. limitations during this study were similar to issues that arise in other studies, thereby providing student researchers the opportunity to experience real research challenges. this project demonstrates that regional medical campuses are situated to conduct this type of research that offers student learning opportunities. in particular, tying specific research projects directly to a regional campus’s unique missions provides meaningful and relatable experiences for students, faculty, and community members. this project also demonstrated that it is possible to create a research instrument within a doi: https://doi.org/10.24926/jrmc.v5i1.4486 journal of regional medical campuses, vol. 5, issue 1 original reports short time frame and allow greater access to research opportunities for students. additional testing to support the reliability and validity of our tool is recommended, as is expanding the diversity of the sample. table 1. sample coding scheme for data from interviews table 2. use of vapes, juuls, mods, or other ecigarettes in participants’ entire lives table 3. days smoked table 4. curiosity to try various forms of tobacco references 1. association of american medical colleges. what is a regional medical campus? accessed november 13, 2020. https://www.aamc.org/professionaldevelopment/affinity-groups/grmc/regionalmedical-campus 2. cathcart-rake w, robinson m. promoting scholarship at regional medical campuses. j reg med campus. 2018;1(1). doi:https://doi.org/10.24926/jrmc.v1i1.999 3. wilson s. what is an indigenous research methodology? cjne. 2001;25(2):175-179. 4. drawson as, toombs, e, mushquash cj. indigenous research methods: a systematic review. iipj. 2017;8(2). doi:10.18584/iipj.2017.8.2.5 5. waapalaneexkweew (bowman-farrell nr). looking backward but moving forward: honoring the sacred and asserting the sovereign in indigenous evaluation. am j eval. 2018;39(4):543-568. doi:10.1177/1098214018790412 6. morton dj, proudfit j, calac d, et al. creating research capacity through a tribally based institutional review board. am j public health. 2013;103(12):2160-2164. doi:10.2105/ajph.2013.301473 7. peltier c. an application of two-eyed seeing: indigenous research methods with participatory action research. int j qual methods. 2018;17:1-17. 8. boudreau g, hernandez c, hoffer d, et al. why the world will never be tobacco-free: reframing “tobacco control” into a traditional tobacco movement. am j public health. preprint posted online ahead april 14, 2016: e1–e8. doi:10.2105/ajph.2016.303125 9. sequist td. urgent action needed on health inequities among american indians and alaska natives. lancet. 2017;389:1378-1379. 10. indian health service. disparities. u.s. department of health and human services. october 2019. accessed june 16, 2020. https://www.ihs.gov/newsroom/factsheets/dis parities/ 11. centers for disease control and prevention. current cigarette smoking among adults in the united states. updated march 17, 2022. accessed june 18, 2020. https://www.cdc.gov/tobacco/data_statistics/f act_sheets/adult_data/cig_smoking/index.htm 12. slobig z. in a good way: indigenous commercial tobacco control practices. clearway minnesota, truth initiative, blue cross and blue shield of minnesota; 2017. doi: https://doi.org/10.24926/jrmc.v5i1.4486 journal of regional medical campuses, vol. 5, issue 1 original reports http://keepitsacred.itcmi.org/wpcontent/uploads/sites/5/2015/02/inagoodwa y_finalweb-1.pdf 13. stanwick r. e-cigarettes: are we renormalizing public smoking? reversing five decades of tobacco control and revitalizing nicotine dependency in children and youth in canada. paediatr child health. 2015;20(2):101-105. doi:10.1093/pch/20.2.101 14. duke jc, lee yo, kim ae, et al. exposure to electronic cigarette television advertisements among youth and young adults. pediatrics. 2014;134(1):e29-36. doi: 10.1542/peds.20140269 15. centers for disease control and prevention. historical nyts data and documentation, 2016 nyts questionnaire. updated march 14, 2022. https://www.cdc.gov/tobacco/data_statistics/s urveys/nyts/data/index.html 16. burten s, kinney a. 2016 minnesota student survey statewide tables. september 2016. https://education.mn.gov/mdeprod/groups/co mmunications/documents/basic/bwrl/mdu5/~ edisp/mde059325.pdf 17. miller k, willson s, chepp v, padilla jl, eds. cognitive interviewing methodology. john wiley & sons; 1994. 18. asche k. the state of rural minnesota, 2019. center for rural policy and development; 2019. accessed june 18, 2020. https://www.leg.mn.gov/docs/2019/mandated /190442.pdf 19. odani s, armour bs, agaku it. racial/ethnic disparities in tobacco product use among middle and high school students—united states, 2014-2017. morb mortal wkly rep. 2018;67(34):952-957. doi:10.15585/mmwr.mm6734a3 20. yu m. tobacco use among american indian or alaska native middleand high-school students in the united states. nicotine tob res. 2011;13(3):173-81. doi:10.1093/ntr/ntq233 21. hoffman l, ganz o, delahanty j, jones c, homsi g, nonnemaker j. tobacco product use health equity among non-hispanic american indian alaska native youth in 29 states, 20072013. am j prev med. 2019;57(2):e43-e50. doi:10.1016/j.amepre.2019.04.005 22. sikorski c, leatherdale s, cooke m. tobacco, alcohol and marijuana use among indigenous youth attending off-reserve schools in canada: cross-sectional results from the canadian student tobacco, alcohol and drugs survey. health promot chronic dis prev can. 2019;39(6-7):207-215. doi:10.24095/hpcdp.39.6/7.01 23. elton-marshall t, leatherdale st, burkhalter r. tobacco, alcohol and illicit drug use among aboriginal youth living off-reserve: results from the youth smoking survey. cmaj. 2011;183(8):e480-486. doi:10.1503/cmaj.101913 microsoft word designingenrichmentprojectsarticle.docx published by university of minnesota libraries publishing designing enrichment projects to complement traditional medical education michael robinson, phd; tyler g. hughes, md z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc michael robinson, phd; associate dean for foundational sciences, ku-som salina, mrobinson2@kumc.edu tyler g. hughes, md; director of medical education, ku-som salina, thughes55@kumc.edu all work in jrmc is licensed under cc by-nc volume 2, issue 3 (2019) journal of regional medical campuses abstract designing enrichment projects to complement traditional medical education michael robinson, phd; tyler g. hughes, md topic two years ago the university of kansas school of medicine undertook a redesign of its curriculum. the current emphasis is on small group and active learning with the intent of bringing clinical experience and correlation to the earlier years of medical school. during the first 2 years of medical school there are nine teaching blocks, eight of which are of nine weeks duration, namely eight weeks of tuition followed by one week labelled ser (scholarship, enrichment and remediation). the majority of students who successfully complete the eight week block carry out an enrichment project from a selection approved by ku-som. at our regional medical school in salina, kansas, we have used these weeks to engage both students and non-traditional faculty in clinical and professional endeavors not typically stressed in the main curriculum. examples include experiences in pathology, ophthalmology, pre-hospital care, aviation safety applied to medical situations, and basic surgical skills, among others. short description this was a presentation at the grmc meeting in spokane, wa in 2019 on the use of short enrichment experiences in the m1, m2 years between teaching blocks to introduce students to areas of medicine not typically included in medical school curriculum at the university of kansas school of medicine, salina. this has been very popular with students and faculty alike. the session will include a discussion of the process, small group discussions on how to implement such programs as well as their research potential and a wrap of results of the session. four questions that were posed to/considered by session participants 1) how can a regional campus best maximize the enrichment opportunity? 2) what topics/activities would be beneficial to students? 3) how do we maximize research opportunities? 4) will all students benefit equally? three take home points from our session 1) enrichment weeks are well accepted by medical students 2) enrichment allows development of knowledge in areas not stressed by the main curriculum 3) enrichment courses can serve as pilot projects for eventual inclusion into the main curriculum microsoft word jrmc_4482.docx margaret r. lewis, md, pi; atrium health carolinas medical center department. of emergency medicine, university of north carolina school of medicine charlotte campus courtney brantley, md; university of north carolina school of medicine charlotte campus, atrium health carolinas medical center department of pediatrics max noe, md; 2d medical battalion, camp lejeune, north carolina william wright, md; university of north carolina school of medicine charlotte campus, eir pax psychiatry corresponding author: margaret r. lewis, md; margaret.lewis@atriumhealth.org all work in jrmc is licensed under cc by-nc volume 6, issue 1 (2023) journal of regional medical campuses original reports “night on call”: evaluating a serious game for knowledge application in a transition to residency course at a regional medical campus margaret r. lewis, md, pi; courtney brantley, md; max noe, md; william wright, md abstract educators are looking for innovations that disrupt education. games, as an educational learning tool, force learners to apply knowledge in new ways and use critical thinking skills. the interactivity and competition in games are motivating factors. a group of educators in charlotte, nc, designed an educational game, “night on call,” as the capstone of the transition to residency course for 4th year medical students at a branch campus of the university of north carolina school of medicine in charlotte, nc. this game was designed after escape-room-style games; it featured ten different challenges, each reflecting cases, patient scenarios, or skills critical for success during the intern year. fourth-year students participated in this game on the last day of their transition to residency course. upon completion of the game, students provided feedback through an anonymous survey and a group debrief session. overall, the students felt that this serious game was a fun way to end the transition to residency course and that educational games help with knowledge retention and application and the challenges reflected tasks they may see in intern year. introduction currently, the model of medical education is being challenged.1,2 educators are looking for innovations that disrupt education and create a new model for competency-based learning. adult learners benefit from active engagement. “serious games,” or games used as educational learning tools, have been shown to increase learner satisfaction and knowledge over traditional methods.3 traditional teaching is based on knowledge dissemination and rote memorization whereas games offer engaging stimulation in which the student has to apply knowledge. through this engagement, students may utilize a higher level of learning, such as application and analysis.3,4 as an example, games have been used in medical education, including point-of-care ultrasound, for both the resident learner through sonogames and the student learner through sonoslam.5,6 games in medical education do not have to be just a quiz-show style review of material. creative games can force learners to apply knowledge in new ways and use critical thinking skills, thereby reinforcing knowledge. the interactivity and competition in games are motivating factors. games also offer a safe environment for learners to practice.4 according to gorbenev, games, as opposed to conventional lectures and teaching, present students with an interesting problem and offer ways to explore the situation. in games, students have the opportunity to achieve a higher level of learning, such as application and analysis.4 games have a feedback mechanism, can be designed with different levels of difficulty, and serious games have a pedagogical purpose.4 out-ofthe-box applications associated with games force a different type of learning, stimulation, and assimilation of skills and knowledge due to the doi: https://doi.org/10.24926/jrmc.v6i1.4482 journal of regional medical campuses, vol. 6, issue 1 original reports required data understanding and manipulation inherent to approaching a novel game. well-designed games can introduce motivational factors and cognitive scaffolds that will help keep the learner engaged and motivated.3 games can break down complex tasks into more manageable concepts and can scale up in difficulty.7 simulated or computerbased games have the added bonus of allowing the learner to control their own pace of learning and receive immediate feedback. a group of medical educators at atrium health carolinas medical center, a branch campus of the university of north carolina school of medicine, developed a serious game as part of the transition to residency course. this ten-challenge contest, inspired by escape-room-style games, was called “night on call.” this game was designed to challenge students to apply knowledge and skills gained in both the transition to residency course as well as throughout their four years of medical school. the challenges represented cases, patients, or skills an intern may experience, deemed important for success in intern year. we will describe the creation of the “night on call” escape room style challenge as well as student feedback based on an overall assessment by means of a likert scale and free responses. methods at the conclusion of a month-long transition to residency course, we divided fourteen students into four groups of three and one group of two. one student was unable to attend. each group completed all ten rooms of the “night on call” escape-room-style challenge. each room or challenge represented knowledge or skill that students should have learned throughout their four years in medical school deemed important for intern year. planning for the transition to residency started eight months prior to the course, and discussion and recruitment of interested faculty started approximately three months prior to the course. faculty members involved in undergraduate medical education as well as residents and chief residents were polled for interest. brainstorming sessions were held with interested faculty and residents in conjunction with the transition to residency planning meetings. the goal of these brainstorming sessions was to discuss important topics that should be applied by a graduating medical student and to weave those topics into an escape-room-style game. the brainstorming sessions not only allowed faculty and residents to generate ideas for the game, but facilitated multidisciplinary discussions and a high level of comradery. faculty members unable to participate were able to help recruit residents from all specialties with an interest in teaching. faculty were also able to approach residents on an elective or educational month to help with the game. residents from all disciplines in particular demonstrated a high level of interest in planning and proctoring the game. the group made the decision to have the game take place over four hours including time for instructions, a break, and transitioning from room to room. a rotation and timing schedule for the morning was developed (table 1). for each room, faculty and residents were instructed to design a challenge lasting no more than eighteen minutes. if students completed the task before the eighteen-minute cutoff, room proctors were told they could give feedback to the teams. at the end of the eighteenminute time period, teams were given an envelope with the location of the next challenge and a clue to the next task. one faculty member was designated as the timer, who sent a group text to all the proctors to begin and end the challenge. this same faculty member also collected score sheets at the end of each time period. doi: https://doi.org/10.24926/jrmc.v6i1.4482 journal of regional medical campuses, vol. 6, issue 1 original reports table 1: rotation schedule for teams (a-e) in “night on call” escape room challenge. time (am) room 8:058:23 8:25 8:43 8:45 9:03 9:05 9:23 9:25 43 break 1010:18 10:2038 10:40 58 1111:18 11:20 38 1 (iv access) a e d c b 2 (antibiotic) b a e d c 3 (ecg/tfcpr) c b a e d 4 (hand-off) d c b a e 5 (airplane) e d c b a 6 (agitated patient) a e d c b 7 (ddr) b a e d c 8 (prioritization room) c b a e d 9 (chutes and ladders) d c b a e 10 (heads up) e d c b a when discussing potential topics for challenges, our group decided to have challenges representing different procedures, antibiotic knowledge, critical ekgs, out-of-hospital scenarios, imaging interpretation, caring for an agitated patient, prioritization, and communication. each faculty or resident designing a challenge had to provide written instructions for the challenge as well as collect or create any needed equipment. scoring was based on time, and the time to complete each task was recorded by each proctor. some challenges had time bonuses and delays. the ten challenges are listed below in table 2. appendix a details the design, doi: https://doi.org/10.24926/jrmc.v6i1.4482 journal of regional medical campuses, vol. 6, issue 1 original reports equipment, and instructions for two individual challenges. table 2: ten challenges and objective for the escape room challenge room challenge overall goal/knowledge tested 1 a is for access identifying difficult iv access and using ultrasound for peripheral and central line placement 2 antibiotic scramble matching antibiotics and dosages to common illnesses 3 ekg room recognition of critical ekg’s and teamfocused cpr 4 hand-off & phone call challenge performing appropriate hand-offs on critical patients 5 is there a doctor on the plane? encountering common medical emergencies in an out-of-hospital scenario 6 agitated patient responding to an agitated patient 7 dance dance revolution dance challenge with performance of common procedures 8 prioritization room prioritizing care for more critical patients and recognizing the potential for deterioration 9 imaging chutes and ladders interpretation of critical imaging findings on xray, ct, and ultrasound 10 “heads up” game medical and nonmedical communication prior to the “night on call” game, room proctors were recruited from interested faculty and residents. if the faculty or resident who planned the challenge was also available to be the room proctor, then they were responsible for their own room. otherwise, room proctors were sent the room instructions the day before. actors in the out-of-hospital scenario were recruited from interested administrative staff. the morning of the game, each room was set up with the proper equipment and designated with a “night on call room x” sign. proctors were given envelopes for each team containing the team’s next room assignment. proctors were also given a scoresheet for their room (table 3). when each proctor received the “start” text from the designated timer, they started their stopwatch. when the team correctly completed the challenge, the room proctor stopped their stopwatch and recorded the time. they also record any time bonuses or delays and the total time. this total time took bonuses and delays into account. the designated timer collected all time sheets for each room and calculated each team’s total time at the end of the game. these calculations were confirmed and validated by another member of the planning committee. the team with the lowest overall time was the winner. at the conclusion of the game, students reconvened for a debriefing of the game and announcement of the winner and other awards. students also completed an anonymous survey regarding the overall effectiveness of the game with responses based on a 5-point likert scale and free response (appendix b). this survey was approved through the atrium health carolinas medical center institutional review board as part of an overall study of the effectiveness of a four-week transition to residency course. doi: https://doi.org/10.24926/jrmc.v6i1.4482 journal of regional medical campuses, vol. 6, issue 1 original reports table 3: scoresheet for each room in “night on call” escape room challenge. room team time (min) bonus time (total) time delay total time (time bonus+delay) a b c d e results overall, students felt the “night on call” escape-roomstyle challenge was a fun and effective way to end the transition to residency course. feedback on the overall game (table 4) noted students’ perception that educational games help with knowledge retention and application, and the challenges reflected tasks they may see in intern year. students ranked the challenges that involved ekg interpretation and team-focused cpr, appropriate antibiotic selection, patient hand-offs, and prioritization as their favorite challenges (table 5). in the free response portion of the post-game survey, the students noted their favorite aspects of the “night on call” escape room game, including: “not knowing what to expect,” “the realism,” “applying useful concepts,” “making decisions, feeling the pressure,” “team-work approach needed,” “fun, interactive & clinically relevant,” “the competitive aspect,” “actually being looked to to provide answers and direction,” “being forced to make decisions,” and “best part of the transition course.” students also listed ideas for improvement, including presenting to attendings as an aspect in some rooms, having them use their physical exam skills, using real phones or pager, and also wanting even harder challenges. table 4: overall feedback for “night on call” escape room challenge. the night on call escape room was a fun way to end the transition to residency course. education games like the escape room challenge help with knowledge retention. education games like the escape room challenge help with knowledge application. the challenges in the escape room reflect tasks i will encounter during intern year. i think that a teambased game like this escape room challenge is valuable in the transition to residency course. average score (scored out of 5) 5 5 4.93 4.93 5 doi: https://doi.org/10.24926/jrmc.v6i1.4482 journal of regional medical campuses, vol. 6, issue 1 original reports table 5: individual challenge ratings on a 5-point likert scale. discussion serious games are an educational learning tool increasing learner satisfaction and knowledge.3 games offer an engaging situation and force the student to apply knowledge in out-of-the-box or unexpected situations.3,4 not only do games offer a safe environment for learners to practice,4 but the interactivity and competition in games are motivating factors. well-designed games can introduce motivational factors and cognitive scaffolds, helping keep the learner engaged and motivated.3 our “night on call” escape-room-style game offers a unique, engaging, and safe manner to challenge students to apply their knowledge gained throughout medical school and the transition to residency course. the structure of the ten-room game allowed the planning team of teaching faculty and senior residents to plan a variety of challenges representing many expected and unexpected aspects of the intern year. the time allotted for each room generally allowed for two to three minutes of feedback from the proctor as well. in this game, students enjoyed working through completely unanticipated problems and challenges as a team in a safe and supportive manner. students overall thought the escape room was a fun way to end the transition to residency course and helped with knowledge retention. students also felt that the challenges helped with knowledge application and reflected tasks they will encounter in intern year, but to a lesser degree. when reviewing the feedback from the ten individual rooms, students ranked rooms that more heavily reflected advanced skills, such as medical decision-making, critical care scenarios, and prioritization, higher when compared to rooms that reflected procedural skills or communication. the imaging interpretation room received a moderate score when compared to the other rooms. although the concept for this game was quite simple, students had to recognize and interpret a variety of images including x-ray, ct, and ultrasound images. students did provide feedback to make some of the challenges more difficult. in future games, it will be important to continue to develop challenges that incorporate the higher-level skills such as decision-making and prioritization as well as critical scenarios in which students may feel more pressure. engaging clinical faculty and senior residents interested in teaching was a critical first step in game development as well as setting the parameters for each challenge. incorporating a team of planners who teach medical students and interns allowed for a variety of challenges representing tasks or patient presentations interns may encounter, or skills important to success during the intern year. given the large scale of this game, it was important to start doi: https://doi.org/10.24926/jrmc.v6i1.4482 journal of regional medical campuses, vol. 6, issue 1 original reports planning months ahead of the actual event. this allowed ample time to identify any gaps in volunteer staffing, schedule conflicts, and other unforeseen obstacles and adjust accordingly. key steps for implementation included designing the overarching structure and theme of the game and then bringing together a planning team to execute the chosen design. we also realized we would need faculty and residents to help proctor the rooms. these were not necessarily the same individuals who planned each room but rather could be there the day of the game. although the game was four hours in duration, it was divided up into two separate twohour blocks for faculty or residents who could only participate for a short period of time. another key to a successful game was having a core team to review all the proposed games and ensure preparation of equipment, rooms, and personnel. for planning and execution, it was critical to give deadlines for each room design and maintain open communication with the planning team and clear instructions for the proctors. during the actual game, it was also important to have a member of the core team act as a ringmaster and oversee the progress of the entire game including timing, taking room proctors any additional equipment, collecting score sheets, and troubleshooting any problems that may arise. following the game, it was important to get feedback from the students regarding the overall experience, what worked well, and areas for improvement. we suggest having an anonymous survey with a free response section as well as a group debrief. overall, our students were very engaged in the game and felt the teamwork, the competitive nature, and the unexpected aspects of each room made the experience great. one limitation in this first iteration of the “night on call” escape-room-style game was that faculty and residents were not directly queried for feedback or satisfaction with each aspect of the game. informal feedback from faculty and residents was verbally solicited and reflected a high level of satisfaction. faculty and resident feedback were queried through a google form in subsequent years. the escape-room-style game was developed as a capstone to a larger transition to residency course and represented material from both third and fourth years of medical school, as well as material reviewed in the transition to residency course. students underwent a pre-test prior to the start of the transition course and a post-test immediately following the escape room challenge on the last day of the course. the multiple-choice test incorporated material from all of the didactics and workshops in the transition course. both the question order and answer order were scrambled for the post-test. when compared to the pre-test scores (mean 73.5%, sd 7.7%), participants’ post-test scores (mean 81.5%, sd 7.8%) were higher (mean of differences 7.9%, ci 3.412.4%, p=0.0022). one limitation of this study is that the preand post-test did not directly assess the impact of the game, but rather the entire transition to residency course. in the overall knowledge assessment for the transition course, 19/30 questions were on material or concepts that were in the escape room challenge. although this game was planned at the end of the transition to residency course, serious games can be incorporated throughout the medical education experience. limitations encountered when planning a comprehensive game in this style may include having a large enough creative team to develop rooms and act as proctors. we found involving residents from several different specialties helped in developing a creative, well-rounded game representing different aspects of medicine. this format for game creation is generalizable to many different concepts and educational points in medical education. our team had planned a new set of challenges for the “night on call” game as part of the 2020 transition to residency course including an acid-base challenge and an appropriate precautions/ppe relay race. however, this game was cancelled due to the covid-19 pandemic. the covid-19 pandemic has highlighted a new limitation with this game: it is designed to be inperson. however, we do feel certain challenges or aspects of this game could be done virtually utilizing web-based technology such as zoom or webex. although the 2020 game was cancelled due to the covid-19 pandemic, a completely zoom-based game was designed and implemented for 2021 which allowed the students to participate remotely and doi: https://doi.org/10.24926/jrmc.v6i1.4482 journal of regional medical campuses, vol. 6, issue 1 original reports maintain social distancing. our team is currently planning to implement a 2022 game at our branch campus as well as a larger campus in north carolina. to implement at other campuses, branch or main campuses, we recommend working with fourth-year medical school leadership to plan timing and space, as well as recruiting faculty and interested residents. we have a core team this year that will be present at the larger main campus to assist with game rollout. disclaimer: the opinions and assertations contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the u.s. navy, department of defense, or the u.s. government. references 1. kahn, marc j., ralph maurer, steven a. wartman, and benjamin p. sachs. 2014. “a case for change: disruption in academic medicine.” academic medicine: journal of the association of american medical colleges 89 (9): 1216–19. 2. wartman, steven a. 2019. “the empirical challenge of 21st-century medical education.” academic medicine: journal of the association of american medical colleges 94 (10): 1412–15. 3. olszewski, aleksandra e., and traci a. wolbrink. 2017. “serious gaming in medical education: a proposed structured framework for game development.” simulation in healthcare: journal of the society for simulation in healthcare 12 (4): 240–53. 4. gorbanev, iouri, sandra agudelo-londoño, rafael a. gonzález, ariel cortes, alexandra pomares, vivian delgadillo, francisco j. yepes, and óscar muñoz. 2018. “a systematic review of serious games in medical education: quality of evidence and pedagogical strategy.” medical education online 23 (1): 1438718. 5. liteplo, andrew s., kristin carmody, matt j. fields, rachel b. liu, and resa e. lewiss. 2018. “sonogames: effect of an innovative competitive game on the education, perception, and use of point-of-care ultrasound.” journal of ultrasound in medicine: official journal of the american institute of ultrasound in medicine 37 (11): 2491–96. 6. boulger, creagh, rachel b. liu, giuliano de portu, et al. 2019. “a national point-of-care ultrasound competition for medical students.” journal of ultrasound in medicine. https://doi.org/10.1002/jum.14670. 7. yunyongying, pete. 2014. “gamification: implications for curricular design.” journal of graduate medical education 6 (3): 410–12. doi: https://doi.org/10.24926/jrmc.v6i1.4482 journal of regional medical campuses, vol. 6, issue 1 original reports appendix a: individual challenges/rooms for “night on call” “night on call” escape room challenge timing max 18 minutes per room. each station is timed by proctor. students may be given a “delay” or bonus “time off”. teams 15 students, 3 teams of 5. each start at a different spot. winner winning team is the team with the least amount of total time. general instructions after each task is complete, the team will be given location or clue to next task. room: 2 antibiotic scramble room creator day-of proctor location equipment needed use labels from snagit and order bottles. can also use saline syringes for injectable meds. ● cap – azithromycin 500mg po qdx 3 days + augmentin 875mg po bid x 5 days. clue: baseball cap. ● uti – nitrofurantoin 500mg po bid x 5 days. clue: nametag “yooti i. burnes” ● cellulitis – bactrim 800-160mg po bid x 7 days and keflex 500mg po q12h x 7 days. clue: room proctor will have arm painted a faint red. ● cervicitis – azithromycin 1g po once and ceftriaxone 250mg im once. clue: broken condom ● prophylaxis for pjp – bactrim ds twice daily. clue: four cds. ● meningitis – ceftriaxone, vancomycin. clue: keurig cup (sounds like kernig) ● primary lesion of lyme disease – doxycycline 200mg po once. clue: a lime. ● otitis media – amoxicillin. clue: picture of an incus, mallet, and stirrup ● prostatitis – cipro 500mg po qd x 6 weeks. clue: picture of asterix + glove + lube scoring additions na doi: https://doi.org/10.24926/jrmc.v6i1.4482 journal of regional medical campuses, vol. 6, issue 1 original reports general instructions you’ve had too many lectures and your brain can’t take it anymore! you can’t remember which infectious disease your patients had. luckily, you left yourself clues to remember which infection they have. when you determine which infection each patient has, give them the correct first-line medication! remember, some infections require multiple medications to adequately treat. use the antibiotics available to treat your patients. you will use all the antibiotics. when you think everyone is adequately treated, notify the attending and he/she will round with you and check your work. room 5 is there a doctor on the plane? room creator day-of proctor location equipment needed equipment: purse, diabetic bracelet & other bracelets, insulin syringe, glucometer, spritz bottle, airplane medical equipment (blood pressure cuff, stethoscope, d50, epinephrine, normal saline, oxygen tubing, bag-valve-mask, oral airways, tourniquet and iv start supplies, iv tubing, aspirin, benadryl, nitroglycerin. personnel: room proctor (captain of plane), 4 “passengers” scoring additions ● 3 min delay: not recognizing anaphylaxis ● 2 min delay: giving benadryl only ● 1 min bonus: treating with epi first ● 3 min delay: do not land plane for chest pain ● 2 min bonus: start iv and have ivf ready to go in case bp drops and patient needs a bolus. macgyver award for student who is able to figure everything out quickly and put together not often used equipment for treatment purposes (room proctor discretion) general instructions you are on a cross-country plane trip and all the passengers get sick! hypoglycemia altered female patient, looks ill and sweaty. look at patient and decide what’s going on. clues: multiple bracelets, one is diabetic bracelet, insulin syringe in purse. ask other passengers for glucometer. if one is not found, then determine if you just want to treat. is she too altered to drink? then decide to place iv and give dextrose. if there is delay in recognition or treating then patient will seize. doi: https://doi.org/10.24926/jrmc.v6i1.4482 journal of regional medical campuses, vol. 6, issue 1 original reports anaphylaxis: patient complains throat feels tingly. patient feels itchy. red skin underneath a long sleeve shirt. patient having trouble talking. must see open bag of nuts/trail mix lying in next to patient. make decision to treat anaphylaxis. chest pain: 66 y/o male becomes diaphoretic, and clutches chest. obtain hx of copd/tobacco abuse, htn. if they get bp it is 220/110, pulse 98. skin exam: clammy, wet/diaphoretic. must give nitro, put on o2, give aspirin. must decide to land plane (pilot/proctor will give pushback). red herring patient: she is eating a bag of peanut trail mix. she happens to have a glucometer and benadryl which she will supply if asked. doi: https://doi.org/10.24926/jrmc.v6i1.4482 journal of regional medical campuses, vol. 6, issue 1 original reports appendix b: post-game anonymous survey (likert scale and free response). unc transition to residency course night on call survey 1.) the night on call escape room was a fun way to end the transition to residency course. no not really neutral it was fun absolutely _________________________________________________________________________________________ 1 2 3 4 5 2.) education games like the escape room challenge help with knowledge retention no not really neutral somewhat absolutely _________________________________________________________________________________________ 1 2 3 4 5 3.) education games like the escape room challenge help with knowledge application no not really neutral somewhat absolutely _________________________________________________________________________________________ 1 2 3 4 5 4.) the challenges in the escape room challenge reflect tasks i will encounter during intern year? no not really neutral somewhat absolutely _________________________________________________________________________________________ 1 2 3 4 5 5.) i think that a team-based game like this escape room challenge is valuable in the transition to residency course? no not really neutral somewhat absolutely _________________________________________________________________________________________ 1 2 3 4 5 6.) the following rooms/situations were valuable: a.) iv access room no not really neutral somewhat absolutely _________________________________________________________________________________________ 1 2 3 4 5 doi: https://doi.org/10.24926/jrmc.v6i1.4482 journal of regional medical campuses, vol. 6, issue 1 original reports b.) cardiac arrest & ekg room no not really neutral somewhat absolutely _________________________________________________________________________________________ 1 2 3 4 5 c.) appropriate antibiotic room no not really neutral somewhat absolutely _________________________________________________________________________________________ 1 2 3 4 5 d.) patient hand-offs & phone call challenge room no not really neutral somewhat absolutely _________________________________________________________________________________________ 1 2 3 4 5 e.) out of hospital scenario room no not really neutral somewhat absolutely _________________________________________________________________________________________ 1 2 3 4 5 f.) agitated patient room no not really neutral somewhat absolutely _________________________________________________________________________________________ 1 2 3 4 5 g.) dance dance revolution procedural room no not really neutral somewhat absolutely _________________________________________________________________________________________ 1 2 3 4 5 h.) prioritization room no not really neutral somewhat absolutely _________________________________________________________________________________________ 1 2 3 4 5 doi: https://doi.org/10.24926/jrmc.v6i1.4482 journal of regional medical campuses, vol. 6, issue 1 original reports i.) imaging room (chutes & ladders) no not really neutral somewhat absolutely _________________________________________________________________________________________ 1 2 3 4 5 j.) communication room (heads up game) no not really neutral somewhat absolutely _________________________________________________________________________________________ 1 2 3 4 5 7.) my favorite aspects of the night on call escape room challenge: 8.) ideas for improvement in the night on call escape room challenge: 9.) general comments/feedback on the night on call escape room challenge: microsoft word ahomestayprogramarticle.docx published by university of minnesota libraries publishing a homestay program as community engagement daniel teraguchi, edd; luisita francis, md; kyle holbrook, ma; ken roberts, phd z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc daniel teraguchi, edd; san francisco state university, dteraguchi@sfsu.edu luisita francis, md; washington state university, luisita.francis@wsu.edu kyle holbrook, m; washington state university, kyle.holbrook@wsu.edu ken roberts, phd; washington state university, kenroberts@wsu.edu all work in jrmc is licensed under cc by-nc volume 2, issue 3 (2019) journal of regional medical campuses abstract title a homestay program as community engagement daniel teraguchi, edd; luisita francis, md; kyle holbrook, ma; ken roberts, phd topic: the community hosting and homestay program (chhp) at washington state university (wsu) college of medicine (com) was created to meet the housing requirements of the college’s curricular model and to engage community members in the educational program of the com. the chhp matches each student with a community host family for the first 2 years of the curriculum. during the clinical campus weeks (ccw), 1-week experiences on their future regional campus, the community host families provide homestays for their matched students and engage them in community connection activities. there are 4 primary qualities which make the chhp innovative: 1. the program engages the community members and broadens the greater medical school community. 2. the chhp provides community exposure to the medical students. utilizing the enthusiasm of community members, students connect with their regional campus community. 3. the program serves to promote initiatives of the community, such as health-related organizations that give our students insight into the social determinants of health that affect the community. 4. this program allows the students to build a longitudinal relationship with the community that spans their entire medical school experience. the chhp has broad applicability to medical schools that use distributed regional campuses for their clinical education. it engages the regional campus local community while providing housing for students. short description: the college of medicine (com) at washington state university has created a community hosting and homestay program (chhp) to meet the housing requirements of the college’s curricular model and to engage community members in the educational program of the com. the chhp matches each student with a community host family. the host families provide homestays for their student and engage them in community connection activities. the chhp has broad applicability to medical schools that use distributed regional campuses for their clinical education. it engages the regional campus local community while providing housing for students. four questions that were posed to/considered by session participants: 1. please discuss the legal aspects of setting up the program such as the onboarding process for homestays. 2. what outcomes is the program producing thus far? 3. what have the students indicated they have gotten out of the program? three take home points from our session: 1. initial program evaluations have indicated that students have broadened their community connections and professional networks (i.e. community resources for different populations) within the region and increased their familiarity with social determinants that may affect their patients’ well-being. 2. the longitudinal relationship for students with community members adds to their success throughout their medical experience through mentorship, emotional support, and insights on accessing community resources and initiatives to support patient care. 3. the program provides a mechanism for community members to be involved in medical education which in turn fosters goodwill, harnesses interest of individuals who want to support the medical school and leads to greater engagement with the medical school. microsoft word teachingemotionalintelligencearticle.docx published by university of minnesota libraries publishing teaching emotional intelligence through the care of gender non-binary patients jaime k. bowman, md z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc jaime k. bowman, md; faafp director, longitudinal integrated clerkship elson s floyd college of medicine at washington state university. jaime.bowman@wsu.edu all work in jrmc is licensed under cc by-nc volume 2, issue 3 (2019) journal of regional medical campuses abstract teaching emotional intelligence through the care of gender non-binary patients jaime k. bowman, md, faafp topic: in a climate of increasingly challenging care delivery and much controversy surrounding the execution of personal integrity, learners deserve methods by which to navigate personal and professional boundaries while maintaining patient centered, timely care. learners, whether ume or gme, acquire selfassessment, self-management, social-awareness, and relationship management skills through the unique exposure to vulnerable lgbtqia+ care. using the structured approach of emotional intelligence and the environment of the vulnerable care of gender non-binary patients, this seminar explores the methods for teaching learners to allow them to develop awareness of boundaries, navigate those boundaries, and do so without interrupting the quality of patient care. short description: teach your learners to develop personal and professional boundaries without compromising the quality or patient centeredness of the care. emotional intelligence, with education in self-assessment, self-management, social-awareness, and relationship management, is a useful format for training learning clinicians how to navigate care boundaries. four questions that were posed to/considered by session participants 1) how might you coach students to take an emotionally intelligent sexual history? 2) why is it important to use preferred pronouns? 3) how can students balance their enthusiasm to learn with patient centered care? 4) how do providers set personal boundaries without limiting access to care? three take home points from our session: 1) learners feel vulnerable until they care for the most vulnerable of patients, then they feel empowered. 2) caring for lgbtqia+ patients is uncertain, intergenerationally challenging, and uncomfortable for most people, providers and patients alike. 3) begin with clear and positive intent. you aren’t alone. you can ask for support and help. microsoft word optimizing student learning article.docx published by university of minnesota libraries publishing optimizing student learning at the regional medical campus: the experience of an amalgamative clerkship model in a single small community kristen grine; angela hardyk; james powell; ryan ridenour; paul sherbondy; jeffrey g. wong doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 1, issue 4 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc kristen grine; penn state hershey medical center physician group – university park regional campus. angela hardyk; mount nittany physicians group – state college, pa. james powell; cancercare partnership and mount nittany physicians group – state college, pa. ryan ridenour; mount nittany physicians group – state college, pa. paul sherbondy; penn state hershey medical center physician group – university park regional campus. jeffrey g. wong; penn state college of medicine – university park regional campus. all work in jrmc is licensed under cc by-nc volume 1, issue 4 (2018) journal of regional medical campuses original report optimizing student learning at the regional medical campus: the experience of an amalgamative clerkship model in a single small community kristen grine; angela hardyk; james powell; ryan ridenour; paul sherbondy; jeffrey g. wong abstract introduction: both benefits and challenges are associated with training medical students in a community-based setting at a regional medical campus (rmc). at the rmc, close relationships between learner and teaching faculty can truly be fostered. however, those volunteer teaching faculty are frequently conflicted due to time constraints, and practice productivity requirements that may run counter to maximizing learner involvement. longitudinal integrated clerkships (lics) have been studied and promoted as clinical clerkship structures that optimize the learning environment for medical students on clinical rotations by taking full advantage of the ongoing relationship between learner, teacher, patients, and practices. in our resource-limited environment, we created longitudinal educational relationships for all university park regional campus (uprc) students with preceptors, practices, and patients that would achieve the educational benefits of a true lic yet not overwhelm the limited resources of this small community. methods: we created an amalgamative lic clerkship model that provided a year-long family medicine experience integrated with 4 other clerkships in the following longitudinal fashion: one-half of the clerkship students did a half year (22 week) integrated obgyn/surgery clerkship subsequently followed by a half year longitudinal pediatrics course with 3 one-week inpatient adult medicine mini-immersions spaced over that time. the sequence of integrated clerkships was reversed for the other half students. neurology, psychiatry, and underserved/rural medicine (4 weeks each) and subspecialty/elective rotations (2 weeks each) remained in traditional self-contained blocks and were interspersed within the longitudinal experiences in different times throughout the year. at 6 and 12 months, we administered a 5-point likert-type survey to both medical students and teaching faculty asking their perceptions of the educational value and resource requirements for our clinical rotation structure and solicited free text answers as well. descriptive averages of the ordinal values were reported. results: eleven out of of 12 students (92.7%) and 11 out of 21 faculty (52.4%) responded to the survey. both students and faculty believed that some of the longitudinal benefits of the amalgamative structure were achieved. the students especially noted that attending feedback was beneficial due to the longer interaction and that they had a greater ability to interact with patients. the faculty teachers found the amalgamative lic to be slightly less satisfying than the students. conclusions: while logistical limitations necessitated our unique rotation design, some optimization of education was achieved. faculty concerns toward adopting this new structure should be considered for other programs structuring lics in a similar sparsely resourced environment such as a rmc. introduction clinical training for medical students at the regional campus of a medical school provides unique opportunities for learning due to the small and intimate nature of community settings. this smallness, however, can also present challenges for providing optimal learning for medical students due to limited teaching resources. furthermore, practice incentives in community-based settings are frequently misaligned with the inherent ‘inefficiencies’ that medical student clerks often impose upon private physician practices.1,2 the longitudinal integrated clerkship (lic) structure is becoming more widespread for the clinical training of medical students.2 in a traditional block clerkship structure, student clerks rotate in one discipline for a brief set period of time, learn from the teachers and patients in that discipline, and then move on to the next discipline on their schedule, often never returning to the first discipline again. the cycle recurs multiple times a year as each clerkship student progresses through different core clinical rotations. in an lic, the student is scheduled in several different disciplines within the same, longer time frame and their experience with each ‘rotation’ is spread-out over the entire year. this prolonged exposure allows for longitudinal continuity to occur,2 and studies suggest that compared to the traditional block clerkships, the lic promotes medical student learning through taking full advantage of the ongoing doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. x, issue x type of article relationship between learner, teacher, patient, and practice.2,3,4 these longitudinal relationships can optimize the learning environment for medical students in the 3 domains of retaining medical knowledge, performing procedural skills, and demonstrating humanistic attitudes in a fashion that has been called transformative when compared to traditional block clerkship models.2,3,5 as the student develops over the course of her clinical year, the developmental gains from increasing clinical experiences can be demonstrated in all of the different disciplines. lics have been reported to improve student satisfaction with clinical medicine and have demonstrated retention and/or improvement of humanistic empathy in medical students.3,6,7 the improvement in humanistic empathy was manifested in student-patient interactions including successfully dealing with ethical dilemmas and genuinely caring when dealing with patients.6 while potentially resource intensive, the lics also have inherent flexibility for scheduling learners in practices at times convenient for the practice. in addition, ‘white-space’ time, provided in the students’ schedules for following continuity patients in ‘real-time’, can provide some respite for busy private practices normally unseen in a more traditional block rotation.8,9 starting in 2012, the university park regional campus (uprc) of the penn state college of medicine (com) became a clinical training site for third-year penn state com clerkship students. this campus, located in state college, pa is approximately 100 miles from the main com campus in hershey, pa. in this small town of approximately 42,000 people, third-year medical students rotated in traditional block time core clerkships. recognizing the potential learning benefits of the lic structure, the curriculum was partially altered in each of the academic years, 2015-16 and 2016-17, wherein 4 of 24 students (in each year) elected to perform their clerkships in an lic structure. the remainder of the students rotated in a block fashion and thus, given the limited clinical resources, the lic students were often in those shared clinical practices simultaneously with other students on block clerkships. some of these concepts were subsequently implemented in the model of this report. coordinating both lic and block students’ schedules concomitantly, based on anecdotal reports from the faculty teachers themselves, was challenging for the clinical sites and was felt to adversely impact learning. furthermore, only a small percentage of learners benefited from the lic experience and so an expansion of the lic was strategically planned. however, the limited resources in the small medical community of state college posed a challenge to these plans. our challenge was the following: creating the best structure in a longitudinal learning experience in multiple clerkships for a larger number of learners in a sparsely resourced community of volunteer teachers. methods in 2016, worley, couper, strasser, et al, crafted a descriptive typology of lics by collecting and analyzing survey data from all lic structured training programs known to the international consortium of longitudinal integrated clerkships.10 three typological clusters were described based primarily on program length and discipline coverage. cluster “a”, an amalgamative-type lic structure, is notable for shorter clerkships that combine learning from a number of disciplines that are longer than the usual block rotation length. cluster “b”, a blended lic structure, is comprised of an lic that incorporates all, or a majority, of the clinical disciplines, but still use complementary discipline-specific rotations to complete the academic year. cluster “c”, a comprehensive lic structure, incorporates all of the years’ disciplines as their core, are delivered as an integrated program, and incorporate only brief in-patient disciplinespecific immersive experiences.10 our clerkship schedules most closely represented a cluster “a” amalgamative structure. longitudinal experiences of 22 weeks were constructed for ob-gyn, surgery, and pediatrics, and the family medicine experience was extended for the full 45 weeks. internal medicine clerkship in-patient immersions, while not technically longitudinal, did account for the learners’ developmental growth as the immersions were dispersed over the 22 week period. these longitudinal learning experiences were interspersed with block clerkships in neurology, psychiatry, and underserved medicine/rural health and these 4-week blocks were interspersed throughout the year (figure 1). figure 1 schematic for the clerkship year outcome measures included the clinical clerkship grades and student performance scores on the usmle subject examinations administered through each clerkship. a comparison of 2017 lic-student scores with 2016 uprc block clerkship student scores was performed using the student ttest comparing means (p <0.05). in addition, a 5-point likerttype survey instrument was created and administered to the learners and the teachers involved in the clerkships affected by the amalgamative structure at the mid-year (6-month) and end-of-year (12 month) periods. the survey questions were doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. x, issue x type of article adapted from those points identified as potential benefits and drawbacks of learning/teaching in a lic by published works 2,6,8 and asked for the respondents’ state of agreement (1= strongly disagree to 5= strongly agree) with statements (figure 2). comparisons of mean data scores between the 6month and 12-month intervals were also compared using the student t-test as above. results were reported as descriptive averages for the groups. additionally, free text questions asking about the “best aspect” of the lic structure and the “one thing they would change” about the lic structure were collected. results all students were successful in passing their clerkship evaluations. the 2017 lic-students’ usmle subject examination scores were slightly higher than the 2016 block clerkship students’ cohorts scores although no statistically significant difference was found (table 1). table 1 comparison subject examination scores ninety-two percent (11/12) of the clerkship students and 52% (11/21) of the teaching faculty in the affected clerkships responded to the survey. in general, the majority of students’ responses to the amalgamative lic structure were favorable. table 2 shows the students’ responses at 6-month and 12month intervals. the items that students felt were most beneficial about the amalgamative lic were that the lic structure allowed for more meaningful feedback to the learners (mean of 4.27 at 6-months/mean of 4.36 at 12months) and that the learner’s ability to relate to patients was enhanced (mean of 4.45 at 6-months/mean of 4.59 at 12-months). a similar table was also analyzed for the teachers’ responses but is not shown. in general, the teachers’ responses tended to be clustered around the “neutral” to “slightly unfavorable” rating without any of the items at the extremes (i.e., > 4.00 or < 1.00). doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. x, issue x type of article table 2 student survey responses a majority of the free text responses from the students centered about the longitudinal aspects of the teacher-learner relationship. a representative statement is as follows: “i enjoyed having my preceptors getting to know me over longer periods of time. they were able to see my growth over the course of months after working together closely.” a majority of the free text responses from the teachers were related to scheduling logistics. a representative statement is as follows: “i think working what a smaller group of student for a longer period of time was better, but the hit and miss of when they would be in clinic with me was difficult”. discussion while the overall rotation length of the continuity portion of our experience was briefer than what is seen in a cluster “c” comprehensive lic structure, the data from our survey suggest that several of the benefits attributed to lics were nonetheless achieved through our amalgamative clerkship structure. lics have been reported to improve learning as well as patient care.11 one of the reasons cited is that the idea of ‘continuity’ as an organizing principle for clinical education in lics better allows for a therapeutic relationship between patient and learner as well as teacher and learner to develop.12 patients often value this increased continuity with learners.13 in our experience, both the teachers and the learners perceived an enhance ability to form meaningful longitudinal relationships with patients, although corresponding data from patients was not collected. we hypothesize that this finding may be due to the small and intimate size of our campus. volunteer teaching faculty at regional campuses are often pulled in different directions related to their roles and their relationships with academic medical centers. volunteer faculty in the community are frequently productivity-based and have, as a central metric, the number of patient visits completed in a given patient care session. having learners in that environment tends to slow clinicians downs and thus can impede their productivity. besides the educational benefits noted above, one of the underlying purposes for creating the amalgamative lic structure was to attempt to address the limitations of the community-based faculty practices by trying to more effectively schedule a smaller number of learners over an extended period of time. this smaller number of familiar learners was mentioned anecdotally by the teaching faculty as a positive change created by the amalgamative lic structure. none of our community-based faculty had trained in an lic structure and the academic years of 2015-16 and 201617 did not provide a great deal of experience. thus, we believe some of the faculty dissatisfaction may stem from the unconventional structure of the clerkships. faculty development for community-based teaching faculty is one aspect thought to be important in the successful implementation of a lic.14 we are examining this aspect in greater detail going forward. the learners at our regional campus were not provided a choice in how to experience their clerkships. based on a sampling of free text responses from the students, some were very pleased with the lic structure, but others did not feel that it worked best for them. our data are strictly self-reported by learners and teachers and were not objectively or externally verified. additionally, this project was specifically designed to address local need and there is no assurance that a similar structure could work in another locale. however, the limited teaching resources in the small town of state college are likely similar to those in small towns elsewhere in the country. based on the clic research group’s published work,8 as well as further conversations within the consortium, the structural varieties of lics are probably only limited to one’s imagination as long as the underlying principles of the lic are maintained.2,14 if those principles are maintained, it is possible that the expected benefits will be achieved. our campus is striving to move the clerkships to more of a cluster “b” or cluster “c” type structure for future years.10 we believe that potentially greater educational benefits can be achieved for our learners, but acknowledge that scheduling logistics will be an ever present challenge in our small community. conclusions we have reported our one-year experiences of an amalgamative clerkship model for our small group of learners at the rmc. in our first iteration, we were able to realize many of the benefits attributed to the lic clerkship structure, but also experience many of the challenges also associated with lics. our past experiences, careful planning, improved coordination, and faculty development are all apparent keys to our future success. we are striving to evolve into more of a cluster “b” or “c” structure in the future. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. x, issue x type of article references 1. adams c, cathcart-rake w. attending physician perceptions of the benefits and disadvantages of teaching medical students on clinical clerkships at a regional medical campus. j reg med campuses. 2018;1(2). 2. poncelet an, hirsh da, eds. longitudinal integrated clerkships: principles, outcomes, practical tools, and future directions. first. north syracuse, ny: gegenstaz press, north syracuse, ny; 2016. 3. greenhill j, poncelet an. transformative learning through longitudinal integrated clerkships. med educ. 2013;47(4):336-339. doi:10.1111/medu.12139 4. hirsh d, walters l, poncelet an. better learning, better doctors, better delivery system: possibilities from a case study of longitudinal integrated clerkships. med teach. 2012;34(7):548-554. doi:10.3109/0142159x.2012.696745 5. strasser r, hirsh d. longitudinal integrated clerkships: transforming medical education worldwide? med educ. 2011;45(5):436-437. doi:10.1111/j.1365-2923.2011.03939.x 6. hirsh d, gaufberg e, ogur b, et al. educational outcomes of the harvard medical school-cambridge integrated clerkship: a way forward for medical education. acad med. 2012;87(5):643-650. doi:10.1097/acm.0b013e31824d9821 7. ogur b, hirsh d. learning through longitudinal patient care-narratives from the harvard medical school-cambridge integrated clerkship. acad med. 2009;84(7):844-850. doi:10.1097/acm.0b013e3181a85793 8. teherani a, o’brien bc, masters de, poncelet an, robertson pa, hauer ke. burden, responsibility, and reward: preceptor experiences with the continuity of teaching in a longitudinal integrated clerkship. acad med. 2009;84(suppl. 10):50-53. doi:10.1097/acm.0b013e3181b38b01 9. hirsh d, worley p. better learning, better doctors, better community: how transforming clinical education can help repair society. med educ. 2013;47(9):942-949. doi:10.1111/medu.12278 10. worley p, couper i, strasser r, et al. a typology of longitudinal integrated clerkships. med educ. 2016;50(9):922-932. doi:10.1111/medu.13084 11. hauer ke. longitudinal, integrated clerkship education: better for learners and patients. acad med. 2009;84(7):821. doi:10.1097/acm.0b013e3181a843b1 12. hirsh da, ogur b, thibault ge, cox m. “continuity” as an organizing principle for clinical education reform. n engl j med. 2007;356(8):858-866. doi:10.1056/nejmsb061660 13. poncelet an, wamsley m, hauer ke, lai c, becker t, o’brien b. patient views of continuity relationships with medical students. med teach. 2013;35(6):465471. doi:10.3109/0142159x.2013.774335 14. ellaway r, graves l, berry s, myhre d, cummings ba, konkin j. twelve tips for designing and running longitudinal integrated clerkships. med teach. 2013;35(12):989-995. doi:10.3109/0142159x.2013.818110 microsoft word covid faces article.docx published by university of minnesota libraries publishing covid faces: unmasking the emotional impact of the pandemic in a cohort of fourth-year medical students mark stephens, courtney kramer, leana eugene doi: https://doi.org/10.24926/jrmc.v6i1.4396 journal of regional medical campuses, vol. 6, issue 1 (2023) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc mark stephens courtney kramer leana eugene corresponding author: mark stephens all work in jrmc is licensed under cc by-nc volume 6, issue 1 (2023) journal of regional medical campuses perspectives covid faces: unmasking the emotional impact of the pandemic in a cohort of fourth-year medical students mark stephens, courtney kramer, leana eugene abstract background: in april 2020, most undergraduate medical education programs across the country ceased in-person activities. in the months that followed, the return to clinical care for graduating students in the class of 2021 was challenging. as the pandemic wore on, the impact of covid-19 on professional identity formation in medical students was an area ripe for investigation. this small cohort study reveals student perceptions of the impact of covid-19 on their developing sense of professional identity. methods: students in the class of 2021 at the pennsylvania state university college of medicine (main campus in hershey, pa, as well as the regional campus in university park, pa) were invited to participate. after approval from the institutional review board, participating students submitted a reflective narrative describing the impact of the pandemic on their educational experience. in addition, students submitted words to describe their sense of projected (external) on the outside of a templated surgical mask and words to describe their sense of true (internal) on the inside of the mask. results: common narrative themes that emerged included doubt, anxiety, fear, disconnection, loss of control, guilt, sacrifice, resilience, and survival. analysis of descriptors of internal and external aspects of the templated surgical masks revealed common themes of anxiety, fear, confusion, and hope. conclusions: this study provides a glimpse into the student experience of covid-19 through several lenses. from the narrative perspective, students expressed elements of disconnection and doubt as well as resilience and grit. from the visual perspective, similar themes emerged from the mask descriptors. overall, covid-19 significantly impacted the emotional experiences of this cohort of fourth-year medical students, particularly in the context of sustained uncertainty and feelings of anxiety. introduction: “the virus has taken away our stage, our work and our identity”* identity is a complex and multifaceted process whereby an individual forms an enduring sense of self that helps to distinguish them from others.1 identity is dynamic and comprised of multiple primary (e.g. race, gender) and secondary (e.g. physician, nurse, student) components that are in a constant state of flux across time and contexts.2 identity formation is an ongoing process that organizes experiences and relationships into a ‘meaningful * https://www.forbes.com/sites/masonsands/2020/04/12/comedians-inquarantine/#1a4518f5512a whole’3 that incorporates personal, private, public, and professional selves.4 in the context of medical education, professional identity is also created (and re-created) through discourse5 and interactions with others.6 who we are, who we might become, and who we are seen to be are central aspects of our identity.7 language, experience, tradition, and ceremony contribute to dynamically incorporate multiple sub-identities into an overall sense of self.8 a large component of identity is represented by the extent to which an individual feels like a true member of their team or journal of regional medical campuses, vol. 6, issue 1 perspectives workplace.9 personal and professional growth continuously evolves through relationships, reflections, and experiences within the contexts, traditions, and ethical foundations of any given community.10 individuals move from having a foundational body of knowledge, to knowing how to perform a skill (competence), to showing how to execute the skill (performance), to demonstrating sustained excellence in the performance of that skill (action). while covid-19 unquestionably presented multiple physical and mental health challenges to medical students,11 the impact of the pandemic on their developing sense of professional identity is not known. methods: this study used a phenomenological approach to examine the impact of covid-19 on the sense of professional identity formation in a cohort of fourth year medical students. following institutional review board approval, 150 penn state college of medicine medical students in the class of 2021 received an invitation to participate in the study. potential participants were provided with a hyperlink directing them to a secure server (redcapô) for study information and consent. following consent, students were asked to decorate a templated surgical mask with ten words to describe how they were displaying their emotions to the world (projected self—outside of the mask) and ten words to describe how they were actually feeling during the pandemic (true self— inside of the mask). they also created a reflective narrative to describe their overall experience as a medical student during the pandemic. the authors (ms; ck; le) independently analyzed each mask and narrative constant comparative method,12 whereby raw data were sorted and organized according to attributes in order to form general themes. the authors met to confirm and discuss the emergent themes. axial coding was then used to further examine the participant ‘voice’ to elucidate elements within each theme. illustrative aspects of each element were then identified by iterative consensus. results: across both campuses, 15 students chose to participate for a 10% total response rate. overall, five students (three from the main campus at hershey, pa, and two from the university park regional campus) submitted all of the requested elements. these five submissions are the focus of the final analysis. five primary themes emerged from the narratives—behavioral, physical, emotional, cognitive, and social. within each of the main themes, specific elements were identified as well. these themes and elements are consistent with previously identified reactions to stressful or traumatic events13 (table 1). themes also emerged from the internal and external aspects of the templated masks (figure 1). common descriptors from the mask interior (true self) included fear, guilt, confusion, and anxiety. in contrast, the mask exterior (projected self), more commonly included descriptors portraying confidence, calm, hope, and fearlessness. this dichotomy suggests a difference between what students were feeling as their perceived experiences within the context of the pandemic and what they actually were projecting to others. discussion: during periods of stability, personal identities are generally well-established.13,14 periods of transition and uncertainty, like the covid-19 pandemic, however, contribute to feelings of identity dissonance.15,16 the present study suggests that for this small cohort of learners, there was a dissonance between what emotions they were experiencing as part of the pandemic and the feelings that they were trying to project outwardly to others. covid-19 significantly impacted the traditional roles and responsibilities of medical students, particularly those engaged in clinical activities. for this cohort of fourthyear students at our institution, away or ‘audition’ rotations were canceled, and in-person activities significantly curtailed. with alterations in the ability to participate in normal workplace endeavors brought on by isolation measures enacted during the pandemic, transitions in roles threatened (or led to changes in) identity. building on our prior experience with mask making,17,18,19 this study provides several insights into medical students’ sense of identity during the early phases of the covid-19 pandemic. this small cohort of students revealed elements of uncertainty and fear, while also expressing significant resilience and adaptability. they indicated feelings of despair and loss, while simultaneously expressing hope and journal of regional medical campuses, vol. 6, issue 1 perspectives gratitude. students exhibited self-care, growth, and perspective formation. they also commented on the impact of isolation, anxiety, and disconnection on their developing identity. several participants writing about their lived pandemic experiences self-disclosed that the pandemic was particularly challenging for under-represented and minority communities in the context of identity and professional development. key limitations of this study include a poor response rate and the fact that this is a single institution study. while these factors may limit generalizability, when taken in the context of the phenomenological study design, our findings still likely represent what many medical students across the country were feeling during the pandemic, particularly in terms of impact on their developing sense of professional identity. as the pandemic eventually draws to a close, lessons learned from this study could help to inform how students respond to other crises in the particular context of identity formation. major life events (such as the covid-19 pandemic) may have a predictable impact on student identity. knowing how students are responding, both internally and externally, in times of crisis provides a framework to guide emotional and academic support. figure 1: mask descriptors mask interior mask exterior journal of regional medical campuses, vol. 6, issue 1 perspectives table 1 students described these thematic responses to the pandemic with these specific elements in these words behavioral adaptability “since the year began, i’ve been in constant survivor mode. i had a steep learning curve on how to be adaptable and make important decisions” resilience “the pandemic has afforded me an opportunity to exercise my resiliency and grit” “instead of being defeated by endless roadblocks, i had to let go of control in order to embrace detours toward my desired goal” emotional fear/panic “have i already been exposed? .. i had an ominous feeling” “i was scared of what was going to happen to the world and how it would affect those i care about” “panic ensued with my classmates, is this really happening?” doubt/uncertainty “…being away from the wards for so long, … allowed some of the unknowns associated with the pandemic to really flourish” “i felt trapped, stuck, and wondered multiple times if this pandemic was a sign that i should reconsider the path i was heading on, career-wise” “not being allowed into the hospital made me question if i would be able to remember my skills/things i have already learned” helplessness “during the pandemic, there have been many moments where i not only felt helpless but had neither the control over the timing nor fruition of the plans i previously made” “i don’t think i loathed being a medical student more than the spring of 2020” “this year has been the most difficult one yet” anxiety “my step 1 was scheduled, …everything rides on that, i couldn’t afford to feel more anxious” “my anxiety couldn’t handle flying during a pandemic, but i was so restless from studying” “the anxiety escalated, … this threat was real” “anxiety is a sickness of my mind; i didn’t realize how sick i was before i went home” loss/denial “there was a certain level of educational momentum that ceased by being away from the wards for so long” “block it out, pretend it’s not real” guilt “i felt guilty being a medical student. my family has always sacrificed for me to advance and succeed in life” journal of regional medical campuses, vol. 6, issue 1 perspectives optimism/hope “i began to make a conscious effort of taking my ‘bad days’ as ‘character building days’” “while there were many moments of uncertainty and doubt, i never doubted my excitement and vigor with which i wanted to treat and care for patients” “i took this opportunity to exercise my ability to be malleable and relentlessly optimistic” “for the first time in a long time, i was filled with hope and reminded of the parts of me that make me human” gratitude “i am grateful for the hardships, because they qualify me to effectively care for and support others during theirs” physical self care “i got back in touch with who i am and what i love” “i learned a lot of good skills during this time and had fun finding hobbies” “i learned to love myself again” cognitive rationalization “limit the amount of time i read about the virus each day. intellectualize and plot the data” growth “for the many things that the pandemic took from me, it has brought me endless opportunities for growth” “amidst the chaos of a pandemic, i became an individual; mentally, spiritually and physically” “i don’t want to go back to the sad, stressed, self-doubting, anxiety-provoking life” perspective “i learned that everything that seems to be a burden isn’t so” “the pandemic taught me to slow down and reconsider my trajectory long enough to see a bigger picture” focus “i keep my head down. i stay focused. i forget about enjoying life because my one goal is to get this right and move on” social isolation “over the course of 3 months of isolation, … it was nearly unbearable to be a medical student from an under-represented area in medicine; a minority” “i started to feel disconnected from not just the world but from the professional identity i had just started to feel really excited about” “since the year began, i’ve been in constant survivor mode” “i had no idea how much i needed my sister before” disparity “i was often the only student of color in my group. many colleagues and faculty looked towards me for answers or insights to the concern at hand” “i was being informed to educate others at the expense of my vulnerability during a time when peace was becoming more fragile under the weight of evolving uncertainty” sacrifice “i felt the weight of this sacrifice more. i had to deny my family in order to pursue my education” journal of regional medical campuses, vol. 6, issue 1 perspectives references 1. cheek jm (1989). identity orientations and self-interpretation. in: buss dm cantor n (eds). personality psychology: recent trends and emerging directions new york: springer. doi: 10.1007/978-1-4684-0634-4 2. grotevant hd (1987). toward a process model of identity formation. j adol research 2(3): 203222 3. cruess rl, cruess sr, boudreau jd, et al. (2015). a schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators. acad med. 90(6): 718–725. 4. jarvis-selinger s, pratt dd, regehr g (2012). competency is not enough: integrating identity formation into the medical education discourse. acad med. 87(9): 1185–1190. 5. marcia, james. (1966). development and validation of ego identity status. j personality and soc psych. 3: 551-8 6. rees c, monrouxe l, ajjawi r. (2014). professionalism in workplace learning: understanding interprofessional dilemmas through healthcare student narratives. in: exploring the dynamics of personal, professional and interprofessional ethics. jindal-snape d, hannah e (eds). policy press pp 295-310. 7. goldie j. (2012). the formation of professional identity in medical students: considerations for educators. med teach, 34(9), e641–e648. 8. holden md, buck e, luk j, et al. (2015). professional identity formation: creating a longitudinal framework through time (transformation in medical education). acad med: 90(6), 761–767. 9. lave j & wenger e (1991) situated learning. legitimate peripheral participation, cambridge: university of cambridge press 10. coulehan j. (2005). viewpoint: today's professionalism: engaging the mind but not the heart. acad med: 80(10), 892–898. 11. meo, s. a., abukhalaf, a. a., alomar, a. a., sattar, k., & klonoff, d. c. (2020). covid-19 pandemic: impact of quarantine on medical students' mental wellbeing and learning behaviors. pakistan j med sci, 36(covid19-s4), s43–s48. https://doi.org/10.12669/pjms.36.covid19s4.2809 12. glaser bg, strauss al. (1967). the discovery of grounded research : strategies for qualitive research. new york: aldine de gruyter. 13. cruess rl, cruess sr, boudreau jd, et al. (2014). reframing medical education to support professional identity formation. acad med; 89:1446-1451. 14. monrouxe, l. v., & rees, c. (2015). theoretical perspectives on identity: researching identities in healthcare education. in j. cleland, & s. j. durning (eds.), researching medical education (1st ed., pp. 129-140). wiley-blackwell. https://doi.org/10.1002/978111883 8983.ch12 15. center for substance abuse treatment (us). trauma-informed care in behavioral health services. rockville (md): substance abuse and mental health services administration (us); 2014. (treatment improvement protocol (tip) series, no. 57.) chapter 3, understanding the impact of trauma. available from: https://www.ncbi.nlm.nih.gov/books/nbk2071 91/ accessed june 21, 2021. 16. stephens, m. b., bader, k. s., myers, k. r., walker, m. s., & varpio, l. (2019). examining professional identity formation through the ancient art of mask-making. j gen int med, 34(7), 1113–1115. https://doi.org/10.1007/s11606-019-04954-3 17. joseph k, bader k, wilson s, et al. (2017). unmasking identity dissonance: exploring medical students’ professional identity formation through mask making. perspect med educ; 6(2): 99-107 18. shapiro j, youm j, heare m, et al. (2018). medical students’ efforts to integrate and/or reclaim authentic identity: insights from a mask-making exercise. j med humanit; 39(4):483-501 19. stephens mb. (2020). unmasking identity: observations from a cohort of entering medical students. fam med 53(2): 120-123. microsoft word engagingcommunityfaculty.docx published by university of minnesota libraries publishing engaging community faculty to meet educational objectives and medical school missions april heiselt, ph. d.; amanda bassett, mba; helene silverblatt, md; nicole bost, bs z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc april heiselt, ph. d. director, office for community faculty, university of nevada, reno school of medicine, aheiselt@med.unr.edu amanda bassett, mba director of office for community faculty; advancement and alumni relations, university of new mexico school of medicine, abassett@salud.unm.edu helene silverblatt, md executive director, office for community faculty, university of new mexico school of medicine, hsilverblatt@salud.unm.edu nicole bost, bs manager, office of community based medical education, university of colorado, nicole.bost@cuanschultz.edu all work in jrmc is licensed under cc by-nc volume 2, issue 3 (2019) journal of regional medical campuses abstract engaging community faculty to meet educational objectives and medical school missions april heiselt, ph. d.; amanda bassett, mba; helene silverblatt, md; nicole bost, bs topic: community faculty (e.g. volunteer, adjunct, clinical) are one of the most vital assets in medical education. in many medical schools they are crucial to meeting educational missions as there are not enough full-time, academic faculty to address the needs of our ever growing pool of learners. despite this critical importance, engaging this group is not always as easy because community faculty face many individual pressures such as being more “productive” in terms of increased patient loads and responsibilities, increasing demands for their time in terms of the electronic health record, administrative burdens, and regulatory paperwork. considering the larger educational mission and how it relates to engagement, development, and retention of community faculty is relevant when determining how to meet the needs of this vital group. in 2015, the university of nevada, reno school of medicine created an office for community faculty to expand and support this vital resource. the university of new mexico school of medicine opened its own office for community faculty soon thereafter. meanwhile, the university of colorado maintains an office of community based medical education. these efforts have helped their institutions meet recruitment goals for their learners and develop an engaged group of community faculty who continue to educate and mentor the healthcare providers of the future. each of these offices engages these educators through faculty professional development, appreciation and awards events, incentives, and benefits. other outreach methods include community faculty advisory boards, communication tools and publications, periodic needs assessment surveys to provide continuous quality improvement, information sharing with student affairs units, and more. by considering engagement, development, and retention of community faculty, educational missions can be met and learners can receive the training they require for success. short description: community faculty provide medical schools with critical resources to support education and other academic missions. however, recruiting, developing and retaining community faculty can be challenging because these volunteers often maintain busy and demanding clinical practices. schools around the country are establishing offices for community faculty to address these challenges by focusing on three main initiatives: engagement, development, retention. these efforts have not only helped their institutions meet recruitment goals for their learners but have developed an engaged group of community faculty who continue to educate and mentor the healthcare providers of the future. four questions that were posed to/considered by session participants 1) how are your community faculty related to your educational and academic missions? 2) what have been the most successful techniques you have used to engage community faculty? 3) how have you incorporated professional development opportunities into community faculty benefits and requirements? 4) how does your school of medicine retain community faculty given increased productivity pressures? three take home points from our session: 1) review your academic and educational missions and how community faculty play a role in contributing to your school of medicine. 2) examine the needs you have related to community faculty engagement, development, and retention and determine how to best meet the needs and requests of community faculty through each of these focus areas. 3) participate in community forums such as the community faculty consortium to continue sharing ideas and strategies to enhance the way your institution engages, empowers, and promotes community faculty microsoft word medicalstudentselectionarticle.docx published by university of minnesota libraries publishing medical student selection – engaging faculty and community members across regions in a holistic, mission-aligned process leila harrison, phd, ma, med; radha nandagopal, md z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc leila harrison, phd, ma, med; associate dean for admissions, recruitment, and inclusion; elson s. floyd college of medicine, washington state university leila.harrison@wsu.edu radha nandagopal, md; admissions committee chair, clinical education director for the art and practice of medicine; elson s. floyd college of medicine, washington state university radha@wsu.edu all work in jrmc is licensed under cc by-nc volume 2, issue 3 (2019) journal of regional medical campuses abstract medical student selection – engaging faculty and community members across regions in a holistic, mission-aligned process leila harrison, phd, ma, med; radha nandagopal, md topic: it is widely acknowledged that serving on a medical school admissions committee, participating as an interviewer, and/or contributing as a screener in the selection process is a considerable investment of time and resources, both on the part of the individual and institution. many medical schools rely solely on their admissions committee members or core faculty for all aspects of the admissions process. in a distributed campus model, engaging those on other campuses in the medical student selection process can be particularly difficult and resource-intensive. however, involving stakeholders from different contexts and campuses can help medical schools diversify the participants in each step of the admissions process, from recruitment, to screening, to interviewing, and to selection. moreover, engaging stakeholders on other campuses and within the community allows for a much broader contribution to the selection of future physicians serving, in our case, the population of washington state. using the regional campus structure poses an advantage to embed multiple constituents, including faculty, staff, and community members, into the entire process supporting collective input in training future physicians for those communities. involving local communities in the admissions process provides the opportunity for more people to become aware of institutional missions and to become invested in the holistic review framework used for candidate selection. this is especially critical when the admissions process is blinded to metrics from secondary application onward, and the focus is on a candidate’s attributes and experiences and fit with the institutional mission. in sum, the effort of including faculty, staff, and community members across regional campuses contributes to an inclusive and collaborative effort which supports upholding school mission. short description: many medical schools rely solely on their admissions committee members or core faculty for all aspects of the admissions process. in a distributed campus model, involving stakeholders from different contexts and campuses, can help medical schools diversify the participants in each step of the admissions process, from recruitment, to screening, to interviewing, to selection. using the regional campus structure poses an advantage to embed multiple constituents, including faculty, staff, and community members, into the entire process supporting collective input in training future physicians for those communities and provides the opportunity for more people to become aware of institutional missions and to become invested in the holistic review framework used for candidate selection. the authors declare no conflicts of interest. this work does require human subjects review. four questions that were posed to/considered by session participants: 1) what are your barriers to including faculty and community members at all regional campuses in your admissions process? 2) who do you want to attract to your college/school of medicine and to your state/region? 3) what does the mission of your college/school of medicine mean to you? 4) what are the goals of your college/school of medicine? three take home points from our session: 1) regional campus participation on the admissions committee (ac) and interviews allows for broad representation of the communities the college serves. diverse voices such as non-physicians, varied specialties and practice environments, and unique personal backgrounds help in the selection of students who fit the mission. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 3 abstract 2) involving members across distributed campuses in admissions means budget allocation for travel for in-person retreats necessary for trust-building. dependable information technology services for videoconferencing during selection meetings is an absolute requirement. 3) barriers to participation on the ac include faculty workload models that may not support service and potential reluctance to embrace holistic review processes. overcoming these barriers requires stressing the mission-alignment of ac work, working with faculty to showcase service, and transparently discussing holistic review with prospective members. microsoft word development and evaluation article.docx published by university of minnesota libraries publishing development and evaluation of a longitudinal integrated ultrasound curriculum for third year medical students margaret r. lewis, md facep; lisa howley, phd; patricia white, md; celeste colcord, mba; bryant k. allen, md. journal of regional medical campuses, vol. 1, issue 2 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc margaret r. lewis, md facep, assistant professor, director of ultrasound in medical student education, department of emergency medicine lisa howley, phd, association of american medical colleges patricia white, md, carolinas healthcare system celeste colcord, mba, department of medical education, carolinas medical center/ university of north carolina school of medicine charlotte campus bryant k. allen, md, assistant professor, department of emergency medicine, carolinas medical center/ university of north carolina school of medicine charlotte campus corresponding author: margaret r. lewis; margaret.lewis@carolinashealthcare.org 843-708-1043 all work in jrmc is licensed under cc by-nc volume 1, issue 2 (2018) journal of regional medical campuses original report development and evaluation of a longitudinal integrated ultrasound curriculum for third year medical students margaret r. lewis, md facep; lisa howley, phd; patricia white, md; celeste colcord, mba; bryant k. allen, md. abstract an overview of the development and implementation of a novel, longitudinal point-of-care ultrasound curriculum implemented for third-year, allopathic medical students at a branch campus is presented. a model employing didactic and hand-on ultrasound education was incorporated into the newly established longitudinal ms-3 curriculum. the ultrasound curriculum was developed in conjunction with student didactics and simulation sessions in a theme-based approach. keywords: ultrasound, education, medical student, regional campus introduction a generation of physicians will need to be trained to view ultrasound as an extension of their sense, just as many generations have viewed the stethoscope. that development will require the medical education community to embrace and incorporate the technology throughout the curriculum.1 in 2010, the university of north carolina school of medicine (unc-som) formally partnered with carolinas healthcare system in charlotte, north carolina to create the unc som charlotte campus. beginning with the 2013-2014 academic year, a program titled the charlotte longitudinal integrated curriculum was established, creating an environment in which third-year medical students were simultaneously enrolled in clinical experiences within all clerkships, rather than the standard 4 to 8 week individual clerkship blocks. this change in curriculum coupled with the lack of a formal introduction to ultrasound within the medical school curriculum and the growing role of “point-of-care” ultrasound (pocus) in medicine led to the creation of the novel longitudinal curriculum described here. the role of ultrasound in medicine has expanded greatly since its initial introduction in 1947, becoming heavily engrained in the fields of obstetrics/gynecology, cardiology and radiology.2 however, it was not until technology advanced, making machines smaller and more mobile, that the concept of “point-of-care” ultrasound emerged.3 placing the imaging power of ultrasonography in the hands of the clinician at the bedside for immediate and simultaneous performance and interpretation revolutionized the field and allowed expansion into new and growing specialties.3 the spectrum of applications and fields that have begun employing this diagnostic journal of regional medical campuses, vol. 1, issue 2 original report technology continue to grow, now becoming used extensively in emergency medicine, ob/gyn, anesthesia, internal medicine, critical care, radiology, surgery and cardiology.3-8 moore, et al. cautions, however, that “ultrasound is a userdependent technology, and as usage spreads, there is a need to ensure competence, define benefits of appropriate use, and limit unnecessary imaging and its consequences.”3 despite the massive expansion of the role of ultrasound in medicine, the growth of ultrasound training in undergraduate medical education (ume) has been limited and greatly varied. according to a 2012 survey, 62.2% of responding allopathic medical schools identified ultrasound as a component of their ume, though no consensus on methodology of introduction was present.9 presently a wide variety of methods for ume have been proposed. early introduction of ultrasound as a tool to augment physical examination teaching has been shown to not only be well received by students, but also appears to improve overall physical examination skills.10-12 early introduction of ultrasound in medical school has led to success in both increased objectively graded objective standardized clinical examination (osce) testing and ultrasound skill level.11, 13 alternatively, short elective courses, seminars and symposia have also shown great success in engaging learners and improving ultrasound knowledge.14-16 finally, hoppmann, et al at the university of south carolina school of medicine enacted a 4-year ultrasound experience, with exposure to ultrasound throughout both pre-clinical and clinical components of undergraduate medical education at a single campus.17 many institutions nationwide that have ultrasound components in ume incorporate ultrasound in the third year of medical school (ms-3), the traditional introduction of clinical rotations.9 given the implementation of a new format of ms-3 curriculum for an entire campus, a unique opportunity to create a novel longitudinal ultrasound curriculum was born. the society of ultrasound in medical education (susme) curriculum database offered several innovative ultrasound curricula to use as a resource in the development of the unc som charlotte campus ultrasound curriculum, most notably the iusc curriculum17, but no single published curriculum met the needs of the growing longitudinal training environment of the branch campus. the purpose of our review is to illustrate the components of the novel longitudinal curriculum and discuss the development of the ultrasound curriculum in conjunction with other aspects including traditional didactics and simulation. longitudinal curriculum the charlotte longitudinal integrated curriculum (clic) hosted its first class in the 2013-2014 academic year. this was a pilot program, with six students the first year, and eight the second year. the curriculum was divided into two phases: 1) july -september; and 2) october june. the first phase consisted of expedited block rotations through internal medicine, surgery, and obstetrics/gynecology. during the second phase of the curriculum, students were assigned to community preceptors in various specialties (family medicine, internal medicine, gynecology, neurology, psychiatry, and pediatrics) and have dedicated clinic time each week to see his or her “panel” of patients. these clinic settings tended to be located in urban underserved clinics, primarily spanish speaking clinics, or more rural clinics. in addition to the community experience, students participated in a variety of other educational opportunities to enhance their clinical education. these included emergency department shifts and “pulse weekends”, formal didactics, simulation and ultrasound curricula. during the “pulse weekend”, students reported to the emergency department on friday afternoon and identified one patient to evaluate and follow throughout their hospital stay. the student then transitioned with the patient to the inpatient team, through surgery if needed, possibly to rehabilitation and outpatient office visits. this “pulse weekend” provided the student a unique perspective and understanding of the medical system. journal of regional medical campuses, vol. 1, issue 2 original report in the second portion of the curriculum, tuesday afternoons and fridays at noon were reserved for the “thread” sessions – a combination of ultrasound, simulation, ethics, and didactics. these thread sessions were scheduled around common themes (table 1). for example, students had lectures on chest pain, ekg reading and chest x-ray interpretation followed by a simulation session on chest pain evaluation. students then had an ultrasound session on cardiac and thoracic ultrasound exams. ultrasound curriculum the approach to the longitudinal curriculum was to divide the intended content into 7 theme-based teaching sessions, with each session to have didactic and practical components. sessions occurred in four-hour afternoon blocks over the course of the ms-3 year. the initial longitudinal curriculum components for academic year 2013-14 are illustrated in table 2. during the introductory year, the ultrasound course occurred over a total of seven four-hour sessions during the clic schedule, encompassing a time frame of approximately 8 months. given the lack of previously described curricula in this setting, components from several examples, including those endorsed by susme, were adapted to maximize student exposure to point-of-care ultrasound education. with the goal of introducing ms-3 students to ultrasound as a tool for screening, diagnostic assessment and procedural guidance, the novel longitudinal curriculum was created. we used a combination of lectures, practical sessions and group competitions as outlined in table 3. didactic activity in order to cover content that incorporated multiple aspects of pocus as well as review of previously covered topics, each session opened with a short, focused theme-based small group discussion. the discussions utilized a variety of patient scenarios to correlate with topics taught in their core didactic sessions as well as simulation. the intent was for the student to appreciate how ultrasound functions in the overall patient evaluation. these discussions were limited to one hour or less and were led by faculty or the fellow of the division of emergency ultrasound within the department of emergency medicine. individual session topics described further in table 2. “hands-on”/practical activity following completion of the didactics, the participant group was divided into smaller groups of 2-3 students for the practical component of the session. each small group then underwent direct instruction on a particular application of point-ofcare ultrasound. standardized patients were used for the majority of exam applications, except for the pelvic ultrasound and central venous catheter placement sessions, which employed blue phantom™ models. these models simulated human tissue and vascular structures that were identifiable by ultrasound as well as simulated female pelvic anatomy including uterus and ovaries. the models also allowed students to learn an invasive exam (transvaginal ultrasound) as well as needle guidance with ultrasound without utilizing standardized patients. after bedside instruction by faculty, students each demonstrated the application technique, receiving immediate feedback. each student was given ample opportunity to obtain images adequate for clinical interpretation, and was offered additional exposure after completion of the session if desired. group competition at the conclusion of sessions 2-6, the group was divided into two equal teams for a friendly ultrasound competition. teams were either given clinical scenarios with corresponding ultrasound images (either normal anatomy or representing pathology) that they had to interpret and make clinical determinations using or they were tasked with performing a specific ultrasound application. the team that interpreted the image correctly and acted accordingly or that performed the desired exams and was found to obtain adequate images was awarded points. a running point total was kept for the duration of the curriculum. the winning team of this competition was awarded both journal of regional medical campuses, vol. 1, issue 2 original report bragging rights and a small prize at the conclusion of the course. individual ultrasound exams students were instructed to assist with or individual perform ultrasound applications during their other clinical rotations within the clic. largely, students performed the exams during their time in the emergency department, with the guidance of ultrasound faculty and/or em residents. each student maintained a log of these exams for the duration of the longitudinal curriculum, and all images underwent quality assurance review by ultrasound faculty. further student ultrasound opportunities students also had the opportunity for a further, more focused ultrasound elective in their fourth year of medical school. in this elective, students rotated with ultrasound faculty members in the department of emergency medicine, performing focused, bedside ultrasounds on emergency department patients. in this rotation, students performed a variety of ultrasounds and were exposed a wide array of pathology. students also reviewed ultrasound related articles and gave a case-based presentation. ultrasound assessment knowledge assessment/course preand posttesting all student participants underwent standardized testing on various ultrasound topics at the beginning and conclusion of the longitudinal ultrasound curriculum. these preand post-test consisted of 20 multiple choice questions authored by members of the faculty of the division of ultrasound within the department of emergency medicine. the preand post-test were identical and were based on prior ultrasound exams given to first year emergency medicine residents during their ultrasound rotation. given the timeframe between test administrations, no randomization or recoding of the test was performed. questions covered topics involving ultrasound physics, ultrasound application logistics, and image interpretation. results from the preand post-test are reported in table 4. skills assessment during the final session, each student’s ultrasound application skills were assessed through six “handson” stations. tested applications include cardiac, thoracic, fast, aorta, and central line placement with a blue phantom™ model. each session was observed by faculty from the division of ultrasound in the department of emergency medicine, an ultrasound fellow or pgy-3 emergency medicine resident. students performed each exam unassisted and informed the observing faculty when they felt an adequate image had been obtained. the faculty used a modified likert scale to grade the image quality and demonstrated skill in obtaining the image (table 5). scores for each intended image were then averaged for the station. students then participated in a session in which they had to identify a series of normal and abnormal ultrasound clips and images. the students were then asked to currently interpret each image, without information regarding the clinical case or scenario. percentage of correct image interpretations was recorded. results and scores from skills assessment for each initial student are included in table 6. survey and feedback each participant was asked to complete a brief survey at both the beginning and conclusion of the curriculum, assessing both their prior exposure and comfort level with ultrasound as well as their sentiment regarding ultrasound education as a component of ume. survey questions are included as attachments 1 and 2. comments regarding the student experience were also collected during the post-course survey. results pre-post testing initial knowledge assessment was performed before any training in point-of-care ultrasound was performed, which was reflected in the scores. data and individual scores are presented in table 4. average score on initial testing was 55%, with a range of 50-65% and median of 52.5%. the same test was given at the conclusion of the course without any changes in question or answer orders. journal of regional medical campuses, vol. 1, issue 2 original report students demonstrated significant improvement across the board, with a group average of 81.7%, ranging from 70-90% with a median score of 82.5%. the average improvement in scores after completion of the novel, longitudinal ultrasound curriculum was 26.7%, with a median individual improvement of 30%. skills assessment the skills assessment was compiled of practical application stations where ultrasound faculty evaluated individual ultrasound exam performance and an image identification station. students were graded on a 5-point likert scale by ultrasound faculty for each examination performed (delineated in table 5) as well as on the percentage of correct image identifications and interpretations (delineated in table 6). students overall achieved scores of 3.8 to 5 for each application and were deemed to have “good” to “excellent” ability to obtain and optimize point-of-care ultrasound images. image identification without supplemental information or description of clinical scenarios was found to be more difficult by students, demonstrated by the average score of 72.2%, with a range of 50-94.4%. student perspectives survey to assess student perspectives regarding the novel, longitudinal ultrasound curriculum, students were given an anonymous mixed methods survey at the beginning of their ultrasound curriculum and during their final session. responses were based on a five-point likert scale (results in table 7). students were surveyed on different ways in which ultrasound education may or may not improve their medical education. survey questions are listed in attachment 2. overall, the student thought that ultrasound education has value in undergraduate medical education and is best incorporated into clinical years. discussion we set out to describe the design and implementation of a point-of-care ultrasound course into a longitudinal third year medical student curriculum. the ultrasound course was created to complement the overall third year curriculum design and allow students to learn a unique skill. students covered fundamentals including ultrasound physics and image acquisition, ultrasound-guided procedures, free fluid assessment, basic cardiac and thoracic, and early obstetric and gynecologic applications. overall the students had improvement in their ultrasound knowledge based on a multiple-choice test. students were also able to perform a series of point-of-care ultrasound exams with good technique: students were able to obtain particular images without prompting or direction, indicating knowledge of ultrasound anatomy. the students did have difficulty with the image interpretation portion of skills assessment, which was designed to test knowledge and identification of abnormal ultrasound images. throughout the course, students were shown ultrasound images representing normal anatomy as well as abnormal anatomy or pathology. however, the images representing pathology were always given with a corresponding clinical scenario. students struggled when ultrasound images were taken out of context. the blinding to the clinical scenario is absent in modern point-of-care ultrasound, where the clinical provider is both the sonographer and interpreter, well versed in the current clinical case. though one could assume that student’s interpretations of images would have improved in accuracy with an association of the clinical scenario, this limitation certainly allows for further exploration and study. students of the novel curriculum felt that ultrasound education incorporated into their third year of medical school enhanced their knowledge of anatomy and pathology, as well as knowledge of diagnostic imaging choices and patient safety. the students also felt that this curriculum helped to improve their physical exam skills and helped them to correlate basic science with clinical reasoning. these results reflect the findings of the iusc curriculum, in which students felt that ultrasound education enhanced their understanding of the physical exam and overall enhanced their medical school education.25 these results are shared and journal of regional medical campuses, vol. 1, issue 2 original report highlighted as part of the collaborative effort through susme. with the growing role of ultrasound in clinical medical practice, much must be done to increase the prevalence of ultrasound education in undergraduate medical education. while some medical schools have achieved this through introduction of ultrasound into early physical examination and anatomy courses11-12, 19, one-time seminars14, 15 and 4th year electives16, these approaches may not work across all medical school curricula. previous success had been reported with implementation of a theme-based format when similar short blocks of time were used for educational purposes with point-of-care ultrasound (pocus).15 additionally, ultrasound at the graduate medical education (gme) level has shown to be most successful when it has employed a combination of ultrasound faculty directed didactics and hands-on experience.18 within a review of emergency medicine resident competencies of pocus, it was found that programs that had 15 hours of didactic education and a formal ultrasound rotation produced residents with higher test scores on standardized ultrasound testing and improved competancy.18 when combined with bedside performance of ultrasound examinations by students, an elective course in pocus combining 4-hours of didactics with image review proved an effective manner in which fourth year medical students could gain basic competency.16 great strides have been made in graduate medical education to create standardized guidelines for ultrasound education. findings such as those listed above have led to professional organizations creating standards for ultrasound education within gme.20, 21 however, these consensus guidelines do not yet exist for ume. a longitudinal approach to ultrasound education within the ume environment has seen significant success. hoppmann et al. formulated a 4-year longitudinal curriculum for implementation in the university of south carolina school of medicine17, resulting in students enrolled in the curriculum feeling that such an approach improved their overall medical education. this approach, however, is not easily reproduced, especially in the growing environment of medical school expansion into remote, branch campuses. the approach we chose at a branch campus level allowed for scaling of the barriers that face curriculum implementation, including finding interested faculty, machines for training and funding. at the inception of the longitudinal ms-3 ultrasound curriculum, there was no comparable ultrasound curriculum at the main campus or other branch campuses. point-of-care ultrasound has not been part of the core curriculum for the ms-3 year, and has been offered at the unc som charlotte campus only as an adjunct to the core curriculum. additionally, pocus is not currently a part of the core entrustable professional activities (epa’s) as set forth by the association of american medical colleges (aamc).26 currently the main campus as well as other branch campuses of unc som are investigating methods to integrate pocus into their curriculum. kman et al. implemented a 10-month longitudinal curriculum at the ohio state university, which was created for those students interested in emergency medicine as a career.22 students, as part of this curriculum, created and maintained an ultrasound portfolio. their students expressed an improved feeling of preparedness for residency in emergency medicine after completion. the novel curriculum described here incorporated third-year medical students with diverse career goals, and they all endorsed the value of ultrasound education in the overall process of ume. the students also embraced the approach of introducing the information in a sequential and continuous pattern. limitations the initial curriculum, a pilot program, was implemented on convenience sample of students participating in a longitudinal clerkship curriculum at a branch campus of a large university. the change in branch campus clerkship curriculum was small in scale, having only 6 students in the first year, significantly decreasing the exposure to the journal of regional medical campuses, vol. 1, issue 2 original report novel ultrasound curriculum. perspectives regarding the utility of ultrasound may be influenced by student’s choice of medical specialty to pursue. we also noted that students overall suffered from a degree of “burnout” towards the end of their third year curriculum that may have affected their survey results. conclusions longitudinal clerkship curricula are growing in number, with programs adopting this approach worldwide.23 the consortium of longitudinal integrated clerkships continues to gain members, with more than 2,700 medical students having completed a longitudinal curriculum in 2009.23 with the growing push toward this approach to the clinical component of ume must come an effort to advance emerging clinical assessments and technology education within the construct. our longitudinal ultrasound curriculum for ms-3 students enrolled in such a program provides a novel model with which to accomplish this goal. references 1. solomon sd, saldana f. point-of-care ultrasound in medical education – stop listening and look. n engl j med 2014; 370(12):1083-5. 2. edler i, lindström k. the history of echocardiography. ultrasound med biol 2004; 30:1565-644. 3. moore cl, copel ja. point-of-care ultrasonography. n engl j med. 2011 feb 24;364(8):749-57. 4. heller m, melanson sw. applications for ultrasonography in the emergency department. emerg med clin north am. 1997; 15:735-44. 5. mollenkopf m, tait n. is it time to include point-of-care ultrasound in general surgery training? a review to stimulate discussion. anz j surg 2013; 83:908-11. 6. american college of emergency physicians. emergency ultrasound guidelines. ann emerg med 2009; 53:550-70. 7. royse cf, canty dj, faris j, haji dl, veltman m, royse a. core review: physician-performed ultrasound – the time has come for routine use in acute care medicine. anesth analg 2012; 115:1007-28. 8. lee w, hodges an, williams s, vettraino im, mcnie b. fetal ultrasound training for obstetrics and gynecology residents. obstet gynecol 2004; 103:333-8. 9. bahner d, goldman e, way d, royall n, liu y. the state of ultrasound education in us medical schools: results of a national survey. acad med 2014; 89:1681-6. 10. shapiro rs, ko pk, jacobson s. a pilot project to study the use of ultrasonography for teaching physical examination to medical students. comput biol med 2002; 32:403-9. 11. dihn va, frederick j, bartos r, shankel tm, werner l. effects of ultrasound implementation of physical examination learning and teaching during the first year of medical education. j ultrasound med 2015; 34:43-50. 12. afonso n, amponsah d, yang j, mendez j, bridge p, hays g, baliga s, crist k, brennan s, jackson m, dulchavsky s. adding new tools to the black bag – introduction of ultrasound into the physical diagnosis course. j gen intern med. 2010 ;25(11): 1248-52. 13. butter j, grant th, egan m, et al. does ultrasound training boost year 1 medical student competence and confidence when learning abdominal examination? med educ 2007; 46:231-40. 14. connolly k, beier l, langdorf mi, anderson cl, fox jc. ultrafest: a novel approach to ultrasound in medical education leads to improvement in written and clinical examinations. west j emerg med 2015; 16(1):143-8. 15. amini r, stolz la, gross a, o’brien k, panchal ar, reilly k, chan l, drummond bs, sanders a, adhikari s. themebased teaching of point-of-care ultrasound in undergraduate medical education. intern emerg med. 2015 mar 13. [epub ahead of print] 16. fox jc,cusick s, scruggs w, henson tw, anderson cl, barajas g, zlidenny a, mcdonough j, langdorf mi. educational assessment of medical student rotation in emergency ultrasound. west j emerg med. 2007 aug;8(3): 84-7. 17. hoppmann ra, rao vv, poston mb, howe db, hunt ps, fowler sd, paulman le, wells jr, richeson na, catalana pv, thomas lk, wilson lb, cook t, riffle s, neuffer fh, mccallum jb, keisler bd, brown rs, gregg ar, sims km, powell ck, garber md, morrison je, owens wb, carnevale ka, jennings wr, fletcher s. an integrated ultrasound curriculum (iusc) for medical students: 4-year experience. crit ultrasound j. 2011; 3(1):1-12. 18. constantino tg, satz wa, stahmer sa, dean aj. predictors of success in emergency medicine ultrasound education. acad emerg med 2003; 10(2):180-3. 19. hammoudi n, arangalage d, boubrit l, et al. ultrasoundbased teaching of cardiac anatomy and physiology to undergraduate medical students. arch cardiovasc dis 2013; 106:487-91. 20. hockberger rs, binder ls, graber ma, et al. the model of the clinical practice of emergency medicine. ann emerg med 2001; 37:745-70. 21. lewiss re, pearl m, nomura jt, baty g, bengiamin r, duprey k, stone m, theodoro d, akhtar s. cord-aeus: consensus document for the emergency ultrasound milestone project. 22. kman, nicholas e. md, bernard, aaron w., md et al. advanced topics in emergency medicine: curriculum journal of regional medical campuses, vol. 1, issue 2 original report development and initial evaluation. western journal of emergency medicine. november 2011 (12), 543-550. 23. norris te, schaad dc, dewitt d, ogur b, hunt dd; consortium of longitudinal integrated clerkships. longitudinal integrated clerkships for medical students: an innovation adopted by medical schools in australia, canada, south africa, and the united states. acad med 2009: 84(7):902-7. 24. kühl m, wagner r, bauder m, fenik y, riessen r, lammerding-köppel m, gawaz m, fateh-moghadam, weyrich p, celebi n. student tutors for hands-on training in focused emergency echocardiography – a randomized controlled trial. bmc med educ 2012; 12:101-106. 25. hoppmann ra, rao vv, bell f, poston mb, howe db, riffle s, harris s, riley r, mcmahon c, wilson l, blanck e, richeson n, thomas l, hartman c, neuffer f, keisler bd, sims km, barber md, shuler co, blaivas m, chillag sa, wagner m, barron k, davis d, wells jr, kenney dj, hall jw, bornemann ph, schrift d, hunt ps, owens wb, smith rs, jackson ag, hagon k, wilson sp, fowler sd, catroppo jf, rizvi aa, powell ck, cook t, brown e, navaro fa, thornhill j, burgis j, jennings wr, mccallum jb, nottingham jm, kreiner j, haddad r, augustine jr, pedigo nw, catalana pv. the evolution of an integrated ultrasound curriculum (iusc) for medical students: 9-year experience. crit ultrasound j. 2015; 7:18. 26. englander r, aschenbrener ca et al. core entrustable activities for entering residency: a faculty and learners’ guide. aamc 2014. table 1: thread session for the 2013-2014 academic year with ultrasound, simulation, ethics, and didactics. date session: ultrasound, simulation, ethics & didactics 8-oct hypertension & clinical decision-making 11-oct intro to sim/acls lite 15-oct chest pain i 22-oct ultrasound session: introduction to ultrasound 29-oct chest pain ii: cardiac arrest 5-nov approach to asthma & copd/ethics i 12-nov ultrasound session: the cardiopulmonary patient 19-nov abdominal pain 26-nov health policy ii/ethics ii 3-dec ultrasound session: the acute abdomen 6-dec fever 10-dec approach to diabetes 7-jan approach to cad & chf 14-jan health policy iii 21-jan dyspnea 28-jan ultrasound session: the acute abdomen ii 4-feb approach to hypotension 11-feb approach to the ob/gyn patient 18-feb approach to the pediatric patient/ lumbar puncture 25-feb health policy iv 4-mar ultrasound session: the pregnant patient 11-mar altered mental status/lumbar puncture 18-mar acute and chronic pain 25-mar approach to the psychiatric patient 8-apr direct observation with standardized patients 15-apr weakness/fatigue 22-apr ics i: difficult conversations journal of regional medical campuses, vol. 1, issue 2 original report 29-apr ics ii: teamwork & communication 6-may approach to patients wit musculoskeletal symptoms 13-may ultrasound session: procedural guidance 20-may approach to cancer patients 27-may direct observations with standardized patients ii 3-jun ultrasound final assessment written test & osce 10-jun approach to neurology patients 17-jun presentations i care assignments 24-jun presentations ii & ethics presentations table 2: longitudinal ultrasound curriculum for the charlotte longitudinal integrated curriculum (clic) program for academic year 2013-14. table 3: sample schedule for ultrasound session ultrasound thread session: 1:00-5:00 pm students 8 instructors 4 practical stations 4 students rotate through stations time activity description 1:00-2:00 fast, aorta didactic lecture journal of regional medical campuses, vol. 1, issue 2 original report 2:00-2:30 station 1 fast exam (1) id morison's pouch & where fluid will accumulate, (2) id perisplenic view, (3) id bladder view in transverse & sagittal planes, (4) id fluid & bowel in ascites patient 2:30-3:00 station 2 aorta (1) id proximal aorta, sma & celiac branches in transverse & sagittal orientation, (2) distinguish aorta from ivc, look for vertebral body & shadowing, (3) id & measure mid and distal aorta in transverse and sagittal planes, (4) id aortic bifurcation 3:00-3:30 station 3 review fast exam & thoracic fast with pneumothorax detection 3:30-4:00 station 4 review cardiac psla, pssa, a4, sc images 4:00-5:00 ultrasound competition case-based ultrasound competition, students divided into 2 teams table 4: knowledge assessment (preand post-test) scores student pre-test (%) post-test (%) improvement (%) 1 50 85 35 2 65 80 15 3 50 70 20 4 50 80 30 5 60 90 30 6 55 85 30 group mean (%) 55 81.7 26.7 median (%) 52.5 82.5 30 pre-test and post-test scores (percentages) for medical students participating in a longitudinal ultrasound curriculum, with percentage improvement across curriculum. mean and median scores for preand post-testing included, as well as cumulative group improvement. table 5: example of ultrasound assessment grading tool key: 1 very poor image acquisition does not know this view at all. 2 limited ability struggles with probe placement, image orientation journal of regional medical campuses, vol. 1, issue 2 original report 3 moderate ability to obtain image general knowledge of image location/ where to obtain image on sp and orientation, image is poor quality 4 good image acquisition able to obtain image, may needs to make depth or frequency/ gain adjustments, minor adjustments 5 excellent ability obtains image and is able to optimize image table 6: skills assessment scores student procedure cardiac thoracic fast aorta image identification (%) 1 4.5 3.8 5 4.8 4.8 94.4 2 5 3.8 4 3.5 4 77.8 3 5 3.8 4.5 3.8 4 83.3 4 4 3.7 4 3.8 4 61.1 5 5 4 3.5 4.5 4 66.7 6 5 4 4.5 4.3 3.8 50 subjective assessment by ultrasound faculty of student's ability to perform ultrasound examinations, modified likert scale (scale: 1 = “very poor image acquisition,” 2 = “limited ability,” 3 = “moderate ability to obtain image,” 4 = “good image acquisition,” 5 = “excellent ability”), and assessment of ability to correctly identify ultrasound images (percentage correct). table 7: student perspectives on ultrasound curriculum student' us'training' has'a'role' in'medical' student' education what'years' should'us' be'taught' in'medical' school pre post pre post pre post pre post pre post pre post pre post post'course post'course 1 5 5 5 5 4 5 4 5 4 4 4 5 5 4 5 ms3'4 2 5 5 5 5 4 5 5 5 3 3 2 5 5 3 5 ms3 3 5 4 4 5 4 2 5 5 5 4 5 3 4 4 4 ms1'4 4 5 4 4 4 3 4 5 5 4 4 4 4 4 4 5 ms3'4 5 5 5 5 5 4 5 5 5 4 5 4 5 4 5 5 ms3 6 5 5 5 5 5 4 5 5 5 4 5 5 5 4 5 ms3'4 group'mean 5 4.7 4.7 4.8 4 4 4.8 5 4.2 4 4 4.5 4.5 4 4.8 median 5 5 5 5 4 5 5 5 4 4 4 5 4.5 4 5 table97:9pre'course9and9post'course9survey9assessing9ms39students9perspectives9on9ultrasound9training.9scale91'59in9value:91=not9at9all,9 2=little/limited,93=neutral,94=somewhat/yes9but9not9critical,95=absolutely.9us=ultrasound us'training' valuable'in' 3rd'year us'training' helps' anatomy' knowledge us'training' helps' pathology' knowledge us'training' helps' knowledge' of'diagnostic' imaging' us'training' helps' improve' physical' exam'skills us'training' helps' correlate' basic' science'with' us'training' helps' improve' patient' safety journal of regional medical campuses, vol. 1, issue 2 original report attachment 1: pre-course survey q1: do you think that ultrasound training will be useful as you rotate through 3rd year of medical school? q2: do you think that ultrasound training will improve your understanding of anatomy? q3: do you think that ultrasound training will improve your knowledge of pathology? q4: do you think that ultrasound training will improve your physical exam skills? q5: do you think that ultrasound training will improve your medical decision-making? q6: to what extent do you anticipate that ultrasound education will help correlate clinical knowledge with basic sciences? q7: do you believe that learning ultrasound in the 3rd year of medical school will improve your overall knowledge of different diagnostic imaging modalities? q8: do you believe that learning ultrasound in the 3rd year of medical school will help improve patient safety? q9: do you believe that ultrasound will be useful in the following specialties? a: surgery or surgical specialties b: internal medicine or medicine subspecialties c: pediatrics d: family medicine e: obstetrics and gynecology f: emergency medicine and critical care g: psychiatry h: neurology q10: please rate your experience with ultrasound (# of ultrasounds performed) q11: what field of medicine do you think that you will go into? q12: please describe any previous or concurrent instruction you have had with ultrasound, either formal or informal. attachment 2: post-course survey q1: would ultrasound training be valuable as part of your 3rd year medical school education (ms3)? q2: do you think that ultrasound training as a ms3 helps your understanding of anatomy? q3: do you think that ultrasound training as a ms3 helps your understanding of pathology? q4: do you think that ultrasound training as a ms3 helps improve your understanding of diagnostic imaging choices? q5: do you think that ultrasound training as a ms3 helps improve your physical exam skills? q6: to what extend do you feel that learning ultrasound helps correlate clinical education with basic science knowledge? q7: do you feel that using ultrasound helps improve patient safety? q8: do you feel that ultrasound education has a role in medical school education? q9: please rate the usefulness of ultrasound in the following specialties: a: surgery or surgical specialties b: internal medicine or medicine subspecialties c: pediatrics d: family medicine e: obstetrics and gynecology f: emergency medicine and critical care g: psychiatry h: neurology q10: would you take an ultrasound course as a 4th year elective? q11: what years do you think that ultrasound should be taught in medical school? q12: what specialty are you planning to pursue? q13: any other comments? q14: please describe previous or concurrent instruction you have had with ultrasound, either formal or informal. q15: please rate your prior experience with ultrasound. (number of ultrasound perform microsoft word journey across state lines article.docx published by university of minnesota libraries publishing journey across state lines: transition to a regional campus amy b. smith, phd1,2, kira k. zwygart, md2, kelli herman, mba1,2 and michael j. larock md1,2 journal of regional medical campuses, vol. 1, issue 2 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc amy b. smith, phd, associate professor, senior education consultant, select clerkship director, university of south florida morsani college of medicine lehigh valley campus, lehigh valley health network, allentown, pa kira k. zwygart, md, professor of family medicine, associate dean for student affairs, university of south florida (usf) morsani college of medicine, tampa, fl. kelli herman, mba, senior specialist, student affairs, university of south florida morsani college of medicine lehigh valley campus, lehigh valley health network, allentown, pa michael j. larock, md, assistant dean of students affairs, university of south florida morsani college of medicine lehigh valley campus, lehigh valley health network, allentown, pa all work in jrmc is licensed under cc by-nc volume 1, issue 2 (2018) journal of regional medical campuses “how we did it” journey across state lines: transition to a regional campus amy b. smith, phd1,2, kira k. zwygart, md2, kelli herman, mba1,2 and michael j. larock md1,2 1. lehigh valley health network, allentown, pa, 2. university of south florida morsani college of medicine, tampa, fl. abstract the university of south florida morsani college of medicine’s select program was developed to equip medical students with healthcare leadership skills as they progress through the medical curriculum by providing them with leadership and management training and a curriculum based on emotional intelligence. medical students spend their pre-clerkship years in tampa, florida and then spend their clinical years at the lehigh valley health network regional campus in allentown, pennsylvania. the authors describe how faculty at the regional campus are involved with student and academic affairs on the main campus, and the process of helping students transition from the pre-clinical to clinical years and from florida to pennsylvania. key words: medical students, transitions, regional campus, usfmcom select conflict of interest: none background in 2011, the university of south florida morsani college of medicine (usfmcom) in tampa, florida, in partnership with the lehigh valley health network (lvhn) in allentown, pa, launched a new medical student curriculum titled select, an acronym for scholarly excellence, leadership experiences and collaborative training. select was developed by healthcare leaders from the university of south florida morsani college of medicine and the lehigh valley health network. leadership at both institutions agreed that both current and future healthcare landscapes required specially trained physicians who would thrive and serve as agents of change within a highly fluid, dynamic healthcare system. select was designed to equip medical students with healthcare leadership skills as they progress through the medical curriculum by providing them with leadership and management training, and curriculum based on emotional intelligence.1,2 students in the select program, in addition to their required medical coursework, take a professional development course that spans all 4 years of medical school and is led by course content experts and faculty coaches.3 foundational select courses focus on the domains of leadership, health systems and values-based patient-centered care. the program also includes a coaching component whereby students are assigned two faculty coaches, one each at the tampa and lv campuses. the students spend pre-clerkship years one and two in tampa and clerkship years three and four in allentown. these professional development coaches work with the students throughout their medical school experience. the regional campus provides a comparable experience, including a student affairs office and student advisors to help with transitioning from second to third year and assist with the logistics of moving north to south to a regional campus that is 1,100 miles away. at the program’s inception, the planning team was aware of the unique situation and explicitly fostered a culture of relationship-building between campuses to establish a smooth transition for students and faculty. the curriculum team works closely across campuses to provide a longitudinal select curriculum that spans four years.4 the first select class matriculated in 2011 with a small cohort of 17 students, and the first transition occurred in 2013. the program infrastructure and faculty training occurred two years prior to the first class. here, we describe the transition of the students from the preclinical years in florida on the usfmcom tampa campus to the clinical years in pennsylvania on the lehigh valley campus. we will describe the communication and planning journal of regional medical campuses, vol. 1, issue 2 “how we did it” with faculty, staff and students on both campuses during the pre-launch, launch and landing phases of the transition. pre-launch we begin addressing the transition with potential students when they are applying to medical school. applicants interview in either tampa or allentown. one component of the interview day is meeting leadership from the distant campus via videoconferencing. applicants also hear from current students and faculty about steps that will be taken to ease the transition. in addition, the admissions office holds a second look event. second look is an opportunity for accepted applicants to meet with current students and talk about living in tampa and allentown. once students start school, they meet faculty, staff and leadership from both campuses. during their orientation to second year (prologue 2), the assistant dean for student affairs on the lv campus flies to tampa and hosts a lunch session to discuss what to expect in regard to moving. having the opportunity to reinforce the relationship in person helps students feel more comfortable with the expected change. launch approximately six months prior to the start of third year, student affairs at both campuses coordinate a mandatory informational class meeting. this meeting is held via videoconference from the regional campus to select students at the main campus in tampa and focuses on the transitioning process. the deans, director, student affairs specialist and invited guests at the regional campus participate in providing pertinent information to the students. prior to the meeting, student affairs at the regional campus collaborates with colleagues, vendors and current students to coordinate services and compile accurate resource documents for transitioning students. local realtors are contacted and a list of preferred realtors is developed to provide students with free rental or purchasing option assistance. health insurance representatives at the regional campus provide an informational sheet for distribution and attend the class meeting to explain insurance products and coverage. student assistance colleagues also attend the meeting to answer questions and outline the free counseling, coaching and consultation services available to students. a panel of three to four current students at the regional campus share experiences and offer transitioning tips. students are encouraged to contact any of the class meeting participants or presenters with questions or requests for more information. several informational documents are created and emailed to students after the class meeting for reference: • transitions resources: information and website links provided in this document include: o preferred realtors o moving, housing and travel o employment o education (local school districts) o daycares and preschools o health and wellness o fitness centers o living in the lehigh valley • housing resources o apartment complex information including maps, contact information, proximity to regional campus hospitals and pricing and discounts if available • health insurance options • student assistance brochure as the time of the move approaches, the assistant dean for student affairs (lv campus) meets with the associate dean for student affairs (tampa campus) to review the list of students moving and exchange information about students who may require extra assistance when they arrive. this may include checking usmle step 1 study progress, assisting with needs for health services and monitoring for academic issues. during the period of step 1 study, new students with such needs may be identified. communication also occurs in regard to testing accommodations. the tampa testing administrator communicates with clerkship directors about those students in preparation for their arrival. landing once students physically arrive at the lv campus, they attend a comprehensive introduction to clerkship course, which incorporates orientation to the lehigh valley. the assistant dean for student affairs (lv campus) re-engages with the class and presents a session on professionalism. the students are also assigned and required to meet with a new campus career advisor. we utilize a secure portal and the advisors have access to meetings and conversations held prior to arrival with the students’ previous tampa campus career advisors. the lv campus students established a regional campus student council, and new students are introduced to the council’s structure and can run for a position. the ms4 students mentor the elected ms3 students. in addition, there is a pre-clerkship position in the council whose duties include assisting students with the campus transition. an early offcampus student-only social wellness event for regional campus students in both classes is planned before starting clinical course work. journal of regional medical campuses, vol. 1, issue 2 “how we did it” the students continue their select specific curriculum on thursday afternoons with lv campus coaches who are physically present, while the tampa campus coaches videoconference into the sessions. the opportunity to continue working with both coaches in different ways helps allay some of the trepidations of transition. the student affairs office at the lv campus continues to work in close coordination with the tampa campus, but not all functions are duplicated. financial aid resources, registrar functions and centralized academic support are provided through the tampa campus. this provides students consistency through the transition. lessons learned since our inaugural class, class size has averaged 50 students per year. as we developed the curriculum, we were cognizant that all sessions and events would need to be adjustable and scalable to meet the larger class size. coaches and students expressed concerns about the transition, such as where students would live, when and where they would study and take step 1 and what social activities were available in allentown. the students attend mandatory meetings to discuss the transition, and we learned that it is as important to meet and share the same information that the students receive with the coaches. input from students who experienced the transition has been an integral part of modifying the transition process. student concerns include the cost of the transition, time spent arranging housing once they arrive in allentown, establishing bank accounts and acquiring driver licenses. we found that the key component to process improvement is to keep a running tally of concerns and provide specific answers to help allay any trepidation students may have about the transition. as with all successful transitions, communication is essential. the student affairs deans have regular meetings and impromptu discussions as student issues arise. there is a biweekly videoconference meeting between the campuses with the key stakeholders in student affairs that allows a forum for ongoing discussion. collaboration and coordinated planning are key features in our process that make the transition to our regional campus successful. references 1. fostering emotional intelligence in medical training: the select program. virtual mentor. 2013;15(6):509-513. doi:10.1001/virtualmentor.2013.15.6.medu1-1306. 2. roscoe l, english a, monroe a. scholarly excellence, leadership experiences, and collaborative training: qualitative results from a new curricular initiative. journal of contemporary medical education. 2014;2(3):163. doi:10.5455/jcme.20140928035359. 3. zwygart kk, english a, smith ab. developing faculty members to serve as professional development coaches for students. the society of teachers of family medicine annual spring conference. may 2013. 4. smith ab, larock mj, zwygart kk. it is all about relationships—teaching from a distance. medical science educator. 2016;26(2):195-198. doi:10.1007/s40670-016-0231-1. microsoft word in the eastern fields of eden article.docx published by university of minnesota libraries publishing in the eastern fields of eden austin r. clark, j. tyler smith, cody s. tucker, eli w. travis, william j. crump, md. doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 1, issue 5 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc austin r. clark, second year medical student, trover rural track student, university of louisville school of medicine j. tyler smith, third year medical student, trover rural track student, university of louisville school of medicine cody s. tucker, second year medical student, trover rural track student, university of louisville school of medicine eli w. travis, college rural scholar and a pre-medical student at university of kentucky william j. crump, md., associate dean, university of louisville school of medicine trover campus at baptist health madisonville. corresponding author: william j. crump, md associate dean university of louisville school of medicine trover campus at baptist health madisonville; 200 clinic drive, 3rd north, madisonville, ky 42071; v: 270.824.3515; f: 270.824.3560; e: bill.crump@bhsi.com all work in jrmc is licensed under cc by-nc volume 1, issue 5 (2019) journal of regional medical campuses original reports in the eastern fields of eden austin r. clark, j. tyler smith, cody s. tucker, eli w. travis, william j. crump, md. abstract july is an interesting time at our small rural clinical campus. in addition to the bright faces of our new m-3 students just settling into their routine while awaiting their usmle step one scores, we host a group of our rising m-2 students just before they return to louisville for their second grueling year of basic science education. they spend three weeks shadowing their future faculty and working with our college rural scholars as they solve a clinical case in small groups. also these two groups conduct free school and sports physicals at local health departments in towns of 600. the rising m-2s perform the physical exams under the watchful eyes of certified health department nurses and supervised by myself or another family medicine faculty. the college rural scholars assist during the physical exams and then take each schoolchild for individual anticipatory guidance. the students use a script they have developed as a group and provide the counselling in a room that includes hands-on props they have collected to keep the kids engaged. both college and medical student groups leave us with wistful looks and eager anticipation of returning next summer. this july an interesting opportunity arose. one of our rising m-2s had grown up in close proximity to a rural amish enclave and visited there regularly as the amish men shod his grandfather’s horses. a certain bond had developed, demonstrated perhaps most beautifully and touchingly by an amish horse-drawn wagon bearing his grandfather to his final resting place after his funeral (figure 1). this student contacted me suggesting that we provide some kind of health screening for one extended family, with the primary contact being the pastor of the congregation church, a man in his thirties. we had just begun a cardiovascular screening project in the county that hosts our campus, and we set out to do something similar for our student’s friends who live 90 miles away in an agricultural area. on a very warm, clear summer morning, i arrived about 15 minutes late because of call responsibilities and my inability to believe that the first sign i saw for squash and tomatoes could really be my turn. my students were already busy inside. as i carefully pulled my car out of the way among buggies undergoing repair, i noticed a very large van with a conventionally dressed woman loading vegetables just bought from the amish vegetable stand. as i approached the house and noticed the traditional garb of the men and women, they all stopped and looked up with the quizzical gaze i’ve seen among the deer with which i share my backyard. once inside, as i watched our students work i felt a sense of peace within the strange but welcoming atmosphere. as a reflective exercise, i asked each student to put their impressions on paper separately, and what follows is an interesting summary of their perspectives. as i had hoped, each viewed the same experience through the lens of their previous life experience and their level of medical training, resulting in a rich mosaic. the closing piece by the student closest to the amish community provides a perfect biblically-inspired summary of what we all felt as we returned to our all-too-modern lives. -bill crump, m.d., associate dean, trover campus i pulled up to a large, white house that was bustling with women in dresses that covered their ankles and bonnets that covered their hair, men in long sleeves and suspenders, and children who were dressed exactly like their older counterparts. to my relief, i spotted a medical student, dressed differently from the bustling crowd. next to him was a young amish man dressed in a blue, long sleeve button up shirt with black pants, suspenders, and straw hat, smoking a corn cob pipe. i didn’t realize it at the time, but i was looking at the two critical components in making this health screening possible. a relationship between the young amish man and the medical student bridged the gap between our cultures and allowed us, as strangers, to enter their home and collect private medical information. the day began with our liaison gathering his amish family in the large living room of their house. men and women ranging from their late teens to older adults, mostly married couples, were present. these were the people that we were to screen. the screening included a finger stick that would yield blood doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 5 original reports glucose and total cholesterol levels, a blood pressure reading, and a discussion of past and present medical issues. we began the screening in the same living room that everyone had gathered in earlier. the room had two large windows, sturdy wood floors, and i took notice of an oil lamp sitting on a table in the corner. sweat began to collect on my foreheadit was a hot day and little relief from the heat came when we walked into the house. i was unsure of how many people lived in the home, but i had been told that several people traveled to the house solely for the screening. as the family had requested, we took one couple into the room at a time to be screened, with the exception of two women whose husbands were too busy to come that day. these women participated in the screening by themselves. with each couple or individual that we screened, my expectations were proven to be more inaccurate. i anticipated this extended amish family to be slightly suspicious, and i predicted them to be outwardly critical of my modern way of life. instead, i found nothing but thankfulness and welcome from our hosts. the men were somewhat stoic but always verbalized their gratefulness for what we were doing. the women always gave warm smiles and even gave a small laugh each time a certain medical student reused his joke comparing collecting blood from a stuck finger to milking a cow. one of the women even poked fun at us, asking, “how are you all doing without ac?” there was no lack of small talk. i will confess that we spoke more of crops, weather, and farming than i would have with people of my culture, but it was no less pleasant than conversation i have with strangers in the supermarket or at a restaurant in my hometown. they even gifted each of us with vegetables on our way out as a way of thanking us. my perception of the amish community as an isolated, unhospitable people was completely changed by my short morning spent there. the couples love one another, the parents love their children, and they thoroughly enjoy fellowship, just like the people in the rest of the state of kentucky do. while our lifestyles are vastly different, it turns out that when it comes down to the important things, the amish and the general population differ in the things we have but not so much in the things we value. -eli travis, college rural scholar a small sign for squash and tomatoes was the only indication of where to go. the gravel driveway was long and passed in front of the man’s large white house next to a larger red barn. if i didn’t know amish people lived there, i’d think it was just another house owned by an average joe neighbor who had a good paying job. in the yard, women and men were dressed in attire i would have expected for amish people only based on my knowledge from movies and the internet as i had never really met or seen any amish people. the man of the house greeted us and welcomed us to his home. he seemed very nice and excited to have us there. his excitement surprised me because i was unsure whether the amish approved of modern medicine or not. we set up our table and equipment in one of the front rooms of the house. it seemed like a room that would be a living room with a big couch and tv in most modern homes, but this room had nothing but wooden tables, chairs, no power outlets, and only oil lamps indicating the source of light that would be used at nighttime. i thought of how interesting it would be to see this house lit up at night using only oil lamps. as we interacted with these people, i learned that most of them had actually seen a physician at least once or twice. however, with this limited exposure to modern medicine, i was impressed at some of their medical knowledge. one woman mentioned being tired and was worried that it could be her thyroid. additionally, they didn’t seem to be apprehensive or nervous about us evaluating them. i know that many people in the city might be anxious about getting their finger stuck and strangers touching them, but these people met this uncertainty head on. as many of the women said, getting their finger stuck wasn’t as bad as some of the times they had stuck themselves with sewing needles. it seemed to me that if one of them had needed a surgery or some invasive medical procedure, then they would approach it positively and would tolerate any difficulties with the procedure well. from my recollection of the numbers, almost everyone had normal results. from health interviews that our lead student conducted, we learned that everyone was very active due to their daily chores/work and ate vegetables frequently. some reported eating fried foods every so often and even confessed that when they go into town they sometimes get fast food. due to their work and diet, i expected their health numbers to be good, but learning about the town trips and eating fast food was a surprise to me. it made me laugh internally and think; well at least some fast food every once in a while might just be alright. -tyler smith, trover campus m-3 i wasn’t surprised that the first amish i’d met were also some of the warmest and welcoming people i’ve ever encountered. i was only marginally surprised to see children with a container of fruit loops and to hear the adults confess to eating fast food. it had never really occurred to me that amish ate fast food. their concerns about their blood sugar and cholesterol were born from the same place as my own! fast food almost certainly makes up a lesser percentage of their diet than mine. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 5 original reports i did have one significant dislocation of expectations during my time in the small amish homestead, though. they were shockingly health literate. they seemed much more educated on the state of their current health situations than many patients i’ve encountered in the city. as i listened, i began to understand that they weren’t averse to modern medicine at all as i had expected. some had problems like high blood pressure and heart burn that were managed with lisinopril and omeprazole. as their concerns would often reach outside of our limited understanding, our routine was to suggest follow up with a physician. this was when i was struck by a great similarity between the amish and wider society. the barrier to care for them wasn’t cultural at all, as i had previously ignorantly imagined. access to care was restricted by the same barriers that affect other minority populations: transportation, financial concerns, and limited availability of providers. i thought of doctors and nurses in the city that i’ve overheard talking about patients with unmanaged disease states who only come in once their situation has become dire. the comments are made without consideration of a lifestyle and circumstance vastly different from their own. i thought of the need for primary care physicians who are willing to reach out to these varied and sequestered populations and embrace them as part of their practice. before leaving we were offered gifts of fresh vegetables as a thank you for performing the screenings. we of course were pleased to accept these, though i earnestly questioned the value of the service we had provided. had we actually helped them at all? as i drove away, i thought about a map of louisville created by the department for health equity that demonstrated the health disparities in certain parts of the city compared to others. the map is designed in layers that each show a different health measure (social and clinical) stratified across the city. when i think about the overall health of the state i try to think about it in this model. there are different map layers for different groups in need. and there are different map layers for the unique barriers that exist for each. where does the need for care exist and what affects a population’s access to care? is the healthcare model practiced in these areas capable of accommodating and serving the populations in need? i came away with more questions than answers, but also with a new level of understanding and appreciation for a neighbor’s culture, as well as a new layer for the map. -cody tucker, trover campus m-2 in the book of genesis, a story is told of how adam and eve lived in a state of paradise where all was perfect; hunger tethered, worries meaningless, and disease non-existent. amish culture is not something we would necessarily call “paradise.” hard work under a relentless sun, trading of the mercedes’ for several black buggies, and hot days without airconditioning are potentially the stuff of nightmares. yet, my experience with my amish friends reminded me that “paradise” just may have more to do with our state of mind and that we modern-folk just may have a thing or two to learn from the simple life. i have heard it said that medicine is a complex science with a multitude of factors contributing to health. that heuristic applied in our case as well. the highest blood pressure reading was 145/81, with most readings falling at or below the normal. not surprisingly, the highest total cholesterol reading was 210 mg/dl, and this could actually have been considered low risk if further testing had shown the high hdl expected of really active folk. what is incredible about these readings is that the participants take very little medication and rarely see a physician or other healthcare provider. during our conversations with them, most were reluctant to take even aspirin for everyday aches and pains, so daily medications that control blood pressure or cholesterol levels would take some time with which to become accustomed for many. if anything, our amish friends demonstrate the strength of the association of lifestyle with well-being. as i reflect on my experiences of that day, i find the noise of modernity falling away like a morning mist and feel an abiding sense of amity amid the clicking of horse hooves and the aroma of freshly harvested vegetables. to say that peace does not contribute to health, i think, is a fool’s claim. thus, maybe we modern folk do have something to learn from simplicity after all, and maybe, if we think deeply, we will be able to recall that long-forgotten memory of a healthy and natural eden. -austin clark, trover campus m-2 acknowledgement we wish to thank our amish friends for inviting us into their home and providing us with this special opportunity and the superb tomatoes. microsoft word jrmc_4405.docx keegan mccabe, medical student; university of minnesota medical school, duluth campus 1035 university drive duluth, mn 55812 ray christensen, md, associate professor; university of minnesota medical school, duluth campus 1035 university drive duluth, mn 55812 catherine a. mccarty, phd, mph, msb, hec-c; university of minnesota medical school duluth campus 1035 university drive duluth, mn 55812 corresponding author: catherine a. mccarty, phd, mph, msb, hec-c; university of minnesota medical school duluth campus 1035 university drive duluth, mn 55812 phone: 218-726-6135 all work in jrmc is licensed under cc by-nc volume 6, issue 1 (2023) journal of regional medical campuses original reports clinical ethics concerns of rural healthcare providers keegan mccabe, bs; ray christensen, md; catherine a. mccarty, phd, mph, hec-c abstract purpose: this project aimed to identify ethical concerns in rural hospitals and elicit ideas for establishing clinical ethics services to meet needs. methods: two-hundred-fifty-six rural physicians were sent an email requesting participation in an electronic survey. data were managed in microsoft excel. findings: seventy-four (29%) physicians responded; 59% have an ethics committee available to them. of these ethics committees, 43% are available 24/7. themes that emerged from the most recent ethical dilemmas were: end of life care (34.5%), vulnerable adults (21.8%), patient autonomy versus best interest (10.9%), limited resources rurally (9.1%), vulnerable children (7.3%), patient capacity (7.3%), genetic abnormalities of fetus/nonviability (7.3%), patient/family discord (7.3%), code status (5.5%), decision makers (5.5%), knowledge about family members/confidentiality (3.6%), and 14.5% unique responses, including professional ethics, transgender issues, cultural differences, double effect, a non-compliant patient, a racist patient, illegal substance use, and a personal moral dilemma in the delivery of care that went against the personal beliefs of the provider. online group-learning was the preferred training method for ethics education. thirty-eight percent would likely use a tele-ethics service if available. discussion: providers in rural health systems face unique and complex ethical dilemmas and would likely utilize remote support for complex bioethical situations. conclusions: given these findings, the next step is to develop and pilot an ethics service that would include the three traditional roles for a clinical ethics service: policy development, education, and clinical ethics consultation services to address the identified need for expanded clinical ethics services. approximately 20% of the us population lives in nonmetropolitan, rural areas; rural residents are often described as “older, poorer, and sicker,” and rural hospitals have fewer services than metropolitan hospitals.1 in addition to higher rates of many common chronic health conditions, rural residents have higher rates of morbidity and mortality associated with rural occupations, including agriculture, forestry, fishing, and hunting.2 like their rural patients, rural providers also often lack access to services to support their practices, such as clinical ethics services to assist when challenging ethical dilemmas arise in their clinical practice. there have been a number of papers published about the doi: https://doi.org/10.24926/jrmc.v6i1.4405 journal of regional medical campuses, vol. 6, issue 1 original reports especially sensitive nature of mental health services, ethics, confidentiality, and dual relationships that are more common in rural settings.3-10 other uniquely rural ethical issues that have been identified previously include increased problems of confidentiality, resource allocation/access, and scope of practice.11-14 the results of surveys published in 2000 and 2010 indicated that clinical ethics services are available at less than 40% of rural hospitals.15-16 a rural healthcare ethics agenda was proposed in 2006; it included developing an understanding of rural healthcare ethics and proposing models for delivering ethics services in rural hospitals.17 the covid-19 crisis has brought renewed interest in addressing ethics needs in rural hospitals.18 there are no recent publications on the availability/accessibility of clinical ethics resources among rural hospitals. the goal of the current project is to identify ethics concerns of providers in rural minnesota hospitals and to elicit ideas for establishing services to meet these needs. once these unique concerns are identified, they will be used to determine how additional ethics training, consultation, or remote ethics services could be developed to support providers in rural locations. methods the project was reviewed by the irb at the university of minnesota and determined not to be human subjects research. emails were sent to 256 physicians across minnesota and western wisconsin in june 2019, requesting their participation in a survey created in surveymonkey.com, seeking their responses to questions about clinical ethical dilemmas and access to healthcare ethics services. these physicians are preceptors in the university of minnesota summer in medicine (sim) program, rural medical scholars program (rmsp), and/or rural physician associate program (rpap). these programs are experiential rural clinical opportunities for first year (sim), first/second year (rmsp), and third year (rpap) medical students at the university of minnesota, and many of the preceptors are graduates of the rpap program.19 one follow-up email reminder was sent two weeks after the initial email to encourage participation. the survey questions can be found in table 1; questions three through six were open-ended. responses from providers who practiced exclusively in urban areas were an exclusion criterion. the survey responses were exported from survey monkey into a microsoft excel file where coding of the qualitative was completed. rural was defined as the hospital being located in a city of 50,000 or fewer people. qualitative analyses were performed by grouping responses into similar themes. all data were stored in password-protected files. the surveys were completed anonymously, only clinic/hospital name was collected as a potential identifier. the response categories were not mutually exclusive. the following response categories were combined into one ‘likely to use in some capacity’ category: utilizing service in rare/unique situations, likely to use service, and very likely to use the service. the ‘unlikely’ and ‘very unlikely’ responses were combined into an ‘unlikely’ category. physician age, preferred training method, and the last ethical dilemma the physicians had experienced were analyzed by individual physician response, regardless of how many health care systems they worked for; e.g., denominators reflect the number of physicians, not the number of clinics/hospitals. inductive thematic analysis was used to evaluate the most recent clinical ethics dilemma reported and to group into common themes. this analytic approach does not presume themes, but instead allows themes to emerge from the data. responses were independently coded by two of the authors, and differences were resolved by consensus between the two coders. responses could be categorized in more than one theme, i.e., were not mutually exclusive. results demographics: seventy-four of the 256 physicians responded to the survey (29% response rate). seventy-one unique rural hospitals/clinics around minnesota/wisconsin were represented. the average number of years in practice was 15.6 years, ranging from two to 47 years, median 13.5 years. availability of clinical ethics services: doi: https://doi.org/10.24926/jrmc.v6i1.4405 journal of regional medical campuses, vol. 6, issue 1 original reports fifty-three (59%) of the health systems assessed had an ethics committee. thirty-five (39%) physicians reported that an ethics committee was not available to them, and two (2%) were unsure. of the 53 systems with an ethics committee, 23 (43%) have 24/7 access. sixteen (30%) of these systems do not have access to their ethics committee 24/7, six (11%) reported being unsure, and eight (15%) reported ad hoc availability. recent clinical ethics dilemmas: fifty-five of the respondents included information about the most recent ethical dilemma they had encountered. themes that emerged from the most recent ethical dilemmas were: end of life care (34.5%), vulnerable adults (21.8%), patient autonomy versus best interest (10.9%), limited resources rurally (9.1%), vulnerable children (7.3%), patient capacity (7.3%), genetic abnormalities of fetus/nonviability (7.3%), patient/family discord (7.3%), code status (5.5%), decision makers (5.5%), knowledge about family members/confidentiality (3.6%), and 14.5% unique responses, including professional ethics, transgender issues, cultural differences, double effect, a noncompliant patient, a racist patient, illegal substance use and a personal moral dilemma in the delivery of care that went against the personal beliefs of the provider. illustrative comments for all themes can be found in table 2. end of life: “i had a patient who was still coherent, but lost his ability to speak or swallow. he had lung cancer and recurrent pneumonia. he was hospitalized on bipap and full code. he tried to indicate that he didn't want further intervention, but it was very difficult to communicate with him. his family was torn with what to do. ultimately, he improved enough to get off the bipap and we were able to communicate enough to change his code status, but we were nearly in an ethical dilemma as to whether or not to continue futile care.” “the last real ethical dilemma was a patient with mental health issues that had cardiac arrest at home and was found down and brought to the er. the patient did not have an advanced directive and no known next of kin. we did revive her, but with the knowledge that her outcome likely would be poor”. “somali end of life transition. patient brain dead, fully vented, multisystem organ failure and 3 pressors to sustain pressure, continuous dialysis and family would not consider comfort care. additional futile services in place for 5 days.” vulnerable adult: “placing a vulnerable adult report and forcing staff at snf to take over medication administration.” “a parent of an adult handicapped male who was encouraged to consider "not treating" his pneumonia because it was stressful for the family when he got sick. parent transferred hospitals due to fear of euthanasia.” patient autonomy versus best interest: “one that i still battle is elderly with cognitive deficits. they live alone and have no one else and i start to worry about memory for driving and living, but they don’t want to move.” “a patient who had three prior c-sections (some emergent) wanted to have a home birth locally, and we had to be prepared as a medical community to encourage her toward safe delivery (not at home) (at a bigger hospital).” limited resources rurally: “the last clinical ethical situation i remember is a case where the family wanted the patient sent to an urban hospital for further evaluation while the patient just wanted to stay in our rural critical access hospital. the family won out and the patient ended up going to the urban center where the patient died. i'm not sure if there are clinical ethics services which would have been of help.” “pt needing services, declines due to distance and cost of getting services”. “how to deal with a problem patient in a facility that is sole community provider”. vulnerable child: “i had a pediatric patient who was a victim of munchausen by proxy. later his family asked to have this diagnosis stricken from his record because they believe it to be false. they want to blame the situation on mother's diagnosis of post-partum depression, but it was no question a case of munchausen. i do not feel it is right to take that off his record. the outcome is still undecided.” doi: https://doi.org/10.24926/jrmc.v6i1.4405 journal of regional medical campuses, vol. 6, issue 1 original reports genetic abnormality of fetus and non-viability: “patient requested an induction of 24 wk fetus that had fatal fetal malformations, in order to potentially have time with him before dying in utero.” possibility for tele-ethics to meet the needs of rural providers responses were received from providers at 83 systems for the question of whether they would use a tele-ethics service if one were available. seventeen (21%) reported they would use this service on rare or unique cases, ten (12%) reported they are very likely to utilize this service, seven (8%) reported they are likely to use this service, twelve (15%) said they were unsure, 28 (34%) reported being unlikely to use the service, four (5%) are very unlikely to use the service, and five (6%) described their usage as dependent upon the service itself. the answers deemed as ‘service dependent’ included a variety of caveats for using a tele-ethics service: not cost prohibitive for the organization, training of the bioethicist, ease of access, appropriate training in its usage, and supported if the hospital system did not prohibit the use of an outside resource. of the 16 responses where a reason was provided for why they would not use a service, 14 (88%) stated they already had adequate resources. thirty-four (41%) respondents reported they would likely use this service in some capacity. thirty-two (39%) stated they were unlikely to use this service. physicians in hospital systems without an ethics committee or without 24/7 access are more likely to utilize a telemedicine ethics consultation service. thirty-seven of the respondents who had an ethics committee available to them stated that they were likely or unlikely to utilize a tele-ethics service. physicians from 22 (60.5%) systems with an ethics committee reported they were unlikely to utilize this service. fifteen (40.5%) physicians with access to an ethics committee reported they were likely to use this service. nineteen of the 29 respondents without an ethics committee (65.5%) stated they were likely to use this service. physicians at 18 systems reported having 24/7 access and being likely or unlikely to use the service; 15 of them (83%) were unlikely to use a tele-ethics service. of the 15 physicians who had ethics service available, but lacked 24/7 access to their ethics committees, 11 (73%) stated they were likely to use a tele-ethics service. providers at 12 health systems reported being unsure if they had ethics committees available to them, and five reported being unaware of their availability. at the 44 systems without 24/7 access, 30 physicians (68%). discussion slightly more than half of physicians in this rural minnesota sample reported having an ethics committee available to them, but less than half of those services were available 24/7. this is similar to what was reported previously in 2000 and 2010.16-17 there is a potential market for using a tele-ethics consult service for: 1) systems without an ethics committee, 2) systems with an ethics committee, but lacking 24/7 access, and 3) a specialist service for systems facing complex situations requiring a trained academic bioethicist. tele-ethics services have been shown previously to be successful, especially through video platforms.20 the service could include the three traditional roles for a clinical ethics service: policy development, education, and clinical ethics consultation services. the themes of recent ethical dilemmas encountered by the rural providers in the present study were similar to what has been reported in other studies of ethical dilemmas encountered by rural providers,3-14 many of which are also seen in urban settings. unique to the rural setting is the scarcity of resources for patients. the reported fear of euthanasia if transferred to another hospital was unexpected and is a potential area for further research. minnesota is not a state that currently has legislation to allow medical aid in dying. conclusions we identified a need for clinical ethics support in rural minnesota. the next step will be to develop and pilot an ethics service to support our rural clinical teaching partners. a tele-ethics service is the most practical. doi: https://doi.org/10.24926/jrmc.v6i1.4405 journal of regional medical campuses, vol. 6, issue 1 original reports issues of privacy and confidentiality have been worked out for emergency access provisions for covid-19. case studies involving ethical situations with resolutions delivered online by a trained bioethicist could be an appropriate educational method to meet the needs of rural providers. project echo provides a model for this case-based education.21 offering continuing medical education credit could enhance interest and attendance at these sessions. there is also the possibility of enlisting experienced rural providers to teach medical students on rural clinical rotations, a model that has been shown to be effective in rural australia.22 in conclusion, these data provide compelling evidence to take the next step to meet the identified need for expanded clinical ethics services in rural minnesota. references 1. national healthcare quality and disparities report chartbook on rural health care. rockville, md: agency for healthcare research and quality; october 2017. ahrq pub. no. 17(18)-0001-2-ef. 2. weichelt b, gorucu s. supplemental surveillance: a review of 2015 and 2016 agricultural injury data from news reports on aginjurynews.org. inj prev 2019;25:228-235. 3. roberts lw, battaglia j, epstein rs. frontier ethics: mental health care needs and ethical dilemmas in rural communities. psychiatr serv 1999;50:497-503. 4. helbock cm. the practice of psychology in rural communities: potential ethical dilemmas. ethics behav 2003;13:367-384. 5. scopelliti j, judd f, grigg m, hodgins g, fraser c, hulbert c, endacott r, et al. dual relationships in mental health practice: issues for clinicians in rural settings. aust nz j psychiatry 2004;38:953-959. 6. allott k, lloyd s. the provision of neuropsychological services in rural/regional settings: professional and ethical issues. appl neuropsychol 2009;16:193-206. 7. townsend t. patient privacy and mental health care in the rural setting. am j ethics 2011;13:282-286. 8. mullin d, stenger j. ethical matters in rural integrated primary care settings. families, systems & health 2013;31:69-74. 9. gonyea jlj, wright dw, earl-kulkosky t. navigating dual relationships in rural communities. j marital fam therapy 2014;40:125-136. 10. werth jw, hastings sl, riding-malon r. ethical challenges of practicing in rural areas. j clin psychol 2010;66:537-548. 11. purtilo r, sorrell j. the ethical dilemmas of a rural physician hastings center report 1986aug:24-28. 12. glover jj. rural bioethical issues of the elderly: how do they differ from urban ones? j rural health 2001;17:332-335. 13. warner td, monaghan-geernaert p, battaglia j, brems c, johnson me, roberts lw. ethical considerations in rural health care: a pilot study of clinicians in alaska and new mexico. comm mental health j. 2005;41:21-33. 14. roberts lw, johnson me, brems c, warner td. ethical disparities: challenges encountered by multidisciplinary providers in fulfilling ethical standards in the care of rural and minority people. j rural health 2007;23:89-97. 15. cook af, hoas h. bioethics activities in rural hospitals. psychol faculty pub 2000;7:230-238. 16. nelson wa, rosenberg m-c, mackenzie t, weeks wb. the presence of ethics programs in critical access hospitals. hec forum 2010;22:267-274. 17. nelson w, pomerantz a, howard k, bushy a proposed rural healthcare ethics agenda. j med ethics 2007;33:136-139. 18. patel l, elliott a, storlie e, kethireddy r, goodman k, dickey w. ethical and legal challenges during covid-19 pandemic are we thinking about rural hospitals? j rural health 2020: april 13, epub ahead of print. 19. rural physician associate program (rpap). https://med.umn.edu/mdstudents/individualized-pathways/ruralphysician-associate-program-rpap. accessed february 11, 2022. 20. kon aa, rich b, sadorra c, marcin jp. complex bioethics consultation in rural hospitals: using telemedicine to bring academic bioethicists doi: https://doi.org/10.24926/jrmc.v6i1.4405 journal of regional medical campuses, vol. 6, issue 1 original reports into outlying communities. j telemed telecare 2009;15:264-267. 21. project echo. transforming how providers treat their patients. https://hsc.unm.edu/echo/what-we-do/focusareas-health.html. accessed february 11, 2022. 22. parker l, watts ld. how we involved rural clinicians in teaching ethics to medical students on rural clinical placements. med teacher 2015;37:228-231. doi: https://doi.org/10.24926/jrmc.v6i1.4405 journal of regional medical campuses, vol. 6, issue 1 original reports table 1. survey questions 1. what facility(ies) (clinic and/or hospital) do you work at? 2. how many years have you been in practice? 3. are there clinical ethics services available at your facility? if so, are they available 24/7? 4. describe the last clinical ethical dilemma you encountered as a rural physician. what was the outcome? what resources could have aided you throughout this experience? please do not include any identifying patient information. 5. if we were to develop educational opportunities for rural providers related to clinical ethics, how would you want to participate? 6. we are considering the possibility of developing a remote clinical ethics service that could be accessed via secure audio and/or video hook-up. how likely are you to use such a service if it was available to you? do you have suggestions for us to consider? doi: https://doi.org/10.24926/jrmc.v6i1.4405 journal of regional medical campuses, vol. 6, issue 1 original reports table 2. illustrative quotes from recent clinical ethics dilemmas experienced by rural physicians theme illustrative quotes end of life “i had a patient who was still coherent, but lost his ability to speak or swallow. he had lung cancer and recurrent pneumonia. he was hospitalized on bipap and full code. he tried to indicate that he didn't want further intervention, but it was very difficult to communicate with him. his family was torn with what to do. ultimately, he improved enough to get off the bipap and we were able to communicate enough to change his code status, but we were nearly in an ethical dilemma as to whether or not to continue futile care.” “the last real ethical dilemma was a patient with mental health issues that had cardiac arrest at home and was found down and brought to the er. the patient did not have an advanced directive and no known next of kin. we did revive her, but with the knowledge that her outcome likely would be poor”. “somali end of life transition. patient brain dead, fully vented, multisystem organ failure and 3 pressors to sustain pressure, continuous dialysis and family would not consider comfort care. additional futile services in place for 5 days.” vulnerable adult “placing a vulnerable adult report and forcing staff at snf to take over medication administration.” “a parent of an adult handicapped male who was encouraged to consider "not treating" his pneumonia because it was stressful for the family when he got sick. parent transferred hospitals due to fear of euthanasia.” patient autonomy vs best interest “one that i still battle is elderly with cognitive deficits. they live alone and have no one else and i start to worry about memory for driving and living, but they don’t want to move.” “a patient who had three prior c-sections (some emergent) wanted to have a home birth locally, and we had to be prepared as a medical community to encourage her toward safe delivery (not at home) (at a bigger hospital).” “patient wants to turn off her defibrillator when she is 95 but otherwise healthy.” limited resources rurally “the last clinical ethical situation i remember is a case where the family wanted the patient sent to an urban hospital for further evaluation while the patient just wanted to stay in our rural critical access hospital. the family won out and the patient ended up going to the urban center where the patient died. i'm not sure if there are clinical ethics services which would have been of help.” “pt needing services, declines due to distance and cost of getting services”. “how to deal with a problem patient in a facility that is sole community provider”. doi: https://doi.org/10.24926/jrmc.v6i1.4405 journal of regional medical campuses, vol. 6, issue 1 original reports theme illustrative quotes vulnerable child “i had a pediatric patient who was a victim of munchausen by proxy. later his family asked to have this diagnosis stricken from his record because they believe it to be false. they want to blame the situation on mother's diagnosis of post-partum depression, but it was no question a case of munchausen. i do not feel it is right to take that off his record. the outcome is still undecided.” patient capacity “did patient have capacity to fill out polst” genetic abnormalities of fetus and non-viability “patient requested an induction of 24 wk fetus that had fatal fetal malformations, in order to potentially have time with him before dying in utero.” patient/family discord “the last clinical ethical situation i remember is a case where the family wanted the patient sent to an urban hospital for further evaluation while the patient just wanted to stay in our rural critical access hospital. the family won out and the patient ended up going to the urban center where the patient died. i'm not sure if there are cues which would have been of help.” code status “determining "code" status on a patient with memory impairment based on conflicting prior records.” “i had a patient who was still coherent but lost his ability to speak or swallow. he had lung cancer and recurrent pneumonia. he was hospitalized on bipap and full code. he tried to indicate that he didn't want further intervention, but it was very difficult to communicate with him. his family was torn with what to do. ultimately, he improved enough to get off the bipap and we were able to communicate enough to change his code status.” decision maker “the most common ethical decisions revolve around end of life care and who is the decision maker when a patient is unable to make their own choices” knowledge about family member/confidentiality “a parent contacted me about her 25 yr old son who is an alcoholic and she shared a lot of information about his current drinking and recent dui but didn't want me to say anything to him because she didn't want him to know she had said anything to me about him. i met with him the following day and had to ask very directed questions that did lead him to share a lot of information with me without divulging the info him mother gave me.” microsoft word neurology telemedicine.docx published by university of minnesota libraries publishing neurology telemedicine as virtual learning for regional medical campuses anne-taylor beck; william j. crump, m.d.; jignesh j shah, m.d. doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 3, issue 2 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc anne-taylor beck, b.s., m-3 medical student, university of louisville school of medicine trover campus, madisonville, ky william j. crump, m.d., associate dean, university of louisville school of medicine trover campus at baptist health, madisonville, ky jignesh j shah, m.d., director, tele-neurology services, university of louisville school of medicine, louisville, ky all work in jrmc is licensed under cc by-nc volume 3, issue 2 (2020) journal of regional medical campuses perspectives neurology telemedicine as virtual learning for regional medical campuses anne-taylor beck; william j. crump, m.d.; jignesh j shah, m.d. abstract small rural regional medical school campuses can be challenged to provide the breadth of learning opportunities required in some specialties. here we report our initial experience with a telemedicine stroke consultation service that addressed one of our concerns. we share an essay from the student perspective as well as those of the regional dean and remote neurology faculty and encourage others to try this technology and report their findings. the authors have no conflict of interest to report and this study was found to be exempt by the baptist health madisonville internal review board. regional dean reflection: small rural regional medical school campuses have advantages and challenges. in this environment, students are often in an apprenticeship model, getting a lot of hands-on frontline experience. their confidence builds quickly in the setting of frequent feedback in this one on one relationship with experienced clinicians as their faculty. when the medical school curriculum includes rotations for specialties that are in short supply, this creates a significant issue for campuses in small towns. neurology is one of the specialties that is truly scarce in small and medium sized towns across america. our campus is based in a town of 20 000, and when one of our neurologists died suddenly and the other moved her practice to a larger town an hour away, this presented a significant problem for us. although the number of available spots on the neurology rotation at the urban main campus was limited, they could accommodate our small number of students. however, sending our students 160 miles away for a 4-week rotation created several obstacles. first, there was the cost of lodging for which we felt responsible. second, there was the issue of “urban disruption” that can sometimes make a student rethink their commitment to small town practice.1 lastly, the students missed longitudinal experiences for these 4 weeks. these longitudinal experiences include providing care for their longitudinal patients at our free clinic2 and our “dean’s hour” meetings every other week where we address clinical reasoning skills through case presentations, as well as complete careful chart review of our free clinic care. while our host hospital organization aggressively recruited another neurologist, we developed a curriculum where students commuted to our former faculty’s practice an hour away. when she was not at that practice, we supplemented with a strong sleep medicine experience locally, as well as inpatient geriatric psychiatry on our campus that presented opportunities to learn about chronic neurological diseases. student feedback and performance on shelf exams using this curriculum were comparable to those students based at the urban campus, and we were able to meet all stated objectives of the rotation. however, there was a significant gap in acute care that centered largely around strokes. if a patient presented to our emergency department (ed) with stroke syndrome, or a stroke occurred during hospitalization, referral to a hospital an hour away was the only option. given the tight time window for aggressive intervention in acute strokes, this could be a problem in terms of clinical care, and obviously created a gap in our students’ education. it was also a significant loss in revenue for our local hospital. when our urban campus proposed telemedicine for stroke consultation, there were understandably many questions as to how patients and clinicians at our hospital would respond. when i proposed this approach as a solution to address the educational needs of our students, there were also understandably many reservations as to whether this could provide a quality learning experience. my own experience with telemedicine almost 30 years ago gave me the confidence that this would work well.3 during my time in texas, in my role as a nasa contractor, i was able to watch as my family medicine residents were directed in performing flexible nasopharyngoscopy by a remote otolaryngologist.4 i also experienced effective telemedicine personally while providing remote support to an offshore oil platform as a test of lower bandwidth technology.5 in one case, a worker had a high fever and rash that was thought by the on-site medic to be petechial. we were able to demonstrate that the rash did, in fact, blanch and the worker had only acute pharyngitis and doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 perspectives an unrelated contact dermatitis. this avoided a helicopter medivac run that would not only have been quite expensive, but can be very dangerous in some weather conditions. as such, i was already convinced of telemedicine’s value. furthermore, during my time in texas we studied the process of faculty teaching remotely, finding that a strong “screen presence” was a key to success.6 the energy and enthusiasm of a few stroke neurologists at our urban campus and careful training and process preparation among staff and physicians at our hospital resulted in an effective tele-neurology service. allowing 3 months of baseline function before we added a learner was important. we are currently collecting detailed case information as well as evaluations from students and will share this data after several rotations have been completed. the first student on this new rotation expresses her impressions as an essay. her narrative suggests that not only were educational goals met, but she acquired confidence in an area that is sometimes challenging even for experienced clinicians. her perspective is shared so others are encouraged to study the effectiveness of remote faculty interaction and report their experience with telemedicine learning as well. student reflection: the third year of medical school training is defined by shifting inconsistency of schedule, confidence, and comfort level. one month you are scrubbing into the operating room, practicing suture technique, and completing preand post-operative checks. by the time you get comfortable doing these tasks, you are off to the next month, where you are treating acute kidney injury in the intensive care unit with nephrology and then presenting your patient to the hospitalists on wards. every day is different. every rotation comes with new challenges to overcome, management protocols to learn, faces and names to remember, and expectations to uphold, all while trying to learn as much as possible about the practice of medicine. at first this new world can be overwhelming, but it is this environment that yields resilience and flexibility and teaches what cannot be extracted from a textbook. as a third-year student, i was pre-rounding on stroke patients at our regional rural hospital. i had planned to see a few patients before rounding with the neurology team at 8 am, and i was feeling nervous. this was partly because it was my first day on neurology, but also because i would be meeting a new attending, a new team, and a new set of expectations. this part was a bit different from my 2 previous rotations (internal medicine and surgery), because i would not be shaking hands with my new attending. instead, he would be displayed on a computer screen within a device fashioned to look like a robot, with two cameras for eyes. i was the first medical student in my class to rotate with tele-neurology as part of my curriculum. promptly at 8 am, the robot was rolled into the tiny room designated for the neurology team. my faculty’s face appeared clearly on the screen. he said hello to familiar nurses and physical therapy staff. i could tell this was routine for the group. they were comfortable with one another and had gotten to know each other well over the last few months. as they chatted, i found an out of the way spot to finish scribbling a few neurologic exam findings on ms. f, when suddenly i heard, “hello medical student. my name is dr. shah. what is your name and how long will you be with us?” i quickly introduced myself and said i would be rounding a few days a week for 4 weeks. he discussed expectations for me as a part of the team and the learning objectives he hoped to cover while i was with them. i instantly felt a sense of relief from his apparent interest in my learning and his passion for teaching. his enthusiasm about patient care was contagious and helped to dispel my worry about having a teacher who was 160 miles away. we quickly went through each patient and discussed improvement, decline, medications, and overall status. now it was time to round. to be honest, i was a little skeptical of how patients and families would respond to seeing their neurologist on a screen instead of in-person. by the end of the morning, all my doubts had dissipated as i watched the interactions between dr. shah and his patients. it was almost as if he was sitting in a chair next to the patient’s bed. he went through a full history and physical exam. when we reached parts of the physical exam that he was unable to complete, he instructed me. my body temperature rose a few degrees and my palms collected moisture when he explained how i should elicit reflexes from mr. b. i had done these maneuvers many times on both standardized and actual patients but doing so in front of an entire team made me anxious. i was so afraid of failure. by day 4 on the rotation, dr. shah was asking me to do more and more of the physical exam as he observed and constructively critiqued my examination. it was about 2 weeks into the rotation when i walked into our tiny meeting room for rounds, and dr. shah and the team were discussing our only patient for the day. he asked me to pull up the patient’s head imaging (mri and ct) onto the desktop. he proceeded to explain which views and settings were best when looking for various pathology, and how to look at multiple images at one time so that i could have a better perspective of what i was seeing. when i turned around to ask him a question, i noticed that everyone in the room was watching our encounter. the eagerness for learning among the group was tangible and no doubt would result in better care for all of our patients. it occurred to me that had this interaction occurred in person, it would not doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 2 perspectives have included all the staff, another unexpected benefit of telemedicine. i began to feel more confident in my abilities after days of practice, but it was sometime during this rotation when i started to realize that failure is an inevitable part of “practicing” medicine. there were days when my assessment of the patient was totally wrong and it took me multiple attempts to complete a physical exam step properly, but i learned something new and moved on. a new mantra materialized in my mind: “you miss every shot you don’t take.” this was one of those pivotal moments that defines the third year of medical training. moments like these occur repeatedly in medical school and throughout one’s career. a new challenge or obstacle appears, and we have the choice to face it knowing that we could fail or ignore it and lose out on the potential learning experience that it offers. telemedicine comes with numerous obstacles, but it also comes with tremendous potential to impact millions of rural families and medical students. when we decide to face the hard challenges head on, our perspective shifts and the fear of failure fades. the moments that define our training and career have little to do with us, but instead occur when we walk (or roll) into our patient’s room and she waves at us for the first time with the hand that she could not lift from the bed just days prior. these moments will remind us why we prayed for this mountain to climb. and with every new challenge that we tackle, we grow stronger and more resilient. with every fear that we face comes an encounter with a grandmother or grandfather, mother or dad, brother or sister, daughter or son who is in desperate need of a caring physician, one who once failed so that today she would succeed on their behalf. remote neurologist perspective: with the advancing technology all around us, we knew health care would eventually catch up. telemedicine technology, which incorporates audio and video communication, brings the patient in a rural site to the physician sitting at their office in an urban referral hospital as if they are present in-person. telemedicine is a win-win situation for both rural and referral hospitals, for patients and physicians, and for both caregivers and administrators. we started doing telemedicine with surrounding hospitals in 2008, but it was in 2015 that the program was revamped to improve the structure. we now have 5 sites where tele-neurology services are provided. in 2019, our tele-neurology service saw almost 900 patients, nearly reaching the number of traditional consults seen at university hospitals. we collaborated with baptist health madisonville in august 2019 to start providing stroke care for patients coming to the ed. the telemedicine structure we provide is comprehensive, with the telemedicine team seeing stroke patients in the ed and also responding to strokes occurring in the hospital, both within a response time of 30 minutes. as appropriate, stroke patients are admitted to a hospitalist service, and we make daily “robot” rounds on these patients. only patients who may need potential mechanical thrombectomy or hemicraniectomy are transferred out. patients receiving tissue plasminogen activator (tpa) who don’t need these infrequent advanced services are able to stay at the local hospital, cared for by physicians they know and visited by local family members. our madisonville site turned out to be unique in another way, as there was involvement of medical students. as i visited madisonville to brief the medical staff just prior to beginning our services, a meeting with the regional dean was all it took to see that we had a common goal. when we round at our main hospital, we have medical students join us routinely, but at telemedicine sites, this was a first. we did realize that in spite of some limitations, teaching can be very effective via telemedicine. our first medical student has summarized her experience very well here, and we appreciate the positive feedback. this shows how effective telemedicine services can be not only for patient care, but also the entire team at a rural site. we look forward to continuing this win-win arrangement and will look for ways to improve our process even further. references 1. crump wj, fricker s, barnett d. a sense of place: rural training at a regional medical school campus. journal of rural health. january 2004; 20(1): 80-84. doi: 10.1111/j.1748-0361.2004.tb00011.x. 2. crump wj jr, king ma, matera el, crump wj iii. experience with a medical student-directed free clinic: patient, student, staff, and faculty perspectives. journal of the kentucky medical association. 2011; 109: 9-14. 3. crump wj, levy bj and billica rd. a field trial of the nasa telemedicine instrument pack in a family practice telemedicine testbed. aviation, space, and environmental medicine. 1996; 67(11): 1080-1085. 4. crump wj, and driscoll b. an application of telemedicine technology for otorhinolaryngology diagnosis. laryngoscope journal. 1996; 106: 595598. doi: 10.1097/00005537-199605000-00014. 5. crump wj. clinical telemedicine: what is the value for the family physician? louisville medicine. september 2000; 48(4): 60-161. 6. crump wj, caskey jw and ferrell bg. the effect of a remote facilitator on small-group problem solving : potential uses of two-way video technology in decentralized medical education. teaching and learning in medicine. 1998; 10(3): 172-177. doi: 10.1207/s15328015tlm1003_9. microsoft word nutrition curriculum article.docx published by university of minnesota libraries publishing effects of pilot nutrition curriculum on medical student knowledge and ability at the university of minnesota medical school duluth campus laura jore, ms3; kate shafto, md; jenny breen, mph, med; samantha friedrichsen, mph; jennifer pearson, md doi: https://doi.org/10.24926/jrmc.v6i1.4663 journal of regional medical campuses, vol. 6, issue 1 (2023) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc laura jore, ms3; university of minnesota medical school duluth campus, duluth, mn kate shafto, md; associate professor of medicine, assistant professor of pediatrics; hennepin healthcare and university of minnesota medical school, minneapolis, mn jenny breen, mph, med; chef and faculty in culinary nutrition in the academic health center and college of food science and nutrition at the university of minnesota, minneapolis, mn samantha friedrichsen, mph; professional data analysts, minneapolis, mn jennifer pearson, md; associate professor, university of minnesota medical school duluth campus, duluth, mn all work in jrmc is licensed under cc by-nc volume 6, issue 1 (2023) journal of regional medical campuses original reports effects of pilot nutrition curriculum on medical student knowledge and ability at the university of minnesota medical school duluth campus laura jore, ms3; kate shafto, md; jenny breen, mph, med; samantha friedrichsen, mph; jennifer pearson, md abstract purpose: undergraduate medical education is facing an increasing need to bridge the longstanding gap between basic nutrition knowledge and its application to patient care. in an effort to improve upon knowledge and confidence in this area, the university of minnesota medical school duluth campus implemented a pilot curriculum to increase content and exposure in the areas of food, food systems, nutrition, and clinical application. methods: two classes of outgoing second-year medical students at the university of minnesota duluth campus were surveyed about personal health, knowledge of nutritional topics, and confidence in implementing these topics in patient care. the control group consisted of outgoing second-year medical students (ms2s) during the 2019-2020 academic year (n=28) prior to pilot nutrition curriculum inception. the cohort group (n=29) consisted of outgoing ms2s from the 2020-2021 academic year who received the new pilot curriculum. findings: survey findings did not yield statistically significant differences in control versus cohort responses in students' personal health and knowledge of nutritional concepts. however, over 90% of the cohort group, versus 54% of control, agreed that they were able to discuss and recommend healthy dietary modifications to a patient with a chronic disease. the cohort group also reported higher confidence in talking with patients about dietary patterns (69% vs 39%), whole-food, plant-rich diets (90% vs 50%), as well as working inter-professionally with other members of the healthcare team around issues of food and nutrition (97% vs 71%). conclusion: results demonstrate that the pilot curriculum increased medical student confidence in evaluating the multidimensionality of food, food systems, and nutrition content as well as the application of this content to patient care. this pilot curriculum may have relevance to other medical schools who are also wishing to bridge this longstanding gap in medical education. funding: authors obtained a herz faculty development teaching award from the university of minnesota medical school from sept. 2019 through june of 2020 for support of curricular innovation. there are no additional financial disclosures. acknowledgements: a sincere thanks to amy seip for her help in distributing surveys, as well as lynsie radovich, for assistance in the irb exemption process. background u.s. medical students receive an average of 19.6 hours of nutrition instruction during 4 years of medical school.1 physicians are finding themselves inadequately prepared to provide patient-centered nutrition recommendations, leaving many calling for curriculum change at the medical school level.2 5 to determine where the lack of confidence originates, we must look at undergraduate medical education. licensing exams emphasize biochemical knowledge and the importance of identifying the clinical manifestations of common nutritional deficiencies. little emphasis has been placed on how societal journal of regional medical campuses, vol. 6, issue 1 type of article conditions play a role in poor diet and nutrition, the translation of basic nutritional biochemistry to the food people eat, or the clinical application of this material through patient-centered care. upon completion of medical school, students should be equipped with strategies to provide basic, evidencebased dietary interventions in patient care. however, medical schools rarely offer an accompanying curriculum that bridges this basic science knowledge to patient care.6 poor diet, obesity, tobacco use, and hypertension are leading causes of morbidity and mortality in the u.s., while diet and high bmi greatly contribute to disease burden.7 many studies support the role of dietary interventions in both preventing and managing chronic disease.1, 7 16 guidelines from major advisory organizations call for optimizing diet as foundational to chronic disease management.14, 17-19 there is also increasing recognition of the role of food access, food insecurity and the larger food system in both individual and community health.20 because of this, medical students need essential training on how to identify the intersectionality between food systems and nutrition in the context of these chronic conditions and address needed dietary interventions. in effort to improve upon knowledge and confidence in these areas, the university of minnesota medical school duluth campus implemented a pilot curriculum to increase medical student exposure to the intersectionality of food, food systems, nutrition, and its application to patient care. this pilot curriculum entailed 5.5 hours of novel curriculum beyond previously taught nutrition topics. the new curriculum included interactive lectures, a hands-on cooking lab, and a nutrition-focused patient case assignment and discussion. duluth’s regional campus has a systems-based 2-year foundational curriculum. the pilot curriculum incorporated these additional 5.5 hours into the gastrointestinal medicine course in the spring semester of year two. given the university of minnesota’s covid19 guidelines during ay 2020-21, the pilot curriculum was created to run virtually. students participated in the following: 1) a 1-hour large-group live virtual introductory session with small-group breakout-room discussions, 2) a 1-hour large-group live virtual discussion of nutrition myths and dietary patterns’ impact on health and disease, 3) a small-group 1.5-hour virtual hands-on cooking lab with students participating from their own home kitchen, 4) a case assignment that students completed asynchronously and submitted in pairs, and 5) a 2-hour large group live virtual discussion of the assignment cases, where chosen students presented each case with large group discussion following. the patient case scenarios that were used for this assignment/discussion covered the following conditions: diabetes, obesity, hypertension, and depression. objectives for each of these sessions are listed in table 1. materials and methods the pilot curriculum was evaluated by use of a qualtrics survey and was sent to students at the completion of their second year of medical school. this survey was developed by expert physician and chef with mph and vetted for face validity. irb review was sought, id: 00008967, and the study was granted journal of regional medical campuses, vol. 6, issue 1 type of article exemption as it was not considered human subject research. students were asked to rate questions via a 5-point likert-type scale, inquiring about their personal health, knowledge of nutritional concepts, and confidence in the ability to implement nutritional concepts in patient care (see table 2 for survey questions). the control group consisted of outgoing second-year medical students (ms2s) during the 2019-2020 academic year prior to pilot nutrition curriculum inception. the cohort group consisted of outgoing ms2s from the 2020-2021 academic year who received the new pilot curriculum within the gastrointestinal medicine course. the year prior to pilot implementation, nutrition workshops had occurred in planning for this curricular change. a small number of students participated in these workshops and were asked to identify themselves within the survey. students from either the control or cohort groups who participated in any of the workshops were excluded from this analysis. there was a total of 66 surveys. one was excluded as a test survey, leaving 65 surveys (36 for 2019-2020 outgoing ms2s [control group] and 29 for 2020-2021 outgoing ms2s [cohort group]). there were three students in the control group that did not indicate whether or not they attended the nutrition workshops, therefore they were excluded from the analysis. there were five students in the control group who indicated they attended nutrition workshops, so they were also excluded from the control group. the final sample sizes were 28 for the control group and 29 for the cohort group; total n=57. to compare the responses between control and cohort groups, nonparametric wilcoxon rank-sum tests were used given the ordinal (non-normal) distribution of the data and small sample sizes. pvalues <0.05 were considered statistically significant and practical significance (i.e., meaningful results) was considered in the interpretation of the results. pvalues were not adjusted for multiple-testing due to the small sample size and exploratory nature of this study. results student personal health survey findings did not yield statistically significant differences in control versus cohort responses in personal health and nutrition. generally, most students reported relatively high ratings for personal health and nutrition. over half of the students chose ratings of a 4 or 5 on a scale from 1-poor to 5excellent for each of the questions about personal health and nutrition. although there were no statistically significant differences in student selfreported personal health and nutrition between the control group and the cohort group, the control group generally appeared to have higher self-ratings. for example, 11% of the control group rated the nutritional quality of their diet as excellent, as compared to only 3% of the cohort group. similarly, 18% of the control group rated their overall health as excellent, as compared to 0% of the cohort group. knowledge of nutritional concepts survey findings did not yield statistically significant differences in control versus cohort responses in knowledge of nutritional concepts. students from both groups reported high agreement for the knowledge questions. more than 90% of the students in both groups agreed they know what it means to eat a nutritionally balanced meal. although agreement did not vary statistically significantly by group, in the journal of regional medical campuses, vol. 6, issue 1 type of article cohort group, 93.1% of students agreed they can define/explain the macronutrients, as compared to only 78.5% in the control group. similar proportions of students agreed with the other knowledge statements. confidence in implementing nutritional concepts in patient care in examining confidence to implement nutritional concepts in patient care, the cohort group reported higher confidence in several areas, as seen in table 3. over 90% of the cohort group agreed or strongly agreed that they were able to discuss and recommend healthy dietary modifications to a patient with a chronic disease, as compared to 54% of the control group. the cohort group also reported higher confidence in talking with patients about dietary patterns (69% vs 39%) and whole-food, plant-rich diets (90% vs 50%), as well as working interprofessionally with other members of the healthcare team around issues of food and nutrition (97% vs 71%). the differences between groups for the other three questions were not statistically significant. table 3. students’ self-reported confidence of applying nutritional concepts to patient care journal of regional medical campuses, vol. 6, issue 1 type of article discussion in effort to meet a clear need within medical education, the university of minnesota medical school duluth campus introduced a pilot curriculum to increase medical student education concerning the multidimensionality of food, food systems, and nutrition content, as well as the application of this content to patient care. although this is a small pilot study, the results suggest an improvement in medical students’ confidence to apply nutrition and food system concepts in patient care settings, with minimal additional curricular effort. with a crescendoing call for expanded nutrition education for students, residents, and physicians,1 -6, 21 this study suggests that a pilot curriculum such as that implemented may begin to fill some of the recognized gaps within medical training. our regional campus plans to continue to deliver and optimize this curriculum, as well as work on a newly developing bicampus curriculum which will be incorporated into both the duluth and twin cities campuses of the university of minnesota. lessons learned within our regional campus can serve as a template for our state's expanded bi-campus curriculum. outcome data will continue to be followed with cohorts of students moving forward. while not statistically significant, the fact that that cohort group rated themselves lower on personal health and nutrition is notable. the question that arises is whether the control group truly came in with a higher level of personal health and nutrition, or whether the differences seen could be representative of the cohort group’s expanded understanding of health and nutrition as a result of the curricular changes, which ultimately changed expectations and left them feeling less personally healthy and knowledgeable as a result. this finding introduces an interesting area for future exploration. limitations of this study should be noted. due to a small cohort, there was limited power to detect statistical differences between student groups. in addition, because these differences are self-reported, they may not represent measurement of knowledge or ability surrounding these topics. demographics were not reported and therefore there may be differences between the two cohorts that could account for findings unrelated to the course. also, given the discussed exclusions from the control group, there is an inability to determine whether inclusion of these students’ responses would have altered the statistical outcome. with limitations recognized, this pilot curriculum may have applications to other medical schools that are also wishing to bridge this critical gap in medical education. curricular sessions such as those implemented at our regional campus may serve as an example template for innovations in medical education ultimately aiming to produce physicians with both nutritional competency and a larger understanding of food systems and structural determinants of health. equipping our region’s future physicians with skills to effectively apply food and nutrition practices to offer disease-modifying interventions in clinical care is the ultimate patientcentered goal. references 1. adams km, kohlmeier m, zeisel sh. nutrition education in u.s. medical schools: latest update of a national survey. acad med. 2010;85(9):1537-1542. doi:10.1097/acm.0b013e3181eab71b 2. devries s, dalen je, eisenberg dm, et al. a deficiency of nutrition education in medical training. am j med. 2014;127(9):804-806. doi:10.1016/j.amjmed.2014.04.003 3. katz dl. how to improve clinical practice and medical education about nutrition. ama j ethics. 2018;20(10):e994-e1000. published 2018 oct 1. doi:10.1001/amajethics.2018.994 4. vetter ml, herring sj, sood m, shah nr, kalet al. what do resident physicians know about nutrition? an evaluation of attitudes, selfperceived proficiency and knowledge. j am coll nutr. 2008;27(2):287-298. doi:10.1080/07315724.2008.10719702 5. devries s, agatston a, aggarwal m, et al. a deficiency of nutrition education and practice in cardiology. am j med. 2017;130(11):12981305. doi:10.1016/j.amjmed.2017.04.043 6. devries s, willett w, bonow ro. nutrition education in medical school, residency training, and practice. jama. journal of regional medical campuses, vol. 6, issue 1 type of article 2019;321(14):1351-1352. doi:10.1001/jama.2019.1581 7. us burden of disease collaborators, mokdad ah, ballestros k, et al. the state of us health, 1990-2016: burden of diseases, injuries, and risk factors among us states. jama. 2018;319(14):1444-1472. doi:10.1001/jama.2018.0158 8. about chronic diseases. cdc.gov. published april 28, 2021. accessed may 11, 2021. https://www.cdc.gov/chronicdisease/about/in dex.htm 9. byrne c, kurmas n, burant cj, utech a, steiber a, julius m. cooking classes: a diabetes self-management support intervention enhancing clinical values. diabetes educ. 2017;43(6):600-607. doi:10.1177/0145721717737741 10. fulkerson ja, friend s, flattum c, et al. promoting healthful family meals to prevent obesity: home plus, a randomized controlled trial. int j behav nutr phys act. 2015;12:154. published 2015 dec 15. doi:10.1186/s12966015-0320-3 11. jacka fn, o'neil a, opie r, et al. a randomized controlled trial of dietary improvement for adults with major depression (the 'smiles' trial) [published correction appears in bmc med. 2018 dec 28;16(1):236]. bmc med. 2017;15(1):23. published 2017 jan 30. doi:10.1186/s12916-017-0791-y 12. may am, struijk ea, fransen hp, et al. the impact of a healthy lifestyle on disabilityadjusted life years: a prospective cohort study. bmc med. 2015;13:39. published 2015 feb 27. doi:10.1186/s12916-015-0287-6 13. mills s, brown h, wrieden w, white m, adams j. frequency of eating home cooked meals and potential benefits for diet and health: cross-sectional analysis of a population-based cohort study. int j behav nutr phys act. 2017;14(1):109. published 2017 aug 17. doi:10.1186/s12966-017-0567-y 14. qaseem a, fihn sd, dallas p, et al. management of stable ischemic heart disease: summary of a clinical practice guideline from the american college of physicians/american college of cardiology foundation/american heart association/american association for thoracic surgery/preventive cardiovascular nurses association/society of thoracic surgeons. ann intern med. 2012;157(10):735743. doi:10.7326/0003-4819-157-10201211200-00011 15. ríos-hernández a, alda ja, farran-codina a, ferreira-garcía e, izquierdo-pulido m. the mediterranean diet and adhd in children and adolescents. pediatrics. 2017;139(2):e20162027. doi:10.1542/peds.2016-2027 16. zong g, eisenberg dm, hu fb, sun q. consumption of meals prepared at home and risk of type 2 diabetes: an analysis of two prospective cohort studies. plos med. 2016;13(7):e1002052. published 2016 jul 5. doi:10.1371/journal.pmed.1002052 17. garber aj, abrahamson mj, barzilay ji, et al. consensus statement by the american association of clinical endocrinologists and american college of endocrinology on the comprehensive type 2 diabetes management algorithm – 2018 executive summary. endocr pract. 2018;24(1):91-120. doi:10.4158/cs-20170153 18. grundy sm, stone nj, bailey al, et al. 2018 aha/acc/aacvpr/aapa/abc/acpm/ada/ags /apha/aspc/nla/pcna guideline on the management of blood cholesterol: a report of the american college of cardiology/american heart association task force on clinical practice guidelines [published correction appears in j am coll cardiol. 2019 jun 25;73(24):3237-3241]. j am coll cardiol. 2019;73(24):e285-e350. doi:10.1016/j.jacc.2018.11.003 19. whelton pk, carey rm, aronow ws, et al. 2017 acc/aha/aapa/abc/acpm/ags/apha/ash/as pc/nma/pcna guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the american college of cardiology/american heart association task force on clinical practice guidelines [published correction appears in j am coll cardiol. 2018 may 15;71(19):2275-2279]. j am coll cardiol. 2018;71(19):e127-e248. doi:10.1016/j.jacc.2017.11.006 journal of regional medical campuses, vol. 6, issue 1 type of article 20. siegel kr, mckeever bullard k, imperatore g, et al. association of higher consumption of foods derived from subsidized commodities with adverse cardiometabolic risk among us adults. jama intern med. 2016;176(8):11241132. doi:10.1001/jamainternmed.2016.2410 21. leggett, l.k., ahmed, k., vanier, c. et al. a suggested strategy to integrate an elective on clinical nutrition with culinary medicine. med.sci.educ. 31, 1591–1600 (2021). https://doi.org/10.1007/s40670-021-01346-3 microsoft word beginwiththeendinmindarticle.docx published by university of minnesota libraries publishing begin with the end in mind: designing and implementing an effective system for evaluation and feedback of learners in regional medical campus residency settings bernadette miller, md, facp and brent w. beasley, md, mba doi: https://doi.org/10.24926/jrmc.v3i1.2259 journal of regional medical campuses, vol. 3, issue 1 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc brent w. beasley, md, mba; the university of oklahoma—tulsa bernadette miller, md, facp; the university of oklahoma—tulsa corresponding author: brent w. beasley, md, mba; the university of oklahoma—tulsa, 4444 e. 41st st. tulsa okla, 74135 cell: 816678-4122 phone: 918-660-3456 email: brent-beasley@ouhsc.edu all work in jrmc is licensed under cc by-nc volume 3, issue 1 (2020) journal of regional medical campuses perspectives begin with the end in mind: designing and implementing an effective system for evaluation and feedback of learners in regional medical campus residency settings bernadette miller, md, facp and brent w. beasley, md, mba abstract developing an evaluation system within a medical education program can be daunting and confusing. the authors present a step by step approach, incorporating education theory, recent trends, and the many facets required by accreditation organizations. introduction regional medical campus residency programs began documenting progressive achievement of milestones soon after the accreditation organizations propagated the new platform.1,2 the work residency programs and their supporting organizations have done on defining the milestones and competencies is commendable; however, the effort required for an individual residency program at a regional medical campus to implement these can feel overwhelming. warm et al documented their experience and recommendations for mapping entrustable professional activities into residency assessment and evaluation systems.3,4 their labors demonstrate the tension in making practical all items that must be accomplished within the parameters provided by accrediting bodies. to add to these, here is one program’s step-by-step approach built upon prior concepts. the purpose of this paper is to describe the 4 phases involved in creating and applying a complete system for the evaluation of learners in any regional medical campus clinical setting. by sharing these methods, educators will be able to: 1) identify and outline evaluation goals and expectations for learners, 2) develop written evaluations linked to these goals with descriptors that result in a “shared mental model” of entrustable professional activities, competencies, and milestones for learners and evaluators,5 3) parcel assessments into everyday clinical situations, creating calendars for evaluators and learners, and 4) implement evaluation sessions, providing face-to-face feedback through the adapt6 or the r2c27 feedback model, and assessments using online evaluations. creating the evaluation system a rule of thumb for educators and evaluation developers is summed up in covey’s “seven habits of highly successful people”: begin with the end in mind.8 for a program director, 2 end goals must be met. our primary job is to develop residents into qualified physicians. second, we must meet our accreditation requirements. throughout this paper, we use as an example the creation of an outpatient general internal medicine continuity clinic evaluation for residents. our residents spend every fifth week throughout the year in this clinic. we will demonstrate our process by building a summative evaluation of their continuity clinic progress to be used twice yearly. identify evaluation goals and expectations using the “five w’s” (where, why, what, who, when, and how), having already stated our where (i.e. gim continuity clinic), next we identify: • the overall purpose of this evaluation, • the content being assessed, • who will be the evaluator, • what timing intervals are required or desired, and • how the evaluations should be performed and the specific curricular requirements to be met. first, we turn to our accrediting body to ensure we meet their requirements, building adherence into the daily tools we use.9 pulling verbiage from the accreditation requirements, we must assess our residents in data gathering, clinical reasoning, patient management, and procedures, by direct observation and with feedback. the timing is at least semiannually, with multiple evaluators, and must be progressive. create the expectations document: linking evaluations to learning goals the next step is to create our expectations document to guide both the evaluator and the learner, and to know what suppositions will be tracked. it should provide: 1) answers to the questions above (the who, where, what, how, when), 2) a narrative description of the type of patient encounter to be observed, 3) a narrative description of the verbal feedback session that should follow the observed encounter, and 4) a doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 perspectives sample of the expected written summative evaluation. the document should be written so that both parties, the evaluator and the learner, can read the same expectations and anticipate what ought to occur during the evaluation. here is an example: figure 1: documenting learner and evaluator expectations create the evaluation form to create the evaluation form, begin by sequencing each evaluation's timing in the overall training learning curve. to do so, answer the following checklist: • should the content areas be assessed chronologically? • must a trainee learn something basic (novice level) before learning new content (knowledge building)? • is mastering a certain skill required before learning others? can the knowledge or skill be assessed at any time during training? • at what training intervals is it appropriate to reassess? to find the answers to these questions we must determine what is considered the standard “entry level” abilities. as reflected in the aamc entrustable professional activities for graduating medical students, primary care internal medicine interns begin clinic with baseline competence in data gathering, clinical reasoning, patient management, and general procedures of a physician.10 next, data gathering is generally mastered prior to clinical reasoning and patient management and should be evaluated earlier during training. procedures, however, occur throughout residency and may be assessed at any time. finally, at least 2 evaluations in each area are necessary throughout the year to demonstrate progressive improvement. by knowing these parameters, an educator can design and sequence the evaluations: one evaluation form to be administered at least twice to show progression in each learning area as required by the accreditation requirements. the evaluation form will be populated with knowledge, attitudes, and skill descriptors (kas), observable actions and behaviors expected of a licensed practitioner by the completion of training. for gim continuity clinic, we approached our outpatient faculty to describe the kas required to perform their job. also, we mined the acgme’s 6 core competencies, subdivided into 22 milestones, as a major source of evaluative descriptors. we recommend no more than 6-8 descriptors per evaluation to avoid evaluator response fatigue. our final 8 descriptors are in figure 2. figure 2: selecting the 6-8 evaluation descriptors and the competency milestones they meet link descriptors to milestones next, the descriptors must be linked to specific competency assessment milestones.11 this will be important for demonstrating to the accrediting body that the residency tracks competence in these areas. for instance, the descriptor “the resident elicited and documented appropriate history of present illness for an acute problem from patient” links to the pc-1 milestone for patient care “gathers and emphasizes essential and accurate information to define each patient's clinical problem.” looking further at other milestones, the descriptor also links to mk-1 for medical knowledge. programs should link each descriptor to as many milestones as appropriate and maintain documentation of these links. see our example in figure 3. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 perspectives figure 3: linking evaluations to competency milestones as previously described, our accrediting body requires trainee evaluations demonstrate “progressive” learning: the lowest level for the novice learner and the highest for “aspirational competence.” as the evaluation form is populated with the kas descriptors, we use a 1 to 5-point scale grounded by progressive designations: “critical deficiency,” “intern/pgy-1 level,” “senior/pgy-2 level,” “senior/pgy-3 level,” and “aspirational level.” a partial example of our final continuity clinic evaluation is shown below in figure 4. figure 4: final continuity clinic evaluation (partially shown) as each evaluation is developed, we maintain a tracking map demonstrating where each milestone is evaluated in a progressive fashion throughout the course of the entire residency. our example of our residency milestone evaluation map in an early stage of documentation is seen below in figure 5. figure 5: residency milestone evaluation map organized implementation: scheduling evaluations creating an academic evaluation schedule is important, including when your evaluations are going to be administered, which evaluators are needed, how many learners you have, and how many evaluators are required. sometimes, all portions of an evaluation may not be completed in one session and might require separating them into shorter mini evaluations. for example, in our academic calendar during the first year, we assess interns on “data gathering” in the first 6 months, and again in the following 6 months; however, “clinical reasoning” will be assessed at the beginning of their second year and again at the beginning of their third year. additionally, it may be advantageous to have one particular evaluator assess a resident’s clinical reasoning at 2 to 3 different points in time to ensure the resident is progressing. therefore, we maintain a chronological evaluation schedule. to achieve this, the evaluation appointment must be scheduled on individual evaluators’ calendars. if evaluators are unaware that they are expected to evaluate a resident, it will not happen. we distribute our expectation documents prior to the scheduled evaluation sessions and set reminders. reminders should be sent soon after the evaluation encounter if deadlines are not met and repeated at short intervals to ensure evaluators recall the resident’s performance when completing the evaluation. we recommend providing faculty development sessions prior to asking faculty to evaluate your residents, training them in the adapt or the s2c2 feedback model.12 additionally, the faculty development should provide time for faculty to discuss the required skills and behaviors and the levels of performance for each post-graduate year to improve interrater reliability. discussion the time required to implement this system depends on the type and number of evaluations needed for a given training experience and whether only one person or a team is working on it. for a longitudinal evaluation of the ambulatory clinic experience as described above, it required we consider learner advancement along the continuum of training. we require our faculty to “check out” each resident in the room in front of the patient, often reviewing their history, doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 perspectives exam, and assessments in real time with allowance for the progression through residency, so that interns provide us more detailed information in the room than third year residents. this provides each faculty member with a “daily” understanding and knowledge of how our residents perform. we believe this likely precludes a “game-day” change in how our residents behave. we developed the evaluations sequentially, first for interns, then pgy2, then pgy3. the whole development process required 5-15 hours of work, resulting in 6 different evaluations for ambulatory clinic throughout residency. overall, revamping the evaluation system for the whole residency is a large effort that warrants a team/committee to take this on with a one-year aim for completion. conclusion we believe the benefits of this system are substantial. first, it highlights the formative progression of a resident through training. second, it ensures the training program is in compliance with accreditation regulations around evaluation and feedback. third, it demarcates where and when resident milestones and competencies are expected to be achieved and demonstrated. fourth, it results in greater objectivity in evaluations rather than subjective impressions of trainees by evaluating faculty. finally, faculty assignments and clear expectations can be scheduled and tracked for the department. references 1. weinberger se, pereira ag, iobst wf, mechaber aj, bronze ms; alliance for academic internal medicine educaiton redesign task force ii. competency-based education and training in internal medicine. ann intern med. 2010;153:751-6. 2. hauer ke, vandergrift j, lipner rs, holmboe es, hood s, mcdonald fs. national internal medicine milestone ratings: validity evidence from longitudinal three-year follow-up. acad med. 2018 aug;93(8):1189-1204. 3. warm ej, mathis br, held jd, pai s, tolentino j, ashbrook l, lee ck, lee d, wood s, fichtenbaum cj, schauer d, munyon r, mueller c. entrustment and mapping of observable practice activities for resident assessment. j gen intern med. 2014 aug;29(8):1177-82. 4. warm ej, held jd, hellmann m, kelleher m, kinnear b, lee c, o'toole jk, mathis b, mueller c, sall d, tolentino j, schauer dp. entrusting observable practice activities and milestones over the 36 months of an internal medicine residency. acad med. 2016 oct;91(10):1398-1405. 5. carraccio c, englander r, holmboe es, kogan jr. driving care quality: aligning trainee assessment and supervision through practical application of entrustable professional activities, competencies, and milestones. acad med. 2016 feb;91(2):199-203. 6. fainstad t, mcclintock a a, van der ridder m j, et al. (december 11, 2018) feedback can be less stressful: medical trainee perceptions of using the prepare to adapt (ask-discuss-ask-plan together) framework . cureus 10(12): e3718. 7. sargeant j, lockyer j, mann k, holmboe e, silver i, armson h, driessen e, macleod t, yen w, ross k, power m. facilitated reflective performance feedback: developing an evidenceand theory-based model that builds relationship, explores reactions and content, and coaches for performance change (r2c2). acad med. 2015 dec;90(12):1698-706. 8. covey, s. r. (1989). the seven habits of highly effective people: restoring the character ethic. new york: simon and schuster. 9. accreditation council for graduate medical education. acgme program requirements for graduate medical education in internal medicine. https://www.acgme.org/portals/0/pfassets/programreq uirements/140_internal_medicine_2017-07-01.pdf effective: july 1, 2017. accessed march 14, 2019. 10. association of american medical colleges (aamc). core entrustable professional activities for entering residency: curriculum developers’ guide. aamc icollaborative, washington, dc. 2014. https://www.mededportal.org/icollaborative/resource/8 87. accessed 1 jan 2016. 11. the internal medicine milestone project. https://www.acgme.org/portals/0/pdfs/ milestones/ internalmedicinemilestones.pdf?ver=2017-07-28090326-787. published july 2015. accessed march 13, 2019. 12. sargeant j, lockyer jm, mann k, armson h, warren a, zetkulic m, soklaridis s könings kd, ross k, silver i, holmboe e, shearer c, boudreau m. the r2c2 model residency education: how does it foster coaching and promote feedback use? acad med. 2018 jul;93(7):10551063. microsoft word university of kentucky rural physician leadership program article.docx paula k arnett, drph, mba; associate dean for administration; university of kentucky college of public health terry stratton, phd; assistant dean, assessment & quality management; office of medical education; university of kentucky college of medicine anthony weaver, md; assistant dean, rural physician leadership program; university of kentucky college of medicine carol elam, phd; associate dean for admissions and institutional advancement; office of medical education ; university of kentucky college of medicine corresponding author: paula k arnett, drph, mba; associate dean for administration; university of kentucky college of public health; 111 washington avenue, suite 212 lexington, ky 40351; (859) 323-7020 office (606) 783-5063 fax; paula.arnett@uky.edu all work in jrmc is licensed under cc by-nc volume 1, issue 3 (2018) journal of regional medical campuses original report university of kentucky rural physician leadership program: a programmatic review paula k arnett; terry stratton; anthony weaver; carol elam abstract this article describes the characteristics and results of the rural physician leadership program (rplp) at the university of kentucky college of medicine. rplp is a successful example of a regional medical campus designed to train physicians at a regional medical campus to serve rural areas through local partnerships. while producing adequate numbers of health care providers is critical to ensuring accessibility, persistent maldistributions away from certain areas have created chronic, geographic pockets of medical underservice across the u.s. as a case in point, a recent workforce report by the kentucky institute of medicine, titled quality through collaboration: the future of rural health care, found that only 30% of physicians currently practice in rural areas across kentucky1, despite 42% of the state’s population residing in such areas.2 to address these shortages strategically, the report recommended expanding the medical school applicant pool to select and train more students from rural and other underserved areas. in addition to recruitment, it was further suggested by a consortium of rural health scholars that medical schools “locate a meaningful portion of the educational experience in rural communities”.3 (page 10) many states with significant rural populations have medical education programs designed to bolster the supply of physicians in these areas,4-9 and recruiting students most amenable to establishing practices in such regions is key to the success of these efforts. recognizing that the pipeline to eventual medical practice begins early, the university of kentucky college of medicine (ukcom) developed the rural physician leadership program (rplp) in 2008 to address the state’s persistent and growing need for rural physicians. a collaborative effort partnering the ukcom in lexington, st. claire regional medical center, and morehead state university, the rplp is administered at the center for health education and research in morehead, kentucky – a community of about 7,000 located in west-central appalachia. the goal of the rplp is to identify and train physicians of all specialties to serve as both medical practitioners and community advocates in rural kentucky. toward this end, graduates gain the knowledge and experience necessary to impact health at both individual patient and community levels. this paper provides an overview of this initiative, which is now in its eighth year, by describing the approach to recruitment and admissions as well as curriculum and special educational initiatives, and providing outcome data related to student performance and residency choice. recruitment and admissions rplp recruitment is strategically focused on attracting applicants with a sincere desire to work in rural kentucky. both the rplp assistant dean and the ukcom associate dean for admissions and institutional advancement routinely tout the program to premedical groups at colleges and universities across the state. other initiatives include meetings with premedical students at events hosted by kentucky’s area health education centers, the kentucky rural health association, and the university of kentucky professional education preparation program. additionally, rplp faculty and staff host open houses throughout the year for prospective students and their families to visit morehead, speak with teaching faculty, administrators, and current medical students, and tour instructional and clinical facilities. in 2014, rplp staff initiated an intensive four-day medical school admissions boot camp for junior and senior undergraduates interested in medical careers. the program prepared rural students from smaller colleges and regional universities in kentucky for the medical school admissions process by providing application reviews, medical college admission journal of regional medical campuses, vol. 1, issue 3 original report test practice examinations, and mock interview sessions. to select the most qualified and desirable applicants, the rplp maintains a distinct but parallel admissions process with the regular md program at ukcom. students interested in the rplp merely designate ‘other special programs’ on their american medical college application service (amcas) application and a supplemental ukcom form. from those screened, selected rplp applicants are invited for personal interviews in both morehead and lexington. clinical faculty members, regional university faculty, medical center administrators, and key community members comprise the rplp interviewers in morehead – after which applicants complete a ‘traditional’ interview with ukcom interviewers in lexington. after a holistic review of candidates’ interests, experiences, and qualifications, the ukcom admissions committee, with rplp input, admits about 10 students annually into the program. curriculum rplp students complete all required preclinical (m1-m2) coursework at the main campus academic medical center (amc) in lexington. during this time, rplp students are kept together for small group learning activities whenever possible. introduction to the medical profession, a first-year ‘doctoring’ course, includes rplp faculty who broach topics such as medical ethics, professionalism, health care disparities, and sociocultural aspects of health care from a rural health perspective. between the m1-m2 years, rplp students experience patient care outside of the large amc during the two-week rplp clinical preparation summer experience at st. claire regional medical center. there, they interview patients, take vital signs, write notes, and make clinical presentations alongside community preceptors and third-year rplp students. during year two, they meet weekly with the rplp assistant dean to discuss rural-related topics in an elective course. third-year clinical training signals a curricular departure from the traditional md pathway at ukcom. based at st. claire regional medical center and other regional sites, rplp students complete core clerkships in family and community medicine, internal medicine, emergency medicine, surgery, obstetrics and gynecology, pediatrics, neurology, and psychiatry, but with a more individualized focus on rural populations. the final year of undergraduate training allows students to further develop and demonstrate their clinical skills and to prepare for residency in their chosen specialty. recognizing that different specialties may have different emphases, the fourth-year curriculum allows students to select rotations that are integral to their future careers. as a result, rplp students can take their two required acting internships at st. claire regional medical center or at the university of kentucky. doi: https://doi.org/10.24926/jrmc.v1i3.1262 similarly, rplp students may complete some or all of five clerkship electives in morehead, lexington, or elsewhere. curricular innovations the rplp boasts three curricular hallmarks: 1) a longitudinal family medicine experience; 2) a business education and leadership certificate program; and 3) a community engagement/intervention project. in the longitudinal experience, students staff a weekly clinic throughout the entire third year, which provides them familiarity with the clinic workings, continuity of care, and community immersion. students observe firsthand the benefits of long-term doctor-patient relationships and the practicalities of running a medical practice. interactions with the local health department, first responders, pharmacies, home health, nursing homes, home medical equipment suppliers, podiatry clinics, and pain specialists allow students to experience and participate in true inter-professional patient care. in collaboration with the morehead state university college of business and public affairs, rplp students are enrolled in a business education and leadership certificate program. utilizing an executive training modular format for instruction and learning, topics addressed include recent changes in healthcare policy and law, financing, payment systems, and insurance, electronic health records and mobile technology to monitor personal health status, and ethical dilemmas in healthcare and public health advocacy. other key topics addressed include strategic planning and organizational management. because the connectedness of community involvement can improve the recruitment and retention of rural medical professionals,11-12 community engagement activities form an integral part of the rplp program. students work with various morehead community leaders, providers, and agencies, including the mayor, chamber of commerce members, legislators, local health department providers, dentists, pharmacists, podiatrists, first responders, and school health nurses. as part of this experience, rplp students have provided health education to community schools, developed and presented wellness programs for local businesses, and participated in community health fairs. during their fourth year of medical school, rplp students complete a project involving research, quality improvement, or community engagement which they present each spring at the st. claire regional research day program. examples of past projects are presented in table 1. journal of regional medical campuses, vol. 1, issue 3 original report table 1. rplp community engagement projects outcomes recruitment and admissions since its inception in 2009, the annual number of rplp applications ranged from 25 to 61, resulting in 363 total applications and 79 matriculants (see table 2). the average medical college admission test (mcat) score (range 1-45) and cumulative grade point average (gpa) of students enrolled in the rplp program was 29.0 and 3.7, respectively. applicants came from 21 different kentucky colleges or universities, predominantly the university of kentucky (35.9%) and morehead state university (19.2%). of the 78 matriculating rplp students, 46 (59.0%) hailed from appalachian counties10 and 14 (17.9%) from other rural areas of the state, including six from western kentucky. to date, 19.2% (15) of students matriculating in the rplp have been from out of state. doi: https://doi.org/10.24926/jrmc.v1i3.1262 table 2. rplp applicants and matriculating students: gpa and mcat averages * 2015 mcat scores converted from 3-digit scale. below, table 3 lists rplp matriculants’ average scores on steps 1 and 2 of the required united states medical licensure exams (usmle). pass rates for firsttime test takers has consistently been at or above the national average, and mean scores on usmle step 2 ck for rplp students have typically been above the national average. to reiterate, rplp students complete the identical ukcom preclinical curriculum (usmle step 1), but complete their clinical clerkship training (usmle step 2) in morehead. table 3. matriculating rplp students: usmle step 1 and 2 ck scores (n=52) year admitted matriculating students average usmle step 1: rplp (us) average usmle step 2 (ck): rplp (us) 2009 7 221.9 (222) 241.6 (233) 2010 7 219.3 (222) 238.3 (236) 2011 8 232.3 (224) 241.4 (238) 2012 9 227.9 (227) 247.4 (239) 2013 11 222.3 (228) 239.7 (240) 2014 10 222.3 (229) n/a residency selection and specialty choice thirty-three percent (39) of rplp graduates went on to attend residencies in kentucky – 28.2% (11) at the university of kentucky. excluding the military, 67% of graduates were accepted into their first residency choice. as shown in figure 1, 22 (56%) of the 39 students who have matched into residency positions did so in a primary care specialty (i.e., internal medicine, family medicine, or pediatrics). at this point, only a small handful of rplp graduates have completed residency training, however, three of the five (60%) have currently established practices in rural kentucky. title description “lifestyle predictors of childhood obesity in eastern kentucky” over two years, students conducted a randomized, cross-sectional study of families attending a community health event. parents were asked to provide height and weight of their oldest child. “outreach event increases adolescents’ self efficacy in discussing mental health issues” students created the “spread the love-a-thon” outreach event to combat suicidal behavior. during this annual event, teens use their own cell phones and laptops to send complimentary ‘lifelines’ to friends and family. “blue in the bluegrass: examining kentucky’s elevated depression rates” using existing data, research was conducted on the relationship among depression, religion, alcohol use, and education. “evaluation of developing a student run free clinic in morehead, kentucky” with recent changes in insurance availability, students conducted a needs assessment at the morehead free clinic for a possible student run supplement. students subsequently developed a community health interest group to provide education and other services to the larger community. journal of regional medical campuses, vol. 1, issue 3 original report discussion three factors have proven essential to a successful implementation of the university of kentucky rural physician leadership program. first was the identification of a trusted local program champion to provide program leadership and serve as a community liaison. this individual must also understand accreditation issues and have regular communication with central campus. second, a strong distance learning program was essential to ensuring campus comparability of educational objectives and assessments. this technology must provide lectures, interactive classrooms, small group meetings, and all other elements of m3 and m4 curricula, and students must be guaranteed dedicated local classroom and study space. finally, regional partnerships with organizations that provide instruction and student services were also essential. the support of local clinicians enthusiastic to teach provides opportunities and mentorships that are otherwise difficult to develop. fortunately, st. claire regional has a long history of clinical teaching – sponsoring residencies in pharmacy and family medicine – and morehead state university had experience in providing services in support of student health, recreation, and wellness. only through these existing strengths was the rplp program able to leverage this expertise to successfully create and sustain a regional medical campus. lessons learned admissions: for admission to the program, the rplp utilizes a regional advisory committee of clinicians and other community members who were initially less familiar with the mcat and other academic requirements for medical school admission. thus, during the first interviews they conducted, new committee members received ‘on-the job’ training on academic considerations and their impact on students’ potential success in medical school, a time-consuming endeavor that occasionally proved frustrating. consequently, this onboarding process was altered so that new members now receive introductory training on the application and doi: https://doi.org/10.24926/jrmc.v1i3.1262 purpose of the advisory committee prior to interviewing. they are encouraged to review applications prior to the interview and seek clarification of any areas of concern. on the day of the interview, a guide is provided to assist each member in interpreting academic scores during the deliberation process. student interaction: as the first two years in the rplp are spent on the central campus, it was soon realized that inadequate contact with students prior to their transition to the regional campus could prove detrimental. on occasions when students were struggling, either academically and personally, rplp program staff were often unaware. in addition, moving from a large, urban amc to a smaller rural medical center was a culture shock for some students, and several initially struggled after arriving in morehead. the differences were also tangible: students familiar with central campus policies and processes needed to shift gears to accommodate those procedures designed to facilitate patient care in a smaller rural hospital. the clinical expectations were also unique: being a small group, learners may be the sole medical students on a service in a rural setting, necessitating their roles as being an integral part on the healthcare team. to gauge success, the rplp program actively monitors shelf scores, class rank, usmle step 1 and 2 (ck and cs) performance, as well as honors and awards received during medical school. after graduation, this surveillance extends to specialty selection, residency program, and location of eventual practice. although a young program with only proximal outcomes, strides have been made in the development and education of future rural providers. time will tell if the rplp will bolster the supply of rural physicians and, ultimately, positively impact the health of rural kentuckians. references 1. comprehensive statewide physician workforce study. kentucky institute of medicine. 2007. 2. 2010 census urban and rural classification and urban area criteria. 2013. http://www.census.gov/geo/reference/ua/urban -rural-2010.html. 3. quality through collaboration: the future of rural health care. the national academies press. 2005. 4. wheat, j.r., leeper, j.d., brandon, j.e., et al. the rural medical scholars program study: data to inform rural health policy. j am board fam pract. 2011;24(1):93-101. 5. rabinowitz, h.k. recruitment, retention, and follow-up of graduates of a program to increase the number of family physicians in rural and underserved areas. n engl j med. 1993;328(13):934-939. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 1, issue 3 original report 6. rabinowitz, h.k., diamond, j.j., markham, f.w., et al. a program to increase the number of family physicians in rural and underserved areas: impact after 22 years. jama. 1999;281(3):255-260. 7. jefferson medical college: physician shortage area program. (2013). http://www.jefferson.edu/jmc/psap.html. accessed 1/31/2013. 8. smucny, j., beatty, p., grant, et al. an evaluation of the rural medical education program of the state university of new york upstate medical university, 1990-2003. aca med. 2005:80(8):733-738. 9. zink, t., center, b., finstad, d., et al. efforts to graduate more primary care physicians and physicians who will practice in rural areas: examining outcomes from the university of minnesota-duluth and the rural physician associate program. acad med. 2010;85(4):599604. 10. appalachian regional commission: kentucky. 2014. from http://www.arc.gov/appalachian_region/kentuck y.asp 11. chipp, c., dewane, s., brems, et al. "if only someone had told me…": lessons from rural providers. j rural health. 2011;27:122-130. 12. hancock, c., steinbach, a., nesbitt, t., et al. why doctors choose small towns: a developmental model of rural physician recruitment and retention. soc sci med. 2009;69:1368-1376. microsoft word producingphysiciansforruralkansas.docx published by university of minnesota libraries publishing producing physicians for rural kansas; the early success of the university of kansas school of medicine-salina regional medical campus william cathcart-rake, m.d. doi: https://doi.org/10.24926/jrmc.v3i1.2314 journal of regional medical campuses, vol. 3, issue 1 (2020) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc william cathcart-rake, m.d., clinical professor of medicine, university of kansas school of medicine-salina, 138 north santa fe, salina, kansas 67401; email: wcathcart-rake@kumc.edu corresponding author: william cathcart-rake, m.d., clinical professor of medicine, university of kansas school of medicine-salina, 138 north santa fe, salina, kansas 67401; email: wcathcart-rake@kumc.edu all work in jrmc is licensed under cc by-nc volume 3, issue 1 (2020) journal of regional medical campuses original reports producing physicians for rural kansas; the early success of the university of kansas school of medicine-salina regional medical campus william cathcart-rake, m.d. abstract physician workforce shortages in rural areas are well-documented problems. the university of kansas school of medicine (kusm) established the salina regional medical campus (rmc) in response to the need to train more physicians interested in primary care in rural kansas. since its founding in 2011, 38 students have completed their training on the salina rmc and received their m.d. twenty-eight graduates (74%) matched in primary care residencies; 18 (44%) in family medicine. eleven of the first 16 graduates have finished residency and entered practice; 9 are in kansas, and 7 of those are in rural kansas. the salina rmc has had early success in producing primary care physicians to serve rural kansas, likely secondary to several factors, including: student background, curricular elements, and financial incentives. the salina rmc in 2011 the university of kansas school of medicine (kusm) opened a small, 4-year regional medical campus (rmc) in salina. salina is a community of approximately 48 000 people in a primarily agricultural region in north central kansas, 180 miles west of the main campus in kansas city. eight students comprised the first class to start their medical education at the salina rmc, and 8 students have been admitted each year since. with a total of 32 students, the salina rmc is the smallest 4-year allopathic medical school campus in north america. the process of developing this rmc and the elements necessary for its creation have been previously documented.1 an impetus for developing a rural medical school campus in kansas partially originated from the 2007 kansas physician workforce report detailing the undersupply and maldistribution of physicians in kansas, especially in primary care.2 the authors of the report recommended the formation of a primary care enhancement task force to make specific proposals addressing physician workforce issues. the 2009 robert graham center study of the specialty and geographic distribution of the physician workforce in the united states provided additional arguments for creation of a rural medical school campus.3 the authors lamented medical students’ decreasing interest in primary care and practice in underserved and/or rural areas. to address the shortage of physicians in rural areas, the authors recommended that medical schools admit a greater proportion of students who are more likely to choose primary care, rural practice, and care of the underserved, and shift substantially more training of medical students and residents to community, rural, and underserved settings. additionally, they recommended that new medical schools be public, with a preference for rural locations. the creation of the salina rmc was one of several measures implemented by kusm to address the documented physician workforce shortage in kansas. other measures included increasing the size of the medical school class on the main campus and creating a 28 students per class 4-year program at the urban wichita rmc in addition to the 50-student per year clinical track (years 3 and 4) established there in 1971. founders hoped that the salina rmc would attract students from rural kansas who were interested in a career in primary care medicine and returning to rural kansas to practice. matriculation on the salina rmc was not limited to students from rural communities, students wishing to pursue a career in primary care, or students wanting to eventually practice in a rural community. students were first judged to be acceptable candidates for admission to kusm before any thought was given to campus assignments. however, students were able to rank the 3 campuses in order of preference (urban kansas city main campus, urban wichita rmc, or the more rural salina rmc) on their kusm supplementary application. campus assignment decisions were made after admissions decisions. salina rmc results to date, 9 classes (a total of 72 students) have matriculated on the salina campus. one student terminated the pursuit of a medical education before graduation. sixty-two of the first 72 matriculants (86%) were kansas residents, and 61 (85%) were from communities with resident populations no larger than salina. nineteen students (26%) were graduates of the scholars in rural health program, which is a kusm program that encourages college undergraduate students from rural doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 original reports kansas to pursue careers in medicine and eventually practice in rural areas.4 rural students tend to be underrepresented in medical school applications. sixteen to 20 students are admitted to this program in their junior year of college. successful completion of this program requires significant physician shadowing hours, completion of a research project, a satisfactory mcat score (approximately 500), and graduation from college. graduates of this program are guaranteed admission to kusm but are not required to attend the rural salina rmc, choose a primary care career, or choose to practice in rural kansas. forty-one salina rmc students (57%) elected to receive kansas medical student (kms) loans to fund all or part of their medical education. this program, offered to all kusm students, funded by the state of kansas and administered by kusm, pays tuition expenses and provides a modest living allowance while the student attends medical school. loans are totally forgiven if the recipient elects to practice primary care in one of the 100 rural counties in kansas or the single medically underserved urban county (wyandotte) in kansas. for purposes of the program, primary care is defined as family medicine, general internal medicine, pediatrics, emergency medicine or geriatrics. one year of loan support is forgiven for each year of practice in a qualifying county. if the kms loan recipient chooses not to fulfill the terms of the loan agreement, he or she must repay the full amount of the loan plus accrued interest of 15% per year on the total unpaid loan amount. by june 2019, 5 classes (the classes of 2015-19)—a total of 38 students—completed their medical education on the salina rmc and received their md. all 38 graduates secured residency positions through the national residency match program (nrmp). twenty-eight (74%) of the 38 salina rmc graduates matched to primary care residencies: 47% in family medicine, 18% in categorical internal medicine, and 8% in categorical pediatrics. additionally, all 9 members of the salina rmc class of 2020 have registered for the nrmp and have applied exclusively to family medicine residency programs. during this same 5-year period, 44% of kusm graduates on the main campus and wichita rmc matched in primary care residencies; 17% in family medicine, 18% in internal medicine or med/peds, and 9% in pediatrics (table 1). table 1. residency match data for kusm-kansas city (kc) and kusm-wichita graduates, 2015-2019 nationally, 38% of u.s. medical school seniors matched in primary care; 9% in family medicine, 19% in internal medicine, and 10% in pediatrics (table 2).5-9 table 2. nrmp match data for all u.s. graduates, 2015-19 5-9 eleven of the first 16 graduates (69%) of the salina rmc (classes of 2015 and 2016) have completed residency training and started practice. nine of the 11 (82%) are practicing in kansas, and 7 (78%) are primary care physicians in rural kansas. four members of the class of 2017 have signed contracts to practice primary care in rural kansas communities upon completion of residency in 2020. ten of the 11 salina rmc graduates currently practicing in rural kansas or committed to practice in rural kansas starting in the summer of 2020 received kms loans. also noteworthy is that several salina rmc graduates currently completing nonprimary care residencies have made commitments to return to rural kansas to practice. discussion rural physician workforce shortages are not limited to kansas, and kusm is not the only medical school attempting to address the issues of fewer medical students choosing primary care practice and/or rural practice. other medical schools in the united states and foreign countries have studied these issues and created programs designed to increase the rural physician supply. the university of minnesota, jefferson medical college, washington university, and the state university of new york are among the u.s. medical schools to document programs addressing the rural workforce shortage.10-14 the multitude of factors influencing a medical student’s decision to pursue a primary care career and/or practice in a rural area must be considered in any discussion of how to address rural physician shortages. in a review of the factors influencing a physician’s decision to practice in a rural location, ballance et al15 stressed the importance of programs that attract rural students to medical school and increase their competitiveness for medical school admission and of rural experiences during medical school and residency. goodfellow et al16 conducted a systematic review of the medical literature to determine the criteria associated with a primary care physician’s decision to locate in an underserved urban or rural area. factors identified included: 1) personal characteristics, attributes, or background; 2) debt or financial incentives; 3) medical school curricula and programs; and 4) doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 original reports graduate medical education (gme) programs. isaac et al17 surveyed students enrolled in the rural clinical school program at the university of new south wales in australia regarding their interest in rural careers. factors associated with an intent to practice in a rural location included: 1) rural background, 2) two or more previous years at a rural clinical school, and 3) preference for a rural internship. curran and rourke18 and woloschuk and tarrant19 noted similar factors related to attracting physicians to rural practice locations in canada: 1) physician characteristics (rural background and interest in family medicine), 2) training environments (rural locations), and 3) a rural training curriculum. in a 1992 report of which medical schools produce rural physicians, rosenblatt et al20 noted that 12 medical schools accounted for over a quarter of all physicians entering rural practice. the authors identified 4 medical school variables strongly associated with a tendency to produce rural physicians: 1) location in a rural state, 2) public ownership, 3) greater production of family physicians, and 4) smaller amounts of nih funding. in 2015 chen et al21 published an updated report regarding which medical schools produce rural physicians. they found the proportion and number of physicians entering rural practice remained stable, and there had been no significant changes in the list of md-granting medical schools producing rural physicians in the 23 years since the rosenblatt study.20 however, several do-granting schools were identified that began contributing relatively high percentages of rural physicians during that time. the study also found that rural family medicine training programs were significant contributors to the rural physician workforce. brooks et al22 reviewed 21 quantitative articles analyzing recruitment and retention of primary care physicians in rural areas from 1990 to 2000. the authors analyzed pre-medical school, medical school, and residency training factors contributing to the choice of rural practice. six studies analyzed pre-medical school factors. rural upbringing and the students’ desire to become a family physician were the 2 factors positively associated with physicians’ practicing in rural communities. fifteen studies analyzed factors related to medical school training that influenced a student’s decision to pursue rural practice. unfortunately, in contrast to premedical school factors, no universal themes were deduced; however, specialized rural curricula and rotations and recruitment of students interested in careers as generalists were cited in some studies as factors increasing rural physician recruitment and retention. finally, the authors emphasized that the postgraduate residency experience was an important factor leading to the decision to practice in a rural area. graduates of family medicine residency programs chose rural practice at a higher rate than other specialties, and rural residency tracks and programs increased the likelihood of producing physicians recruited to a rural practice. in summary, multiple factors are associated with a physician’s decision to practice in a rural location: 1) a rural background; 2) training in a rural location; 3) inclusion of rural curricula in the medical school educational program; 4) family medicine residency, especially when located in rural areas or providing rural tracks; and 5) financial incentives. the salina rmc is rural and attracts students from rural communities with a strong desire for a career in family medicine upon entering medical school. the majority of these students do not change their minds during medical school. being a rural campus, students are continuously exposed to the rewards and challenges of rural practice and are mentored by rural practitioners on the faculty. although there is not a formal rural medicine curriculum at the salina rmc, starting in the first year of medical school all students attend educational sessions facilitated by rural physicians. all students spend at least 4 weeks in year 3 at the local family medicine residency program (smoky hill), which has a mission to train physicians for rural practice and spend a minimum of 4 weeks in year 4 with a rural primary care physician in communities other than salina. it is hoped that the more opportunities medical students are given to work with rural physicians, the more likely they will like what they see and choose a career in rural medicine. conversely, students have less exposure to urban life and practice and the desire to live and work in such an environment may be less. finally, the state of kansas offers financial incentives to students committed to practicing primary care in underserved areas of the state, and the majority of salina rmc students have benefited from this program. unfortunately, there is no guarantee that a physician will remain in a rural community long-term once the service commitment is fulfilled. sempowski23 reviewed the effectiveness of financial incentives in exchange for rural and underserved area return-of-service commitments. although financial incentives were effective recruitment tools, the one prospective cohort study he reviewed revealed that physicians who voluntarily chose rural practice were more likely to stay long-term compared to those who chose rural practice as the result of financial incentives. perhaps pathman et al24 correctly summarized the issue of preparing and retaining rural physicians: “physicians who are prepared to be rural physicians, particularly those who are prepared for small-town living, stay longer in their rural practices.” conclusions although the numbers are small, the salina rmc has had a dramatic impact on the production of primary care physicians who stay in or return to kansas, especially rural communities. several factors may contribute to salina rmc’s success, including: 1) kms loan forgiveness, 2) family ties, 3) returning to rural communities similar to those of their childhood, 4) ample opportunities to work with rural practitioners during medical school, 5) an appreciation for the challenges and rewards of rural practice developed during their undergraduate medical education years at the salina rmc, 6) not establishing ties in an urban area, and 7) specializing in doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 original reports family medicine and other primary care specialties. undoubtedly, the terms of forgiveness of a kms loan are powerful incentives for recipient physicians to practice primary care in rural kansas. nevertheless, for the medical student who knows he or she wants to become a primary care practitioner in rural kansas regardless of finances, receiving a kms loan is a rational decision, and is not the driver of the student’s specialty and practice location choices. from 2015-19, nearly one-half of salina rmc graduates matched in family medicine residency programs, five-fold greater than the match rate for all u.s. seniors participating in the nrmp, nearly three-fold greater than the match rate in family medicine for the other two kusm campuses, and three-fold greater than the match rate into family medicine among the graduates from 29 rmcs reported by liaw, et al.25 as noted, enrollment on the salina rmc is not limited to students raised in rural communities or committed to primary care and/or rural practice; however, the rural salina rmc may be the campus of choice for students with rural backgrounds who want to become primary care physicians and return to a rural community to practice. it is entirely possible that, if the graduates of the salina rmc students had attended the main kansas city campus or the wichita rmc, they would have made the same residency and practice choices; however, it is also quite possible that a medical education on an urban campus could have resulted in different specialty and practice location choices. although it is still young, and its production of rural primary care physicians to date is no guarantee of future results, kusm is optimistic that the salina rmc will stay true to its mission and make even greater strides in expanding healthcare access for rural kansans. the success of the salina rmc in training physicians who choose rural practice provides evidence—and hopefully inspiration—for other medical schools to support similar programs. programs like kms may be financially difficult for other medical schools to duplicate; however, many of the elements the salina rmc has identified that influence a medical student’s choice of rural primary care can be duplicated by medical schools, especially geographically rural rmcs. references 1. cathcart-rake w, robinson m, owings s, kennedy m, paolo a, chumley h. the birth of a rural medical school—the university of kansas school of medicine salina experience. med sci educ. 2012; 22(4):250 258. doi: 10.1007/bf03341793. 2. greiner ka, paolo a, kennedy m, cook d, cox gg, nazir n, et al. kansas physician workforce report. the university of kansas medical center and the kansas department of health and environment office of local and rural health. kansas workforce advisory board, topeka and kansas city, ks; march 12, 2007. 3. phillips, rl, dodoo, ms, petterson, s, xierali, i, bazemore, a, teevan, b, et al. medical student and resident choices? the robert graham center: policy studies in family medicine and primary care, washington, dc, 2009. 4. kallail kj, mccurdy s. scholars in rural health: outcomes from an assured admissions program. fam med. 2010; 42:729–731. pmid: 21061206 5. national resident matching program. results and data; 2015 main residency match. washington, dc: national residency matching program; april 2015. 6. national resident matching program. results and data; 2016 main residency match. washington, dc; national residency matching program; april 2016. 7. national resident matching program. results and data; 2017 main residency match. washington, dc: national residency matching program; april 2017. 8. national resident matching program. results and d ata; 2018 main residency match. washington, dc: national residency matching program; april 2018. 9. national resident matching program. results and data; 2019 main residency match. washington, dc: national residency matching program; april 2019. 10. h alaas gw, zink t, finstad d, bolin k, center b. recruitment and retention of rural physicians: outcomes from the rural physician associate program of minnesota. j rural health.2008; 2 4(4):345-351. doi: 10.1111/j.1748 0361.2008.00180.x 11. rabinowitz hk, diamond jj, markham fw, rabinowitz c. long term retention of graduates from a program to increase the supply of rural family p hysicians. acad med. 2005; 80:728-732. doi: 10.1097/00001888-2005080000-00004. 12. rabinowitz hk, diamond jj, markham fw, santana aj. increasing the supply of rural family physicians: r ecent outcomes from jefferson medical college’s physician shortage area program (psap). acad med. 2011; 86(2):264-269. doi: 1 0.1097/acm.0b013e31820469d8. 13. norris te, coombs jb, house p, moore s, wenrich md, ramsey pg. regional solutions to the physician workforce shortage: the wwami experience. acad med. 2006; 81(10):857-862. doi: 10.1097/01.acm.0000238105.96684.21. 14. smucny j, beatty p, grant w, dennison t, wolff t. an evaluation of the rural medical education program of the state university of new york upstate medical university, 1990-2003. acad med. 2005; 80(8):733-738. doi: 10.1097/00001888-200508000 00006. 15. balance d, kornegay d, evans p. factors that influence physicians to practice in rural locations: a review and commentary. j rural health. 2009; 25(3): 276-281. doi: 10.1111/j.1748-0361.2009.00230.x. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 3, issue 1 original reports 16. goodfellow a, ulloa jg, dowling pt, talamantes e, chheda s, bone c, et al. predictors of primary care physician practice location in underserved urban and rural areas in the united states: a systematic literature review. acad med. 2016; 91(9):1313-1321. doi: 10.1097/acm.0000000000001203. 17. isaac v, watts l, forster l, mclachlan cs. the influence of rural clinical school experiences on medical students’ levels of interest in rural careers. human resources for health. 2014; 12:48-53. doi: 10.1186/1478-4491-12-48. 18. curran v, rourke j. the role of medical education in the recruitment and retention of rural physicians. med teacher. 2004; 26(3):265-272. doi: 10.1080/0142159042000192055. 19. woloschuk w, tarrant m. does a rural medical educational experience influence students’ likelihood of rural practice? impact of student background and gender. med ed. 2002; 36:241-247. doi: 10.1046/j.1365-2923.2002.01143.x. 20. rosenblatt ra, whitcomb me, cullen tj, lishner dm, hart lg. which medical schools produce rural physicians? jama. 1992; 268(12):1559-1565. doi: 10.1001/jama.1992.03490120073031. 21. chen f, fordyce m, andes s, hart lg. which medical schools produce rural physicians? a 15-year update. acad med. 2010; 85(4):594-598. doi: 10.1097/acm.0b013e3181d280e9. 22. brooks rg, walsh m, mardon re, lewis m, clawson a. the roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of the literature. acad med. 2002; 77(8):790-798. doi: 10.1097/00001888-200208000 00008. 23. sempowski ip. effectiveness of financial incentives in exchange for rural and underserviced area return-of service commitments: systematic review of the literature. can j rural med. 2004; 9(2):82-88. pmid: 15603680. 24. pathman de, steiner bd, jones bd, konrad tr. preparing and retaining rural physicians through medical education. acad med. 1999; 74(7):810-820. doi: 10.1097/00001888-199907000-00016. 25. liaw w, cheifetz c, luangkhot s, sheridan m, bazemore a, phillips rl. match rates into family medicine among regional medical campus graduates, 2007-2009. j am board fam med. 2012; 25(6):894 907. doi: 10.3122/jabfm.2012.06.110336. article published by university of minnesota libraries publishing the role of non-physician health care professionals in the education of medical students at satellite campuses kelly lien, jennifer kays-sommer, alexandra bite, zamin ladha, rhiana roeper, andrew costa doi: https://doi.org/10.24926/jrmc.v1i1.998 journal of regional medical campuses, vol. 1, issue 1 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc https://doi.org/10.24926/jrmc.v1i1.998 https://pubs.lib.umn.edu/index.php/jrmc/index amichael g. degroote school of medicine, mcmaster university 1280 main street west michael degroote centre for learning and discovery (mdcl) 3104 hamilton, on l8s 4k1 canada corresponding author: kelly lien; email: kelly.lien@medportal.ca 10b victoria street south kitchener, ontario n2g1c5 canada all work in jrmc is licensed under cc by-nc volume 1, issue 1 (2018) journal of regional medical campuses original report the role of non-physician health care professionals in the education of medical students at satellite campuses kelly liena, jennifer kays-sommera, alexandra bitea, zamin ladhaa, rhiana roepera, andrew costaa abstract phenomenon: satellite campuses of medical schools in canada introduce smaller communities to new medical learners. non-physician health care professionals (nphcps) in regional hospitals may have had little prior exposure to learners. lack of clarity regarding the role of the medical student is a barrier that hinders interprofessional collaboration. the purpose of this project was to examine the educational relationship between students and nphcps in regional hospitals. approach: surveys were distributed to nphcps of various disciplines at two community hospitals in waterloo region. a second survey was distributed to medical students attending a satellite medical campus of mcmaster university. findings: surveys completed by 141 nphcps identified the following themes: frequent student interaction, no orientation to students, uncertainty of roles, willingness to teach, and barriers to teaching. student surveys demonstrated frequent interactions, lack of familiarity of their role by nphcps at regional hospitals, desire to learn from nphcps, and specific teachable procedures. insights: nphcps and medical students agree that interprofessional medical education can improve patient care, communication and the quality of education. while there is interest in involving nphcps in teaching, orienting nphcps to the roles of students in regional hospitals may improve relationships and allow informal teaching opportunities. funding: this work was supported by the michael g. degroote school of medicine, mcmaster university. keywords: interprofessional education; regional medical school; medical education; assessment; teaching introduction over the past decade medical schools across canada have introduced satellite campuses at regional sites, with goals to expand the enrolment capacity of existing medical schools as well as to address the maldistribution of physicians across geographical areas.1 training more students outside of densely populated urban areas has been demonstrated to influence the decision to remain or seek out work in smaller, underserved communities.1 as satellite medical campuses become established in communities, the local hospitals inevitably experience an influx of student learners, creating a need to increase engagement of community preceptors.2 most local physicians – having been through medical school themselves – will be familiar with the roles and learning objectives of students. however, students frequently interact with non-physician health care professionals (nphcps; i.e., nurses, dieticians, pharmacists, physiotherapists, etc.) who may not be familiar with the role of a medical student as part of the healthcare team, or their scope of practice as it pertains to patient care. mailto:kelly.lien@medportal.ca https://creativecommons.org/licenses/by-nc/4.0/legalcode https://doi.org/10.24926/jrmc.v1i1.998 journal of regional medical campuses, vol. 1, issue 1 article common themes have emerged in the literature with respect to the teaching of medical students by nphcps. benefits identified with nphcps being involved in medical education include providing support and sharing the time burden with busy physician educators, improving the quality of education while controlling costs,3 enhancing attitudes towards and understanding of healthcare roles, and improved interprofessional teamwork.4, 5 in addition, nphcps identify an increase in job satisfaction and personal enjoyment derived from teaching students.6 while many nphcps are involved in the teaching of medical students, barriers to effective teaching include a lack of guidance and training, an increase in workload and lack of provision of protected time to teach students,6-8 students’ negative attitudes towards nurses,5, 9 as well as negative perceptions about receiving teaching from nphcps instead of physicians. it is inevitable that nphcps and medical students interact during the provision of patient care, and invariably, there are mixed reports of the quality of interactions and relationships. lack of information regarding student learners-such as their current knowledge level, needs and interests of learners, as well as their competencies and expectations-have been identified in the literature as recurring challenges for nphcps working with medical students.6, 10 this concern may be of particular significance in communities that are exposed to medical students for the first time through satellite medical school campuses. little research has been undertaken to understand the particular challenges experienced by medical students and nphcps in regional or community hospitals. our primary objective was to examine the current educational relationship between medical students and nphcps at community hospitals associated with satellite medical campuses. in understanding the relationships, we sought to identify barriers that could be addressed to improve interprofessional education (ipe) of medical students in the clinical setting. we hypothesized that based on individual student experiences at the waterloo regional campus (wrc) of mcmaster university; nphcps working within the regional hospitals had limited experience working with medical students, creating a possible gap in collaboration and learning. methods study design this was a cross-sectional study of medical students and nphcps. it was developed using a quality improvement (qi) framework and was reviewed by the program for interprofessional education and research (piper) and the quality improvement boards at participating hospitals. in order to evaluate the current experiences, role familiarity, and participation in medical student education of nphcps at local hospitals, we generated an online survey that included both close-ended questions (multiple choice, likert, rank order) and open-ended questions with space for respondents to include more detail if they wished (appendix 1). similarly, we generated a second survey to evaluate medical student experiences working with nphcps in regional hospitals, with emphasis on their experiences being taught by nphcps and their attitudes towards receiving further teaching (appendix 2). questions were vetted by members of the professional advisory committees of both hospitals, and by members of the program for interprofessional education and research (piper) and michael g. degroote school of medicine waterloo regional campus faculty. the completion of both surveys was voluntary, with the incentive of being entered into a draw for a $50 gift card. this study was granted a waiver of formal reb approval due to a ruling of low risk and institutional support as a quality improvement project. study settings and participants the wrc is a satellite campus of the michael g. degroote school of medicine at mcmaster university. situated in kitchener, ontario, the campus admitted its first class of fifteen students in 2007 and since has grown to admit approximately twenty-eight students to each incoming class. medical students at the wrc complete their core clerkship training at three main community hospitals. https://doi.org/10.24926/jrmc.v1i1.998 https://doi.org/10.24926/jrmc.v1i1.998 journal of regional medical campuses, vol. 1, issue 1 article an online anonymous survey for nphcps was distributed december 2014 via email through the professional advisory committees at two affiliated regional hospitals. another online anonymous survey was distributed to medical students at the wrc in march 2015. all students were eligible to participate, leading to a potential sample size of 83 medical students. variables and data analysis closed-ended question responses were analysed using a four-point likert scale. open-ended question responses were manually coded by two research authors and grouped into the following three deductive categories determined a priori: (1) perceived barriers to nphcp involvement in medical education, (2) perceived benefits to nphcp involvement in medical education, and (3) potential teachable moments for medical students. the post hoc analysis further quantified each category into various emergent themes: (1) time, attitude, workload, logistics, role and attitude for perceived barriers, (2) patient safety, patient care, medical education, interprofessional communication and relationships, understanding of roles for perceived benefits, and (3) skill-based, patient case, documentation, role explanation, shadowing as potential teachable moments. descriptive statistics were generated for each analysis using microsoft excel (microsoft, redmond, wa). results nphcp survey results as the online survey was distributed by hospital administration, we were unable to determine the number of potentially eligible participants. we received 141 completed surveys that were included in the study and in the final analysis. the majority of responders were female (86%, n = 122) and from nursing staff (51%, n = 72), although responses were received from 18 different professions (table 1). almost ninety percent of respondents indicated that they had encountered medical students in their work (n = 119), with 33% of these indicating that they encounter medical students at least once per week (n = 44). almost all (99%, n = 117) of respondents, however, indicated that they had never received formal training regarding their role when encountering medical students. responses to a question regarding the scope of practice of medical students revealed a lack of clarity about the abilities and limitations of medical learners, particularly in regards to writing orders, communicating diagnoses and test results, and performing practical skills (table 2). the majority of respondents (90%, n = 120) indicated that it would “probably” or “definitely” be beneficial to have these roles and responsibilities clarified. a large number of respondents (81%, n = 96) also felt their profession had a role in teaching medical students. potential foreseeable barriers to their participation in medical education included time constraints (48%), student attitudes (21%), and the perception of increased workload (11%). many respondents felt teaching medical students would increase their workload (60% in the short term, 50% in the long term). however, figure 1 demonstrates that nphcps also acknowledged potential benefits (“probably” and “yes” answers) to patient safety, patient care, interprofessional communication, and the quality of medical education (80%, 67%, 86% and 77% respectively). student survey results of the 83 eligible students at wrc, 67% (n = 56) were included in the study. 5 participants did not complete the entire survey. there was an equal distribution in responses between the three classes. most respondents (94%, n = 49) indicated that they have encountered nphcps in clinical practice. nursing, pharmacy and social work were the most frequently encountered professions, while spiritual care and speech language pathology were encountered less often. figure 2 demonstrates respondents felt most familiar with the roles of nursing, pharmacy, physiotherapy, and social work, and were less familiar with the roles of spiritual care, speech, and language. https://doi.org/10.24926/jrmc.v1i1.998 https://doi.org/10.24926/jrmc.v1i1.998 journal of regional medical campuses, vol. 1, issue 1 article figure 1. figure 2. https://doi.org/10.24926/jrmc.v1i1.998 https://doi.org/10.24926/jrmc.v1i1.998 journal of regional medical campuses, vol. 1, issue 1 article students indicated that they felt there was overlap between their scope of practice as medical students and the skills and responsibilities of various healthcare professions, particularly in the fields of nursing, pharmacy, social work and respiratory therapy. many of the respondents acknowledged the expertise each profession had for the overlapping skills. 88% of respondents indicated that they felt nphcps had a direct role in the education of medical students (n = 45), and 94% indicated that they would be open to receiving teaching from nphcps in clinical practice (n = 48). potential “teachable moments” identified by medical students fell under the following themes: demonstrating or supervising a procedural skill, discussing patient care, reviewing documentation, discussing scope of practice, or shadowing an nphcp. furthermore, procedural skills, swallowing assessments, medication interactions, dietary considerations and mobility support were frequently cited by respondents as specific concepts and/or procedures they would like to receive instruction from an nphcp. internal medicine was cited the most ideal rotation to receive teaching from nphcps (76.5%, n = 39). other rotations that were most favourable include pediatrics, intensive care, psychiatry, emergency and obstetrics. students preferred to learn from nurses and pharmacists the most. figure 3 shows that most respondents (n = 50) felt that incorporating nphcps into the education of medical students would lead to improved (i.e. “probably” and “definitely” responses) to patient care (94%), patient safety (84%), interprofessional communication (96%), and higher quality of md program education (94%). additional benefits of teaching from nphcps identified by medical students were a greater appreciation of the roles of nphcps, better understanding of the multidisciplinary resources available to patients, more positive interprofessional relationships, and a broad, wellrounded undergraduate medical education with increased proficiency in clinical skills. students identified similar barriers as the nphcps to this additional teaching: time constraints, logistics, lack of clarity of the medical student role, and attitudes of the nphcps and md preceptors. figure 3. https://doi.org/10.24926/jrmc.v1i1.998 https://doi.org/10.24926/jrmc.v1i1.998 journal of regional medical campuses, vol. 1, issue 1 article in comparing their experiences at a regional campus to those at a larger academic centre, many respondents identified that nphcps in larger academic centers were more familiar with their role as medical students compared to those in regional sites (53%, n = 32). there was no difference in frequency of interactions with nphcps, variety of nphcps encountered, or how active nphcps were in the training of medical students. discussion to our knowledge, this is the first study to investigate the particular challenges that regional medical students face when interacting with nphcps at regional or community hospitals as compared to larger academic centres. firstly, there is a paucity of understanding regarding medical students’ roles and responsibilities in a hospital setting. this is evidenced through the self-assessments completed by the health professionals and through our survey questions that required them to correctly identify certain competencies and responsibilities of medical students. the reason for this gap in knowledge is likely multifactorial, but may include a lack of previous exposure to medical students, as many nphcps at newer satellite campuses may have never have worked with medical students prior to the creation of the campus. the survey also revealed that nearly all nphcps surveyed had not received any orientation to working with medical learners, suggesting that this may represent a previously unidentified gap in planning when introducing new satellite campuses. as distributed medical education models are being expanded across canada, planning committees should consider incorporating this demonstrable gap in preceptor and staff preparation, as it may have important impacts on patient care and safety, in addition to the quality of medical education experience. furthermore, our study showed students perceived very little difference between the number and variety of interactions with nphcps at regional and larger teaching centers. however, students felt that nphcps at larger academic centers had a better understanding of their abilities and limitations. their doubts appear to be well-founded, as the results of our survey showed that nphcps were frequently unaware that students were not able to give verbal or written orders. undoubtedly, this confusion may create a scenario whereby patient safety could be compromised, as there may be confusion in proceeding with treatment orders that have not yet signed by a physician. until nphcps in regional hospitals understand the roles and limitations of a medical student, effective teaching and collaboration within health care teams may be hindered. to this end, we have begun a trial of disseminating this information in the form of posters located in physician and nursing work stations inside community hospitals detailing “working with a medical student”. other strategies may include online training modules or supplementary handouts given out during the hiring process for new staff. themes that were generated post hoc from the survey sent to medical students indicate that students are keen on engaging with and learning from nphcps. specific skills they would like to be taught by nphcps, as well as which specific health care providers they would ideally like to learn them from were identified. the teaching of specific skills has been noted in the literature to improve attitudes and relationships between medical students and nurses, leading to better interprofessional collaboration.3-6 these learning objectives could be incorporated into the undergraduate medical education program to prepare students, provide comprehensive education, and to improve interprofessional relationships. for example, formal teaching labs or sessions led by nphcps could be conducted with students of other health care professions e.g. nursing students. limitations this study is limited to an analysis of nphcps working at regional and community hospitals and students at a regional medical school campus. the ideal study would have included nphcps and medical students from larger academic centres to allow for a thorough comparison of the four groups. in particular, the answers nphcps gave regarding the limitations and abilities of a medical student could have been compared. despite this, the fact the 8 out of 11 questions were answered with fewer than 60% correct responses show that nphcps at regional sites https://doi.org/10.24926/jrmc.v1i1.998 https://doi.org/10.24926/jrmc.v1i1.998 journal of regional medical campuses, vol. 1, issue 1 article do not confidently know what medical students can and cannot do. in addition, the school and hospital administration were not surveyed to determine if any formal orientation of hospital staff was implemented prior to the introduction of learners when the regional campus was first opened in 2007. it is possible that previous hospital department leads had the relevant information about medical learners, but current workers did not receive any formal orientation. furthermore, in a larger academic setting, it is unknown if newly hired nphcps receive formal job orientation regarding the presence of medical learners, or if this knowledge comes from colleagues “on-the-job.” conclusion this study sought to evaluate the experiences of medical students and nphcps at community hospitals associated with satellite medical campuses. the lack of clarity regarding the role of a medical student in hospitals presents a rectifiable barrier at regional medical school campuses that may improve interprofessional collaboration and patient care and safety. prior to working with nphcps, the student’s role as a member of the health care team and within hospitals needs to be clarified. the usage of formal online teaching modules, orientation handouts or posters in hospital workspaces are some strategies that may be able to bridge this gap in knowledge. references 1. kondro w. eleven satellite campuses enter orbit of canadian medical education. cmaj. 2006;175(5):461-2. 2. piggott t, morris c, lee-poy m. preceptor engagement in distributed medical school campuses. can med educ j. 2015;6(2):e20-8. 3. riesenberg la, little bw, wright v. nonphysician medical educators: a literature review and job description resource. acad med. 2009;84(8):1078-88. 4. afriat ci. nurse-midwives as faculty preceptors in medical student education. j nurse midwifery. 1993;38(6):349-52. 5. rudland jr, mires gj. characteristics of doctors and nurses as perceived by students entering medical school: implications for shared teaching. med educ. 2005;39(5):448-55. 6. howe deborah crofts kate billingham a. can nurses teach tomorrow's doctors? a nursing perspective on involvement in community-based medical education. med teach. 2000;22(6):576-84. 7. smith p, cotton p, o'neill a. 'can you take a student this morning?' maximising effective teaching by practice nurses. med educ. 2009;43(5):426-33. 8. walsh a, moore a, barber a, opsteen j. educational role of nurse practitioners in a family practice centre: perspectives of learners and nurses. can fam physician. 2014;60(6):e316, e8-21. 9. nadolski gj, bell ma, brewer bb, frankel rm, cushing he, brokaw jj. evaluating the quality of interaction between medical students and nurses in a large teaching hospital. bmc med educ. 2006;6:23. 10. beber s, antao v, telner d, et al. examining the teaching roles and experiences of non-physician health care providers in family medicine education: a qualitative study. bmc med educ. 2015;15:15. https://doi.org/10.24926/jrmc.v1i1.998 microsoft word thewritestuffarticle.docx published by university of minnesota libraries publishing the write stuff: a rural longitudinal integrated clerkship addresses workforce needs. misbah keen, md, mbi, mph; danielle gunder, med; toby keys, ma, mph; douglas schaad, phd; david evans, md doi: https://doi.org/10.24926/jrmc.v2i5.2103 journal of regional medical campuses, vol. 2, issue 5 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc misbah keen md, mbi, mph; professor and executive vice chair, department of family medicine, university of washington, 1959 ne pacific st, box 356390, seattle, washington 98195 usa; mkeen@uw.edu danielle gunder med; education specialist, office of rural programs, university of washington school of medicine, 1959 ne pacific st, box 356340, seattle, washington 98195 usa; dbienz1@uw.edu toby keys ma, mph; lecturer, department of family medicine, university of washington, 1959 ne pacific st, box 356390, seattle, washington 98195 usa; keyst@uw.edu douglas schaad phd; division head of medical education and evaluation, biomedical informatics and medical education, university of washington, box 358047, seattle, washington 98195 usa; schaad@uw.edu david evans md; rosenblatt family endowed professor in rural health, program director university of washington family medicine residency, 331 ne thorton place, box 358732 seattle, washington 98125 usa; evansd9@uw.edu corresponding author: misbah keen md, mbi, mph; professor and executive vice chair, department of family medicine, university of washington, 1959 ne pacific st, box 356390, seattle, washington 98195 usa; mkeen@uw.edu all work in jrmc is licensed under cc by-nc volume 2, issue 5 (2019) journal of regional medical campuses original reports the write stuff: a rural longitudinal integrated clerkship addresses workforce needs. misbah keen, md, mbi, mph; danielle gunder, med; toby keys, ma, mph; douglas schaad, phd; david evans, md abstract introduction: the university of washington school of medicine has 6 campuses in the 5 state wwami (washington, wyoming, alaska, montana, and idaho) region. the write (wwami rural integrated training experience) program is a 22 to 24 week long rural longitudinal integrated clerkship experience offered to medical students in their clinical phase (third year) of training. this program seeks to meet the rural workforce needs of the wwami region by increasing the number of medical students going into primary care. critics of lics have expressed concern about overall quality control of the more remote educational experience and the lack of specialty specific teaching. the aim of this study was to compare medical school and pgy-1 performance of write and non-write students while determining how well each cohort is meeting the primary care regional workforce needs. methods: the study group was all uwsom students who matriculated from 2009 to 2013, advanced to graduation, and subsequently matched to a residency through the national residency match program. write and non-write cohorts were compared for usmle step 1 and 2 scores, mspe (medical student performance evaluation) key word, and self and program director assessments in the first year of residency. the match results of the 2 cohorts were also compared to determine the proportions entering primary care residencies. finally, for both cohorts the specialty choice at matriculation was compared with the match results. descriptive statistics were used to test the comparisons. results: the medical school performance of the write and non-write cohorts was equivalent in all metrics (usmle step 1 and 2, mspe key word, self and program director assessment of performance in the first year of residency). write students were significantly more likely to match into primary care (67.6% vs. 48.3%, p<0.001) overall and, in particular, family medicine as their specialty (40% vs. 14.3%, p<0.001). write students were also more likely to match into the same specialty that they indicated on the uwsom matriculation survey. for family medicine the loss of fidelity between matriculation and match among write students was 3% (43.4 40.4) and among non-write students, it was 6.3% (20.6 14.3). conclusions: performance outcomes of the write program are equivalent to a traditional block curriculum. however, the write cohort is significantly more likely to go into primary care fields, especially family medicine, and is more likely to stay with the declared specialty at matriculation. medical schools that seek to increase the number of students going into primary care may benefit from adopting a similar model. introduction the united states healthcare system faces a shortage of primary care physicians. this shortage is especially critical in rural communities. there are approximately 80 primary care physicians per 100,000 people in the united states; however, they are unequally distributed with 68 per 100,000 in rural areas and 84 per 100,000 in urban areas. 1 washington, wyoming, alaska, montana, and idaho (wwami) comprise 27% of the us landmass and 3.4% of the population, journal of regional medical campuses, vol. 2, issue 5 original reports accounting for some of the most rural areas in the united states. these states are all part of the wwami program, the university of washington’s regional medical education partnership. development of a strong rural physician workforce in this region is of paramount importance to the university of washington school of medicine (uwsom) and its wwami partners in this 5 decades old regional medical education program. 2 the clinical phase of medical education should optimally allow learners to participate in a social learning process through continuous and collective activities within a community. 3 training in an environment that provides students an opportunity to observe and experience relationships among physicians, patients, and members of the health care team encourages learners to become a member of the healthcare community. 4 longitudinal integrated clerkships (lics) were created with continuity as a main pillar of structure. this style of clerkship allows students to stay in one place with a set of continuity patients and integration of multiple clinical specialties for extended periods of time, thus enhancing the educational experience in primary care. in contrast to the traditional block rotation curriculum, lics seek to allow the student to master clinical competencies across multiple specialties concurrently, participate in continuity of care with a community of patients, and develop a continuous relationship with preceptors on site. critics of medical education in a community-based setting have expressed concern about overall quality control of the more remote educational experience, including maintaining faculty development, faculty expertise, exposure to adequate patient numbers, and patient acuity. 5-8 there is also a perception that the lack of specialty specific teaching during a longitudinal clerkship detracts from knowledge acquisition. 9 developed in 1996, the wwami rural integrated training experience (write) is a rural lic offered to medical students during their third year of medical school at uwsom. the aim is to help meet the need for rural primary care physicians in the wwami region. administered by the office of rural programs with the support of the regional clinical deans across 6 regional campuses, write students participate in an integrated experience spanning 22 to 24 weeks within one assigned rural community. this rotation consists of an 18week core curriculum, including 6 weeks of family medicine, 6 weeks of outpatient internal medicine, 3 weeks of outpatient pediatrics, 3 weeks of outpatient psychiatry, and either 6 weeks of obstetrics/gynecology or a 4-week advanced family medicine clerkship. students spend at least one day per week in clinic with their primary care preceptor and consistent community-based patient panel. the remainder of the week is spent with preceptors within the community to achieve the required components of the other clinical disciplines. the remainder of clerkships, including inpatient internal medicine, pediatrics, and psychiatry, are done during the other half of the clinical year in tertiary care centers connected to the academic healthcare system. the surgery clerkship is not part of the write curriculum and is completed anywhere in the wwami region during the 6month “inpatient” clerkship block. write sites are selected based on clinical services offered in the community and physician commitment to teaching. quality of the clinical experience is maintained through a collaborative effort of involved departments, regional clinical deans and the write director, and staff through regular meetings and biennial site visits. this study reports on the academic performance of write students compared to non-write students who entered the uwsom over the 5-year period from 2009 to 2013. it further examines match rates into primary care specialties between write versus non-write students. the results of this study contribute to an ongoing vigorous discussion of the role of lics in medical education, their academic integrity, and their ability to meet stated workforce objectives. methods subjects this retrospective cohort study analyzed data from all uwsom students who matriculated from 2009 to 2013, advanced to graduation, and subsequently matched to a residency through the national residency match program (nrmp). the total number of students in the study group who completed the write program was 99, referred to as write students. there were 1016 uwsom students meeting the selection criteria who did not complete write, referred to as non-write students. setting at the time of the study, uwsom was the only allopathic medical school in the 5 state wwami (washington, wyoming, alaska, montana, and idaho) region. wwami has 6 regional campuses (seattle, spokane, anchorage, bozeman, moscow, laramie) in 5 states. uwsom has 100+ decentralized clinical training sites in the region. uwsom’s mission, in part, is to provide for the physician workforce needs in this rural region. students complete the third year required clerkships either in traditional block format (majority of students) or in the longitudinal integrated clerkship model in the write program. write clinical sites are all in rural areas of the wwami region and administered, in part, by regional campus assistant deans. students interested in write participation apply to the program during their ms2 year and are interviewed by write leaders for admission to the program. write candidates are interviewed and selection is based on interest in a rural experience and good academic standing. all uwsom students take usmle step 1 before their clerkship experience, then take step 2 after their core clinical clerkships, including write. data sources journal of regional medical campuses, vol. 2, issue 5 original reports de-identified student data on academic parameters, nrmp match specialty, and specialty interests at matriculation were obtained from the university of washington division of medical education and evaluation for the entering year (ey) classes of 2009 to ey 2013 (5-year period). the division of medical education contacts graduates and their residency program directors 6 months into the pgy1 year to assess graduate performance as a resident compared to peers. parallel questions are asked of the graduate and the residency program director. written consent by the graduate is required to contact residency program directors. surveys are sent by mail to the graduate in care of the residency program into which they matched. response rates during the years studies very highly variable for the student survey as well as for the directors survey. the variability is likely because our school requires student consent before these surveys are administered. analysis differences between write and non-write students with respect to academic performance and specialty selection were examined. measures were selected to be considered as important milestones and evidence of overall performance in medical school. parameters utilized included comparison of usmle step 1 scores, usmle step 2 scores, and medical student performance evaluation (mspe) key words (good, very good, excellent, outstanding) as metrics of overall performance in medical school. the mspe keyword is a summative of the medical student performance and shows where each student ranks in comparison to their peers. to assess preparedness for residency, pgy-1 self and program director assessments were compared. the specialty match results of write and non-write students were compared, and specialties were divided into primary care and non-primary care according to the aamc’s definition of family medicine, internal medicine, pediatrics, and med/peds. the match rates of individual primary care specialties were then compared. write and non-write student indicated specialty choice at matriculation and this was compared with actual specialty choice at match. the write and non-write comparisons were made as a cohort for all categories except for the usmle step 1 and 2 scores. this was necessary because of the large variation in year to year usmle mean scores. descriptive statistics were calculated for all comparisons. we calculated the mean, standard deviation, and p scores using the paired ttest. the university of washington human subjects division determined this study not to be human subject research. results write students performed at an equivalent level to students in the traditional curriculum (non-write students). no statistically significant differences between write and nonwrite students were found in usmle step 1, usmle step 2, mspe key word, self-assessed performance in pgy-1 year, or residency program director assessed performance during pgy-1 year (tables 1-2, figures 1-2). table 1: comparison of medical student performance evolution (mspe) keywords between write and non-write students table 2: comparison of usmle step 1 and 2 performances between write and non-write students by entering class cohorts journal of regional medical campuses, vol. 2, issue 5 original reports figure 1: comparison of residency program director pgy-1 assessment of performance between write and non-write students figure 2: comparison of pgy-1 self-assessment of performance between write and non-write students write students were significantly more likely to choose primary care (67.6% vs 48.3%, p<0.001) overall and, in particular, family medicine as their specialty (40% vs 14.3%, p<0.001) (figure 3). write students were also more likely to match into the same specialty that they indicated on the survey done at matriculation. for family medicine the loss of fidelity between matriculation and match among write students was 3% (43.4 40.4) and among non-write students, it was 6.3% (20.6 14.3). for total primary care the loss of fidelity between matriculation and match among write students was 3.7% (71.3 67.6) and among non-write students, it was a gain of 2.9% (45.4 48.3). figure 3: comparison of specialty match data between e09 e13 write and non-write students discussion in this study, it was found that students who participated in the write program performed in medical school and in pgy1 at an equivalent level to that of the students following the traditional curriculum (non-write students). mspe key word distribution (key summary metric of medical school performance), usmle step 1 and step 2 performance and the pgy-1 self and residency program director assessment were considered. while overall performance was the same, the write students were much more likely to choose primary care overall and, in particular, family medicine as their specialty. smaller positive trends were also present in internal medicine and pediatrics specialty choice among the write students but were not statistically significant. furthermore, write students who chose family medicine as a specialty choice at matriculation were more likely to match in family medicine than non-write students who chose family medicine at matriculation. wwami is a 5-state area encompassing over one million square miles. except for in washington, about 50% of the wwami population live in a non-metro area. it has been estimated that by 2035 the u.s. needs 33,000 additional primary care physicians to meet the needs of the growing and aging population. 10 this gap can only be closed by increasing the number of medical students matching into primary care specialties. 11 in 2010, washington ranked number 17 for number of active physicians per 100,000 population with wyoming at 47 th alaska at 26 th , montana at 32 nd and idaho at 49 th . 12 as additional states within wwami expand medicaid access under the affordable care act, it is expected that workforce needs will be further aggravated. 13 in general, educational and admissions interventions that have been shown to be effective in attracting medical students to primary care and family medicine include: targeted admissions, supportive longitudinal curricula, and exposure to positive role models. the write program is a journal of regional medical campuses, vol. 2, issue 5 original reports longitudinal program that exposes students to rural primary care clinicians as role models and has been previously described. 14 previous studies of lics have largely compared program structure. other studies have compared academic performance outcomes, such as step scores and nbme exams. this research demonstrates similar or better performance among longitudinal students compared to traditional block students. 8, 15-21 studies of lics that have examined workforce outcomes have previously shown graduates are more likely to practice primary care. 20, 22-24 our findings are consistent with these previous studies of primary care-focused longitudinal clerkships and highlight the importance of such programs to address workforce goals. there are multiple strengths to this study. data was examined over a 5-year period and directly compared our study group to an appropriate control group. multiple commonly accepted variables used to evaluate student performance were also examined. this study has limitations as well. it was performed at one institution with a unique structure and a stated interest in meeting a rural workforce needs. students self-select to participate in the write program and may already be inclined to match into primary care and family medicine. our workforce results may be influenced by disproportional exposure among write students to primary care preceptors during clinical clerkships. the results show an association between write participation and family medicine match, but the study is not designed to show causality. the post graduate survey (pgy) response rate is variable and frequently low. however, this is the best available data to measure pgy performance. conclusion this study confirms that the educational outcomes of the write program are similar to a traditional block curriculum. while performance measures between write and nonwrite students were similar, write students selected primary care specialties, especially family medicine, at higher rates than non-write students, thus addressing the workforce needs of the rural wwami region. these results are important to medical educators and workforce policy makers and contribute to the growing body of literature supporting lics as both a quality educational experience and a potential solution to specific workforce needs. references 1. petterson sm, phillips jr rl, bazemore aw, koinis gt. unequal distribution of the u.s. primary care workforce. american family physician [internet]. 2013; 87(11). available from: https://www.aafp.org/afp/2013/0601/od1.html. 2. ramsey pg, coombs jb, hunt dd, marshall sg, wenrich md. from concept to culture: the wwami program at the university of washington school of medicine. acad med. 2001;76(8):765-75. 3. hirsh da, ogur b, thibault ge, cox m. "continuity" as an organizing principle for clinical education reform. n engl j med. 2007;356(8):858-66. doi: 10.1056/nejmsb061660 4. teherani a, irby dm, loeser h. outcomes of different clerkship models: longitudinal integrated, hybrid, and block. acad med. 2013;88(1):35-43. doi: 10.1097/acm.0b013e318276ca9b 5. morrison t, brown j, bryant m, nestel d. benefits and challenges of multi-level learner rural general practices--an interview study with learners, staff and patients. bmc med educ. 2014;14:234. doi: 10.1186/1472-6920-14-234 6. alhaqwi ai, taha ws. promoting excellence in teaching and learning in clinical education. journal of taibah university medical sciences. 2015;10(1):97101. 7. murray e, jolly b, modell m. a comparison of the educational opportunities on junior medical attachments in general practice and in a teaching hospital: a questionnaire survey. med educ. 1999;33(3):170-6. 8. couper i, worley ps, strasser r. rural longitudinal integrated clerkships: lessons from two programs on different continents. rural remote health. 2011;11(2):1665. 9. hemmer p. longitudinal, integrated clerkship education: is different better? counterpoint. acad med. 2009;84(7):822. doi: 10.1097/acm.0b013e3181a843b1 10. petterson sm, liaw wr, tran c, bazemore aw. estimating the residency expansion required to avoid projected primary care physician shortages by 2035. ann fam med. 2015;13(2):107-14. doi: 10.1370/afm.1760 11. rosenblatt ra. commentary: do medical schools have a responsibility to train physicians to meet the needs of the public? the case of persistent rural physician shortages. academic medicine: journal of the association of american medical colleges. 2010;85(4):572. doi: 10.1097/acm.0b013e3181d306b8 12. the kaiser family foundation state health facts. data source: the centers for disease control and prevention (cdc), national vital statistics reports (nvsr), vol. 66, no. 1: births: final data for 2015, january 5, 2017. 13. allen sm, ballweg ra, cosgrove em, engle ka, robinson lr, rosenblatt ra, et al. challenges and journal of regional medical campuses, vol. 2, issue 5 original reports opportunities in building a sustainable rural primary care workforce in alignment with the affordable care act: the wwami program as a case study. acad med. 2013;88(12):1862-9. doi: 10.1097/acm.0000000000000008 14. erickson js, norris te, schaad dc. administering a rural longitudinal integrated clerkship across 5 us states. the open medical education journal [internet]. 2013; 6:1-11. 15. zink t, halaas gw, finstad d, brooks kd. the rural physician associate program: the value of immersion learning for third-year medical students. j rural health. 2008;24(4):353-9. doi: 10.1111/j.17480361.2008.00181.x 16. myhre dl, woloschuk w, jackson w, mclaughlin k. academic performance of longitudinal integrated clerkship versus rotation-based clerkship students: a matched-cohort study. acad med. 2014;89(2):292-5. doi: 10.1097/acm.0000000000000110 17. woloschuk w, myhre d, jackson w, mclaughlin k, wright b. comparing the performance in family medicine residencies of graduates from longitudinal integrated clerkships and rotation-based clerkships. acad med. 2014;89(2):296-300. doi: 10.1097/acm.0000000000000113 18. norris te, schaad dc, dewitt d, ogur b, hunt dd, consortium of lic. longitudinal integrated clerkships for medical students: an innovation adopted by medical schools in australia, canada, south africa, and the united states. acad med. 2009;84(7):902-7. doi: 10.1097/acm.0b013e3181a85776 19. hirsh d, gaufberg e, ogur b, cohen p, krupat e, cox m, et al. educational outcomes of the harvard medical school-cambridge integrated clerkship: a way forward for medical education. acad med. 2012;87(5):643-50. doi: 10.1097/acm.0b013e31824d9821 20. walters l, greenhill j, richards j, ward h, campbell n, ash j, et al. outcomes of longitudinal integrated clinical placements for students, clinicians and society. med educ. 2012;46(11):1028-41. doi: 10.1111/j.1365-2923.2012.04331.x 21. latessa r, beaty n, royal k, colvin g, pathman de, heck j. academic outcomes of a community-based longitudinal integrated clerkships program. med teach. 2015;37(9):862-7. doi: 10.3109/0142159x.2015.1009020 22. halaas gw, zink t, finstad d, bolin k, center b. recruitment and retention of rural physicians: outcomes from the rural physician associate program of minnesota. j rural health. 2008;24(4):345-52. doi: 10.1111/j.17480361.2008.00180.x 23. zink t, center b, finstad d, boulger jg, repesh la, westra r, et al. efforts to graduate more primary care physicians and physicians who will practice in rural areas: examining outcomes from the university of minnesota-duluth and the rural physician associate program. acad med. 2010;85(4):599-604. doi: 10.1097/acm.0b013e3181d2b537 24. hirsh d, walters l, poncelet an. better learning, better doctors, better delivery system: possibilities from a case study of longitudinal integrated clerkships. med teach. 2012;34(7):548-554. doi: 10.3109/0142159x.2012.696745 evaluation article.docx published by university of minnesota libraries publishing evaluation of a summer research program for medical students on a regional medical campus lynsie radovich, phd; paula m. termuhlen, md; catherine a. mccarty, phd, mph, hec-c doi: https://doi.org/10.24926/jrmc.v6i2.4970 journal of regional medical campuses, vol. 6, issue 2 (2023) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc lynsie radovich, phd; university of minnesota medical school, duluth campus paula m. termuhlen, md; western michigan university homer stryker m.d. school of medicine catherine a. mccarty, phd, mph, hec-c; university of minnesota medical school, duluth campus corresponding author: dr. lynsie radovich memory keepers medical discovery team university of minnesota medical school, duluth campus 624 e 1st street, suite 201 duluth, mn 55805lradovic@d.umn.edu 218-726-7940 all work in jrmc is licensed under cc by-nc volume 6, issue 2 (2023) journal of regional medical campuses original reports evaluation of a summer research program for medical students on a regional medical campus lynsie radovich, phd; paula m. termuhlen, md; catherine a. mccarty, phd, mph, hec-c abstract in 2015, the university of minnesota medical school duluth campus implemented a summer research program for medical students between their first and second years of training. the goal of the medical student summer research program is to provide support for students who wish to participate in research as part of their medical training and to provide support for faculty for their ongoing research. the program is not a required part of the curriculum and students self-select to participate. we have fostered relationships with faculty mentors from our institution, two regional hospitals, as well as external institutions to support this program. here we report on attitudes and assessments about this program over the first seven years. student surveys indicate that the amount of additional stress of taking on a research project is manageable, overall critical thinking skills and communication skills improved by participating in research, and a greater appreciation for the importance and relevance of research to their practice was developed. faculty survey results indicate that the stress of mentoring is manageable and many faculty report deliverable outcomes such as publications and grant submissions after having mentored students, however there are still some faculty needs that must be addressed. the overall survey results, and the continued support from faculty as mentors, highlight the culture of respect for research, training, and service at the medical school duluth and the importance of having a dedicated and sustainable medical student summer research program available to our students. background in the united states, the liaison committee on medical education (lcme) accredits medical education programs resulting in an md degree. the accreditation process is voluntary and peer-reviewed to ensure that medical education programs uphold 12 established standards. two of the 12 standards explicitly mention research opportunities being a requirement for medical education programs. specifically, a medical education program must be carried out in an environment that fosters intellectual challenge and the spirit of inquiry, and provides sufficient opportunities and support for student participation in research. additionally, faculty in a medical education program must ensure that the medical curriculum includes instruction in the scientific method, scientific principles and ethics, and how research is evaluated and applied to patient care.1 as competitiveness in careers for medical graduates increases, research skills as part of the curriculum have come to the forefront at medical schools worldwide. integrating research skills into medical curricula can increase students’ confidence in not only carrying out research post-graduation but also their ability to critically evaluate scientific literature.2 in recent years the paradigm in medical education has embraced evidence-based medicine (ebm) such that scientific data are used to guide diagnosis, and physicians need additional skills to interpret and apply published data in their practice. using research opportunities to develop these skills can be considered a foundation in medical education. when encouraged to participate in research, medical student participation varies by medical school and country, varying from 25% to 95%, suggesting that formalized research programs are needed to promote student participation in research. additionally, formalized research programs promote completion of research projects and publication or presentation of data.3 journal of regional medical campuses, vol. 6, issue 2 original reports here we describe the medical student summer research program (mssrp) implemented at the university of minnesota medical school duluth campus (medical school duluth) and report student and faculty assessments and attitudes toward the first 7 years of the program. the medical school duluth is a regional campus medical school, and students train during the first two years of their medical education in duluth and complete their third and fourth-year clerkships at various sites in minnesota. formalized research programs widen access to research opportunities for underrepresented groups by providing a positive experience.4 in this case, the mssrp opens up research opportunities to students who choose to train at a regional medical campus, which can present its own challenges due to fewer resources, support, and infrastructure for mentoring.5 however, at the duluth campus we have leveraged our smaller class size (65 students in each entering class) to be nimble in designing programs to support medical students. the medical school duluth developed the medical student summer research program for medical students in 2015 to provide a more formal venue in which students can participate in research and gain valuable training through biomedical, social/behavioral, educational, or clinical studies. in addition to research skills, participants from research programs have reported that research helped them to develop interpersonal skills, including collaborative research ability and an increased sense of confidence in forming research questions, analyzing data, and writing manuscripts.6 critical to our program are research mentors who volunteer to participate. research mentors are identified not only at the medical school duluth but also at the medical school twin cities campus, two local hospitals, as well as other opportunities identified by students at external institutions. the majority of medical students at the duluth campus work with investigators from the medical school duluth. in this way, the mssrp supports faculty and clinicians’ research goals in addition to students’ goals and training needs. methods program details and components the mssrp is specifically in place for students who have completed their first year of medical school, with research to be carried out over eight weeks during the summer between their first and second years. each year, a brief description of research opportunities for students is requested from potential mentors and available projects are compiled into a list and distributed to first-year medical students early in the spring semester. students are responsible for contacting the mentors to establish a working relationship. in addition to the mentorprovided project descriptions, students are encouraged to propose their own research ideas (with a faculty advisor) or continue working on projects on which they have previously worked. as part of the mssrp, a summer stipend ($2000) is offered to students on an application-based system. the application includes a one-page project summary, including research aims and/or hypotheses and a plan for institutional review board approval (if required). students must also outline their role in the project and their goals related to the research experience. the mssrp also provides up to $1000 to research mentors for research expenses on a reimbursement basis; the stipend for mentors is provided to all students whose applications are approved for the summer stipend. students and mentors who participate in the mssrp are selfselected; thus far the limiting factor for participation has been students as the number of available projects has outnumbered student participants. the overall timeline for the process of mentor matching and reviewing stipend applications encompasses most of the spring semester. in early february, faculty and clinicians are queried via email about participating in the program as research mentors. the list of available mentors and projects are distributed to first-year medical students in early march. applications for student stipends are due in mid-march and notifications are sent to students by the end of march. students are encouraged to meet with their research mentor as soon as possible to allow time to submit any required irb documentation. coursework for first year medical students is completed by the end of june and students are encouraged to be poised to begin their data collection at that time. journal of regional medical campuses, vol. 6, issue 2 original reports training and compliance in addition to providing a venue in which students can participate in research, the medical student summer research program also prepares students for the required training and compliance to complete research. a didactic research integrity and onboarding session is hosted by the directors of the mssrp and is required for students who wish to participate in the program. the session covers requirements for collaborative institutional training initiative (citi) training, research integrity and reporting, and institutional review board (irb) submission requirements. compliance with these requirements is closely monitored. the mssrp has a dedicated irb specialist who guides students and research mentors through the application process and associated documentation requirements. because the summer research timeline is short, students are encouraged to begin preparing their irb documentation early in the spring semester to leave ample time for irb approval without compromising the time needed for data collection. symposium and awards those who participate are required to present their research at the medical student research symposium specifically designed for students in the mssrp. the symposium is held in the spring semester after the summer research experience. the requirement to present serves as a safeguard that students will complete their research projects in a timely manner and also provides an opportunity for students to share their results with peers and mentors. each student is required to present a three-minute talk about their research. using the short talk model allows for over 25 students to give talks in a two-hour timeframe and also reinforces the idea of developing elevator speeches to succinctly describe their research, which has been shown to increase scientific communication skills.7 following the student talks is a one-hour poster session during which each student presents a poster. associated with the medical student research symposium are a number of research awards sponsored by the mssrp and by individual departments at the medical school duluth. faculty (including leaderships) are recruited each year from both the duluth and twin cities campuses to serve as judges for both the student talks and posters with prepared rubrics. the students with the two highest scoring talks and posters earn awards (a small monetary amount and a certificate) which are presented at the second year student farewell banquet attended by peers, faculty, and staff. program staff and support the mssrp at the medical school duluth campus has identified program directors and is a collaborative effort. the program directors interact with students and mentors to facilitate matching of students with projects. additionally, one of the program directors is the irb specialist for the duluth campus. while students and mentors are required to complete their own irb documentation, the irb specialist provides continuity by having familiarity with the students, mentors, their research projects, and irb requirements for submission and compliance. the duluth campus houses two departments, biomedical sciences and family medicine and biobehavioral health, both of which are highly supportive of the research program and provide financial and infrastructure support. there is also involvement from the education departments at both local hospital systems, essentia health and st. luke’s hospital, to onboard and train those students who choose to work with investigators from those institutions. irb compliance the project to evaluate the research program was reviewed by the irb at the university of minnesota and determined not to be human subjects research because personal identifiers were not collected in the surveys. medical students at the university of minnesota medical school duluth between their first and second years of training were surveyed via redcap to collect their assessments of the mssrp. faculty at the medical school were also surveyed via redcap to collect their attitudes and assessment of medical student research and the mssrp. surveys were sent to 112 medical students and 51 faculty; the response rate was 29% for students and 63% for faculty. results there has been a steady increase in the number of students who have participated in the mssrp on the duluth campus since its inception in 2015 (figure 1). journal of regional medical campuses, vol. 6, issue 2 original reports notably, there was a steep increase in the number of students who participated beginning in 2019 as compared to previous years. this is reflective of the fact that there was a call put out to faculty and clinicians at local hospitals to submit project descriptions appropriate for a summer research experience for a medical student. previous to 2019, a formalized list of mentors and projects was not distributed to students, leaving the bulk of the responsibility on the students to identify research mentors. the types of research projects undertaken by student researchers are not limited by the mssrp. projects from 2020 and 2021 were categorized into one of four categories: clinical, biomedical, educational, or social/behavioral. most students pursued a clinical project often under mentorship of a practicing clinician. while the percentage of biomedical projects remained constant over the two years assessed, there was a small shift from the proportion of clinical projects to educational and behavioral/social (figure 2). mentors are recruited for the mssrp on a volunteer basis. the proportion of mentors who have primary appointments at the medical school duluth campus/medical school twin cities campus (dmed/tmed), a regional institution (st. luke’s hospital and essentia health), remained nearly constant in 2020 and 2021 (figure 3). journal of regional medical campuses, vol. 6, issue 2 original reports notably, the large proportion of mentors are faculty from the medical school duluth. students were surveyed before and after their research experience for their assessment of the mssrp and the skills they may have gained from research experience. as shown in table 1, students’ confidence in critically evaluating data/literature showed a statistically significant improvement (p<0.05) due to their research experience. while not statistically significant, the results from the other survey questions were overwhelmingly positive. improvements were reported for students’ confidence in sharing their scientific/medical ideas with peers and critical thinking skills. additionally, students reported that they see research as relevant to their future career goals, including practicing evidence-based medicine, and are more likely to participate in research and collaborative relationships in their practice after participating in the mssrp. notably, the amount of perceived stress added to their academic burden was nearly the same before the research experience as compared to after. finally, student responses indicated no change in the idea that a research experience would be helpful in preparing for qualifying exams. faculty at the medical school duluth were surveyed to assess their attitudes toward the mssrp. of 32 respondents, 26 indicated that they have mentored a medical student researcher as part of this program and the reasons for those who indicated they had never mentored a student centered on a lack of student interest. the content of the research is unknown for those citing a lack of student interest but does identify a need to ensure that potential mentors and projects are adequately advertised to students. faculty were also asked four questions regarding the amount of stress a student researcher added to their academic burden, the amount of progress that was made toward research goals, the relevance of research experience to medical training, and the likelihood of them mentoring a student in the future (table 2). the responses to the faculty survey were largely positive. the amount of stress added to faculty’s academic burden seemed to be, on average, manageable though the range of responses indicated that some respondents had very little extra stress while others experienced much more. academic progress also had a large range of responses from no progress to student-dependent progress. the responses to the relevance of research experience to medical student training were largely positive and this is reflected in our observation that we continue to have faculty mentors volunteer to mentor students year after year. finally, there was a wide range of responses to the likelihood of faculty mentoring students in the future. on average the response is positive but the range of scores indicates there are some faculty who will not likely mentor a student in the future. journal of regional medical campuses, vol. 6, issue 2 original reports as a follow-up question, we also asked what additional kind of support would help faculty in their roles as mentors. not surprisingly many answers centered on needing more financial support for research and additional professional support from a statistician and additional staff to help with manuscript preparation and data management. some responses indicated that a longer-term relationship with the student would be helpful as well as more accountability for student researchers. taken together these ideas may reflect the high stress scores and low scores for the other three questions and identify gaps in the program that must be addressed. to assess outcomes of the mssrp, we asked faculty to report student presentations, publications, and grant submissions resulting from mentoring a student researcher. forty-two percent of faculty mentors reported student presentations as a result of the research experience while 50% reported publishing manuscripts and 12% reported grant submissions. the expectation for the mssrp is not that every student will generate a manuscript, but these data indicate that mentors are identifying discrete enough projects to be completed in the given time frame and enough work to warrant authorship for students. discussion research experiences during medical school are becoming more common as medical education evolves to encourage physicians to not only be engaged in acquiring medical knowledge but also understanding how that knowledge was generated.8-9 duke university school of medicine and stanford university school of medicine have both had scholarly research programs as part of medical education for more than 60 years, though those programs journal of regional medical campuses, vol. 6, issue 2 original reports encompass 10-12 months of research.9 similar to the mssrp at the medical school duluth, the university of texas medical branch at galveston has implemented a summer research experience between the first and second years of medical school as an elective that is part of the curriculum and is assigned a pass/fail designation at the completion of the course.8 the mssrp at the medical school duluth is not a required component of medical students’ training and does not require students to sign up for course credit (though the option is available for those who choose). there is also no formal assessment (graded or pass/fail) of a student’s research efforts other than the required presentation at the medical student research symposium which is assessed by a rubric for award selection. based on the results of the student surveys (table 1) the amount of stress that adding research to students’ academic burden was manageable, suggesting that adding research as a required component of the curriculum could be considered. however, there are other summer programs offered by the medical school duluth including the summer internship in medicine (sim) during which students from both the duluth and twin cities campuses have an immersive experience to learn about life as a rural health professional. making the mssrp a required component of the curriculum, in its current form, would take away from other, equally important opportunities for students. additionally, while the mission of the medical school duluth is focused on rural health and training rural, family medicine physicians, many students choose to enter more competitive specialties and are better served by a research program and vice versa for those who intend to practice as rural physicians and benefit from sim. one of the goals of the mssrp at the medical school duluth is to support students who choose to be involved in research. in figure 1 there is a notable increase in student participation in 2019 as compared to previous years. prior to 2019, mssrp was a formalized program, but mentors were not recruited and asked to develop project descriptions appropriate for a summer medical student researcher. instead, students were expected to contact faculty and clinicians and ask if they would be willing to mentor a student. this can make it difficult and intimidating for students to approach potential mentors and likewise potential mentors do not have time to prepare projects and assess whether they are able to supervise a student during the summer. by formalizing the process of identifying potential mentors and available projects, identifying a research mentor became less onerous for students and students and mentors are more easily paired. the covid-19 pandemic had an effect on participation in the mssrp; figure 1 shows that the number of participants decreased in 2020 as compared to 2019. the number of students who were interested in research remained nearly constant but with pandemic-related restrictions in place there were some projects that were unable to be implemented. the medical student research symposium was retooled to be held virtually via zoom in spring 2021 so that students who were able to complete their research remotely had a venue in which to present their projects and be considered for research awards. as covid-19-associated restrictions are decreasing, the number of students participating in research not only recovered but increased in the summer of 2021. these data demonstrate the resiliency of our students and the overall importance of offering a research program as part of medical student training. the composition of research projects is not surprising considering the number of faculty who do clinical research at the medical school duluth, as well as the relationships we have built with the two local hospitals (st. luke’s and essentia health), each of which have physician investigators who mentor students from the medical school duluth (figures 2 and 3). additionally, considering these are medical students pursuing research experiences, it is likely that clinical projects are chosen most frequently because the content aligns with their career interests. mentors being from dmed/tmed versus external institutions likely varies year-to-year as all mentors do not take students each summer and we have observed that some mentors tend to take students every other year, which helps to explain the distribution of institutional representation. it should be noted that in 2020 and 2021 the number of mentors from the university of minnesota medical school (both duluth and twin cities campuses) remained nearly constant. this reflects the support of faculty mentors at our institution and a culture that journal of regional medical campuses, vol. 6, issue 2 original reports respects the importance of research and of training students. the results of the student surveys indicate that research experience increased students’ skills and confidence, likelihood to participate in collaborative relationships in their practice, and increased their perception of the relevance of research to their practice (table 1). the level of confidence students have in critically evaluating data and literature showed a statistically significant (p<0.05) increase after the research experience. as medical education and practice continues to shift to evidence-based medicine, the ability to evaluate primary literature will become increasingly imperative for physicians and having a research experience to hone these skills is an effective way to incorporate them into the curriculum. the amount of perceived stress research would add to students’ academic burden was similar before and after the research experience, which reflects well on the design of the mssrp and the expectations made of students. this also suggests that research mentors are identifying appropriate projects for students. student survey results also show that students do not think that research is helpful in directly preparing for their qualifying exams. however, as step exams transition to pass/fail rather than scored exams, research experiences will become more important to set students apart from their peers when competing for residency positions, and we anticipate an increase in student researchers in coming years. finally, student attitudes toward the importance of a research program reflect the perceived importance of the mssrp, as well, though the reasons behind those survey scores were not collected. faculty were asked if they had ever mentored a student as part of the mssrp, and if they had not, to describe why. the most often cited reason was lack of student interest. the current method for advertising available mentors and projects is a list of mentors and project descriptions that is distributed electronically to the first-year medical student class. project descriptions are written by the mentors. however, in order to garner additional student interest, it may be helpful to have potential mentors describe their projects to students directly to generate more enthusiasm. the responses from the faculty survey were largely positive, but we identified gaps in the mssrp that must be addressed. the amount of stress incurred by faculty mentors appears to be largely manageable but the range of values in response to the academic progress made toward research goals and how likely faculty are to mentor a student in the future indicate that there are unmet needs for faculty mentors. as a follow-up question, faculty were asked to identify what they need to be more supported in their roles as mentors as a free-response question within the survey. needs included longer term relationships with students and more accountability for student researchers. summer is an unfortunately short time period within which to fit a research project into students’ schedules. extending the research/data collection period is not feasible with student schedules, but the introductory phase between the student and mentor could be extended by making the list of mentors and projects available to students earlier in the year. an in-person or zoom session with mentors and students would also help foster these relationships as previously mentioned. a need for more financial support for student research was another common theme from the faculty survey, as well as support from a statistician and staff for manuscript preparation and data management. specifically, it was noted that for bench science projects, the cost of having a student researcher can be thousands of dollars in laboratory consumables while for clinical or social/behavioral projects the cost may be minimal and is not equitable. the financial aspect of implementing a medical student research program is not trivial and the sustainability of the program relies heavily on research mentors. as such, their needs must be considered when preparing funding proposals for the program. finally, increased student accountability was mentioned as a need for mentors. the mssrp has some requirements that help to ensure that students will finish their projects in an efficient timeline, but other criteria will need to be put in place. funding applications should include discrete, journal of regional medical campuses, vol. 6, issue 2 original reports attainable research goals for the students that are agreed upon with the mentor. currently the students are asked to outline their research goals but there is no required input by the mentor. asking mentors to outline expectations early in the partnership will increase student accountability and make it clear to both the student and the mentor what the expectations are for the project. by increasing the accountability of students, one would predict that faculty-reported academic progress may increase in future years. while there are gaps to address in implementation of the mssrp, the student outcomes of the mssrp, as reported by faculty, indicate that half of faculty have published manuscripts with a medical student researcher, 42% reported student presentations (outside of the required medical student research symposium), and 12% reported grant submissions. while it is difficult to reconcile the wide range of reported scores in response to the question about academic progress, it seems that many faculty mentors are making important progress with deliverable outcomes when mentoring students. the student surveys used to collect the data reported on here did not ask about whether students had published a manuscript or presented their data elsewhere but will be an addition to future surveys to get a clearer picture of how many students are getting the opportunity to publish and present. in the years since implementation of the mssrp in 2015, the program has evolved to better serve our students and mentors and will continue to do so in response to these data. sustainability of a summer research program the financial commitment to a program such as the mssrp at the medical school duluth is not trivial. in 2015 the regional campus dean designed the mssrp and contributed finances as well as significant effort to implementing this program. in 2022 the dean of the medical school committed $90,000 to the mssrp on the duluth campus; part of those funds will be carried over for 2023. the two departments at the medical school duluth, biomedical sciences and family medicine and biobehavioral health, have contributed both financially and with infrastructural support. with a strongly supported program we have been fortunate that every student who has applied for a summer stipend in 2020 and 2021 was funded. considering the number of students that participate and costs associated with the symposium, our annual cost for the program varies but at a minimum is $3000 per student plus the expenses associated with the research integrity training and research symposium. as such, significant financial support, including external grant support, is required for a research program to not only be sustained but also to have the opportunity to grow as student and mentor needs change. as the mssrp grows, dedicated staff are needed to direct the program. currently there are identified program directors, but the mssrp has been a responsibility taken on as a service to the medical school duluth. directors recruit mentors, ensure projects are appropriate for a summer medical student, host a research integrity and onboarding session for students, review summer stipend applications, and assist with irb applications for over 25 students and projects. additionally, the directors plan and implement the medical student research symposium and develop rubrics for scoring talks and posters. throughout the academic year directors also serve as direct contacts for students with questions about their research and how best to navigate their experience. with a steadily increasing number of students participating each year, and increased needs to be filled for faculty and students, the responsibilities of mssrp directors will comparably increase and become more than service-oriented roles. training and compliance are always at the forefront of the mssrp. for a medical school to implement a program like that at the medical school duluth, access to citi training and irb oversight is imperative. additionally, in order to collaborate with mentors from local and regional institutions, a research program should have a director with expertise in navigating irb requirements among multiple institutions. the mssrp heavily depends on mentors volunteering each year. thus far the number of mentors and projects available has not been a limiting factor but as the number of students who participate in the program continues to increase, the need for mentors journal of regional medical campuses, vol. 6, issue 2 original reports will similarly increase. there are no financial incentives for mentors, so the success of our program relies on the strong culture of training and service at the medical school duluth and twin cities campuses, essentia health, and st. luke’s hospital in duluth, as well as at the external institutions that have supported research for our students. future directions prior to collection of these data there were no formal learning objectives outlined for the mssrp, nor a mission for its purpose. while only one of the student survey questions showed a statistically significant change in the mean, the overall trends can be used to inform and shape the learning objectives and mission of the mssrp to be published on the program website. having discrete learning objectives may also contribute to faculty mentors being more satisfied with the program. implementation of a mid-summer gathering of students and mentors is another way we intend to increase accountability of student researchers, increase collegiality, and offer a venue in which students can informally report on how their research is progressing and any barriers they are experiencing. the research program at the university of texas medical branch at galveston requires a written report at mid-term for students and may be another effective way to keep projects on pace.8 the benefit of having an informal gathering versus a more formal, written report is that reports must be assessed by program staff and do not promote the collegiality of an in-person meeting with verbal self-assessments of students’ research projects. additionally, with a short time period for students to collect data, their time should be dedicated to data collection rather than developing a written report. to help promote the mssrp at the medical school duluth and garner increased interest from students, the program will be described during medical student orientation at the beginning of students’ first year. because the program has been successfully implemented for seven years, students may hear about the opportunity for research from their secondyear peers, but a formalized introduction to the mssrp will help students form initial thoughts about their research interests. additionally, program directors will host an in-person session with the entire first-year medical student class early in the spring and show a pre-recorded video compilation of mentors briefly describing their projects so students can better identify which projects interest them. promotion and visibility of the mssrp at the medical school duluth will not only make it easier for students to participate, but also help the sustainability of the program. currently the mssrp has a website with a description of the program (https://med.umn.edu/about/duluth-campus/officeresearch-support/medical-student-researchopportunities). however, the program can also be incorporated into the admissions process by asking students about their research experience, interests, and goals.9 the mssrp website will continue to be updated with infographics, timelines within the program, details about the available stipend, and a list of program directors and staff. acknowledgments the authors would like to thank essentia health and st. luke’s hospital in duluth as well as dr. peter nalin and dr. jean regal, chairs of the departments of family medicine and biobehavioral health, and biomedical sciences, respectively, at the umms duluth campus, as well as dean jakub tolar, dean of the umms, for their continued support of the mssrp. references 1. liaison committee on medical education (2020). functions and structure of a medical school. standards for accreditation of medical education programs leading to the md degree. https://lcme.org/publications/#standards 2. lee, m. g. y., hu, w. c. y., & bilszta, j. l. c. (2020). determining expected research skills of medical students on graduation: a systematic review. medical science educator 2020 30:4, 30(4), 1465– 1479. https://doi.org/10.1007/s40670-020-01059z 3. bonilla-velez, j., small, m., urrutia, r., & lomberk, g. (2017). the enduring value of research in medical education. international journal of medical students, 5(1), 37–44. https://doi.org/10.5195/ijms.2017.168 journal of regional medical campuses, vol. 6, issue 2 original reports 4. nimmons, d., giny, s., & rosenthal, j. (2019). medical student mentoring programs: current insights. advances in medical education and practice, 10, 113. https://doi.org/10.2147/amep.s154974 5. walmsley, l., fortune, m., & brown, a. (2018). experiential interprofessional education for medical students at a regional medical campus. canadian medical education journal, 9(1), e59-67. retrieved from https://pubmed.ncbi.nlm.nih.gov/30140336/ 6. chang, y., & ramnanan, c. j. (2015). a review of literature on medical students and scholarly research: experiences, attitudes, and outcomes. academic medicine, 90, 1162–1173. https://doi.org/10.1097/acm.0000000000000702 7. ponzio nm, alder j, nucci m, dannenfelsser d, hilton h, linardopoulos n, & lutz c. learning science communication skills using improvisation, video recordings, and practice, practice, practice. j microbiol biol educ. 2018;19(1). doi:10.1128/jmbe.v19i1.1433/suppl_file/jmbe19-15-s001.pdf 8. cain l, kramer g, & ferguson m. the medical student summer research program at the university of texas medical branch at galveston: building research foundations. https://doi.org/101080/1087298120191581523. 2019;24(1). doi:10.1080/10872981.2019.1581523 9. laskowitz dt, drucker rp, parsonnet j, cross pc, & gesundheit n. engaging students in dedicated research and scholarship during medical school: the long-term experiences at duke and stanford. acad med. 2010;85(3):419-428. doi:10.1097/acm.0b013e3181ccc77a microsoft word narrowingexpansivehorizonsarticle.docx published by university of minnesota libraries publishing narrowing expansive horizons: experiences of first-year medical students and teaching faculty in a new multidirectional digital classroom for 3and 4-year medical school programs kristina kaljo, ph.d.; robert treat, ph.d.; matthew tews, do doi: https://doi.org/10.24926/jrmc.v2i4.2044 journal of regional medical campuses, vol. 2, issue 4 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc kristina kaljo, ph.d., assistant professor, medical college of wisconsin robert treat, ph.d., associate professor, medical college of wisconsin matthew tews, do, professor, medical college of georgia all work in jrmc is licensed under cc by-nc volume 2, issue 4 (2019) journal of regional medical campuses original reports narrowing expansive horizons: experiences of first-year medical students and teaching faculty in a new multidirectional digital classroom for 3 and 4-year medical school programs kristina kaljo, ph.d.; robert treat, ph.d.; matthew tews, do abstract introduction: to address the country’s shortage of primary care physicians and increasing medical student debt, the medical college of wisconsin matriculated students into accelerated 3-year campuses in central city and packer city, while maintaining its traditional 4-year campus in brew city, wisconsin. to ensure consistent content delivery within the basic science curriculum, students at all 3 campuses simultaneously participate in daily learning activities, utilizing distributed learning through a multidirectional digital classroom incorporating video-conferencing and audience response systems. methods: to best uncover and understand the perspectives and attitudes of faculty and medical students, qualitative and quantitative research methods were employed framed within constructivist grounded theory. this framework is rooted in social processes of the participant’s lived experiences and views these experiences as paramount to the analysis and presentation. prospectively, data was acquired regarding individual experiences from first-year medical students and medical school teaching faculty across the 3 campuses. beginning in the 2015–2016 academic year, 9 semi-structured focus groups were conducted with concluding surveys. these focus groups were separated by campus location: medical students at brew city, medical students at packer city, and faculty who taught at either the 3-year regional campus or 4-year campus. in winter 2017, the study expanded including one additional student-centered focus group in central city. each focus group was recorded using a hand-held device, transcribed, and analyzed using the constant comparative method. this inductive approach required close examination of the transcriptions and line-by-line analysis to assign codes that captured the emerging themes. to triangulate the data and further understand the medical student and faculty lived experiences, a concluding survey was distributed to participants. this survey included eight 7-point likert-scale questions to further ascertain experience and overall satisfaction with the new learning environment. numerical data was analyzed with ibm® spss® 24. this study was approved by the institutions review board. results: in 2015–16, packer city students rated their overall learning experience significantly (d=0.74, p<.050) higher (mean (sd)=7.6 (0.6)) than students in brew city (6.7; 1.6) and significantly higher (d=1.21, p<.034) than the faculty (6.0 (1.0)). during 2016–17, overall learning experience scores did not differ from those of the previous years for packer city (d=0.0) or brew city students (d=0.0). a comparison of scores across all 3 campuses in 2016–17 yielded a significant change (d=1.28, p<.037) between the central city campus (mean (sd)=7.8 (1.1)) and the brew city campus (6.7 (0.5). no significant changes were reported between packer city and the other 2 campuses. three overarching themes emerged from both the students and faculty throughout the study: 1) the construction of a knowledge-based community of practice, 2) responsiveness to diverse learning preference, and 3) how participants negotiated teaching and learning within the multidirectional digital classroom. conclusion: these findings have the capacity to provide guidance when re-designing and facilitating medical school curricula and for learners who engage in new multidirectional digital environments. regardless of teaching site, all educators must be mindful of students’ learning needs and recognize how the overall learning experience is influenced by faculty, physical environment, and the ways in which students interact with one another daily. introduction the primary care physician shortage in the united states and the inevitable medical school debt crisis1-3 has motivated many academic institutions to consider 3-year medical schools as an efficient solution to both problems.4 as medical schools have transformed their curricula from the traditional flexnerian 4-year biennial curriculum, 3-year programs have provided shortened academic tracks and reduced the length of medical school by nearly 30%.5 with support from the josiah macy jr. foundation, 12 medical schools collectively formed the consortium of accelerated medical pathway programs (campp), which enrolls small cohorts of medical students to complete a 3-year curriculum.4,6 research reports that graduates from accelerated programs attain comparable doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 type of article milestones as those from traditional 4-year medical education programs.1 as a commitment to educational innovation and equitable medical training, these accelerated programs are dedicated to graduating students with equivalent clinical skills and medical knowledge to those of their peers in traditional 4-year medical schools. the medical college of wisconsin (mcw) is an accredited private institution located in the midwest. originally established in 1893, mcw operated as an independent institution since 1967 with the original 4-year campus located in brew city. mcw recently developed 2 new regional campuses in packer city and central city, which offer only an accelerated 3-year medical degree program. in 2015, the packer city campus matriculated its first class of medical students, and the central city campus launched its program in 2016. all 3 campuses follow the same basic science curriculum during the first and second years of medical school. these are identical in content and chronology, with the inclusion of a new multidirectional digital learning environment distributing the content across all 3 campuses. using video conferencing and an audience response system with desire2learn (d2l) as the online learning platform, approximately 500 firstand second-year students across all 3 campuses engage simultaneously in one learning environment over the 2-year period. a majority of the mcw teaching faculty are physically located in brew city, utilizing a video conferencing system to interact with students in packer city and central city. thus, regardless of the students’ physical location, they all engage in the same content simultaneously with the same faculty during the first 2 years. the design and implementation of this multidirectional digital learning environment required input from mcw faculty, technology experts, students and staff, as well as colleagues from outside institutions. all faculty teaching in this new learning environment received professional development to effectively engage students with the new audiovisual (av) equipment, both in person and remotely, and balance the use of asynchronous and synchronous teaching and learning strategies. faculty development was delivered with in-person demonstrations, online podcasts, and electronic documents that could be accessed independently. the aim of this research design was to obtain essential and immediate insights from faculty and medical students regarding the ways multidirectional teaching and learning affects the new learning environment for an established 4year medical school campus and new 3-year regional campuses. methodology the study was designed using a constructivist grounded theory approach7,8 to provide for an exploratory, inductive approach to collect and analyze qualitative data. this method allows the researchers to genuinely capture the essence of the events taking place over the time of the study with the intention to explore the perceptions of the new learning environment. initially beginning in the 2015-2016 academic year, students and faculty from packer city and brew city were recruited via email; medical students were reminded of the study through in-class announcements provided by a medical student liaison. in the subsequent year, central city was included in the study during its inaugural year, similarly inviting students and faculty to participate in the research study via email and in-class announcements. the intention was not to compare student and faculty experiences, but to build on the knowledge gained during each participant interaction. the study was approved by mcw’s institutional review board and funded by an mcw institutional learning resources grant. focus groups were selected as the qualitative method to collect rich narratives from students and faculty. all focus groups were conducted by one author (kk), who facilitated the discussion with semi-structured questions to thoughtfully engage each participant and allow emerging perspectives to come forth naturally (figures 3 and 4, semi-structured interview questions faculty and students). this author was not an instructor in the firstor second-year courses, and she had no preexisting relationship with any of the students that would influence the focus group or survey responses. the student focus groups in brew city met face-to-face with kk, and the focus groups in packer city and central city were conducted via videoconferencing, which used a television screen, video cameras, and an audio recording system. figure 3. semi-structured interview questions – faculty figure 4. semi-structured interview questions – students doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 type of article all faculty focus groups were conducted separately from the student groups. faculty attended sessions that utilized both in-person and videoconferencing, dependent on faculty physical location. all focus groups were recorded with a handheld recording device, and each session was transcribed verbatim using transcribeme, a transcription service. deidentified focus group transcripts were coded using the constant comparative method, an inductive strategy that fragments data line-by-line and word-by-word to construct a series of related categories or patterns that illustrate both student and faculty perspectives.8 upon saturation of data, these categories were organized into overarching themes. for appropriate triangulation and confirmation across multiple data points,9 faculty and students were asked to complete an anonymous survey at the end of their focus group session (figures 5 and 6). the survey included 9 items scored on a 7point likert scale (1=strongly disagree, 7=strongly agree) and one overall learning experience (ole) scored on a 10-point scale (10=high). statistical methods included univariate and kruskal-wallis analysis of variance to analyze mean and median differences across the 2 academic years and between campuses, respectively. cohen’s d calculated for effect sizes of mean differences. relational statistics included pearson (r) correlations and stepwise multivariate linear regressions to determine the association of survey items. inter-item reliability was determined with cronbach alpha, and was used to assess the internal consistency of survey data. numerical data were analyzed with ibm® spss® 24.0. figure 5. student survey figure 6. faculty survey results quantitative analysis, survey results in 2015–16, the first year of the 3-year program in packer city, students rated their ole significantly (d=0.74, p<.050) higher (mean (sd)=7.6 (0.6)) than students in the 4-year program in brew city (6.7 (1.6)) and significantly higher (d=1.21, p<.034) than faculty (6.0 (1.0)), as reported in table 1. when student ole scores from both campuses were combined (mean (sd)=7.0 (0.8)) and compared to faculty scores (6.0 (1.0)), there was no significant difference (d=1.10, p<.184). table 1. overall learning experience (ole) mean scores across academic year (ay) and campus during 2016–17, there were no significant changes in mean ole scores from the previous years for the packer city doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 type of article students (d=0.0, p=1.000) or the brew city students (d=0.0, p=1.000). a comparison of mean ole scores across all 3 campuses from 2016–17 yielded a significant change (d=1.28, p<.037) between the central city campus (mean (sd)=7.8 (1.1)) and the brew city campus (6.7 (0.5). no significant changes were reported between packer city and the other 2 campuses. when student ole scores from all 3 campuses were combined (mean (sd)=7.2 (1.2)) and compared to faculty scores (6.7 (1.1)), there was no significant difference (d=1.00, p<.132). median scores for the individual likert-scale items reported some differences among campuses (figure 1). the brew city students reported the highest median (7.0) scores for faculty providing time to ask questions. the central city students rated receiving faculty feedback (median=5.5), having an adequate physical environment (6.5), and the current classroom design as conducive to learning (7.0) the highest. they also rated being prepared to learn within a distance education environment significantly (p<.050) higher than the students at the other 2 campuses (7.0). being encouraged to have discussions with their peers (6.0) ranked higher in packer city than in central city and brew city. figure 1. student survey median scores split by campus (2015–16 and 2016–17 combined) across both academic years, the best predictor of ole (r²=0.64, p<.001) was learning with multiple sites at one time (beta=0.5) followed by classroom design (beta=0.4). classroom design was rated significantly higher (p<.032) by the central city students (median (interquartile range) = 7.0 (1.0)) than by the packer city students (6.0 (1.2)) or the brew city students (5.0 (1.0)). the inter-item reliability of all 9 items was alpha = 0.70. qualitative analysis, focus group results from the wealth of data acquired, all delineated codes were subsequently assembled into overarching themes. three themes emerged from both student and faculty focus groups: 1) the construction of a knowledge-based community of practice, 2) responsiveness to diverse learning preferences, and 3) negotiating teaching and learning in a multidirectional digital classroom (table 2. qualitative results – code book). table 2. qualitative results code book theme 1. construction of a knowledge-based community of practice. communities of practice are defined as “groups of people who share a concern, a passion about a topic, and who deepen their knowledge and expertise by interacting on an ongoing basis.”9,10 when this characterization was bridged with the students’ desire to acquire knowledge and advance in a clinical practice, the notion of a knowledge-based community of practice emerged as an overarching theme for both students and faculty. intertwined in this framework is the notion of self-efficacy, or the ability to succeed in specific situations due to a positive learning environment and seeing others being successful.11 as the students in packer city and central city were the first matriculating class during their respective first year, they revealed how building a knowledge-based community of learners was imperative to their own success: “…if we have a question, we'll talk among ourselves before we truly go to anybody else to ask it, which is a lot nicer. i like the small classroom atmosphere. and again, it makes for a lot more intimate setting between the students and how we're able to work together as a team and really work on our doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 type of article problem-solving skills from day one.” (packer city student, 2015) one brew city student explained that having another campus learning simultaneously reduced some of the academic pressure: “i enjoyed when the professor was being more inclusive with the packer city class, because i forget they're there all the time. because we don't see them. and it's a nice little surprise when he calls on the [packer city students] instead of us. it's like the spotlight's not on you. you're like, ‘oh yeah, packer city is there, awesome. somebody else can answer the question.’” (brew city student, 2015) furthermore, a student from central city appreciated that some faculty diligently included students from the other campuses to encourage active learning: “one professor in particular was really good about getting us involved. there were specific questions that [the professor] would pose to us in [central city] and call us out based on what we were wearing. [this professor] was able to involve us, which i found super helpful with how i learned the material.” (central city student, 2016) of note, ‘community’ was actively sought out by students who were eager to learn from one another and address questions in a lower-stakes environment. theme 2. responsiveness to diverse learning preferences. faculty and students acknowledged the wide variety of learning preferences that spanned the 3 campuses and existed within individual student groups at each campus. for one student, learning preference became intertwined as work/life balance, appreciating the flexibility of multidirectional online learning, “i've got a 2-year-old at home, and just the flexibility of the schedule makes medical school and the demands more tolerable and possible. having everything [lectures] recorded is nice where i'm not necessarily having to plan school around my life.” (packer city student, 2016) similarly, a student from brew city also related work/life balance with their preferred learning modality: “sometimes i will not go [to class] because i'll just live-stream it. so, i'm literally watching at the same time as everyone else at the same speed, but i just didn't want to wake up earlier to get ready. some fridays, we'll just have eight-to-noon lecture and then nothing. so, there'd be no other reason for me to be here. it's just more comfortable being at home and relaxing and watching. if anything, i'm more focused.” (brew city student, 2016) the idea of learning preferences emerged across 2 separate interpretations. one that seemed popular with students was the ability to live-stream their class and watch from home or wherever they preferred. not every student wants to physically sit within the confines of the traditional classroom. as the curriculum integrated a system to live-stream content, anyone with access to the classroom link could watch lectures from any desired location. however, various students from all 3 campuses said they preferred to physically attend classes and interact with classmates and professors. thus, it is significant to acknowledge that physical presence and interaction in a common space contribute to satisfaction of a learning environment. theme 3. teaching and learning in a multidirectional learning environment even before the new campuses opened, there was trepidation about preparedness for teaching with new technology and with more variables to consider during a lecture. one common concern was that a technical problem might disrupt a faculty member’s teaching rhythm and concentration, requiring them to stop and try to troubleshoot the problem. however, measures were put in place to make the experience as seamless and supportive as possible and, in retrospect, there were very few technological glitches. the faculty reflected on this in their focus groups and noted that teaching in this environment was not as intimidating as they thought it would be. they even identified this new teaching environment as a unique opportunity to improve their own pedagogical practices. “i think how to acknowledge that you're being broadcast somewhere else is a unique skill. it's to recognize that students are at a distance and then to make sure you don't walk out of camera view and still be focused on those who are physically in the classroom where you’re teaching.” (faculty, 2015). furthermore, as the faculty gained experience with the environment, they acknowledged a desire to supplement student learning by including additional resources to make their time more interactive: “i also think we could better use the d2l (desire2learn) discussion board.” (faculty, 2015). other faculty saw teaching within this space as fairly easy, without needing to substantially change their delivery methods. “i don't—again, i think i've said this before—i don't think the burden is there. it's pretty seamless, [teaching this way] is so easy. you just show up and do your thing and look at a screen and you acknowledge the people. i've talked to a few people who forget those students are on the screen. just try to remember they're there.” (faculty, 2016). encouraging faculty to reimagine their traditional or common practice into a new multidirectional environment has the capacity to promote professional development and explore new strategies to engage students situated in different spaces. discussion the literature has reported the benefits of 3-year accelerated medical student curricula, which our study supports,2–7 by closely examining the intricate perceptions and lived experiences of medical students and teaching faculty in this new multidirectional classroom that supports the 3-year accelerated campuses, we add to this existing literature. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 type of article extensive research and planning went into designing the multidirectional classrooms at each campus, but the development of the physical classroom space to support the multidirectional digital design was based on each campus’s unique needs. for example, the brew city classrooms had to fit the digital layout and equipment into a preexisting lecture space. packer city remodeled existing space and incorporated distance technology and layout. central city had the ability to build an entirely new space, integrating best practices and early lessons learned from packer city’s multidirectional digital classroom remodel. as a result, the central city students gave significantly higher ratings to their physical environment and classroom design being conducive to learning than did the packer city or brew city students. the same held true for the ole ratings. the importance of designing a classroom specifically to accommodate multidirectional digital learning was important to both learners and faculty, as demonstrated by classroom design being the second-best predictor of ole (topped only by learning at multiple sites). the practical significance of the layout and design of a multidirectional digital classroom was clearly demonstrated between the 3 different approaches to creating the classroom for learning purposes. as medical education continues to evolve due to diversity of learners, individuals must acquire and recognize traits that naturally help them become master adaptive learners.11,12 this concept of adaptive expertise seeks to “balance the efficiency of routine expertise with more effortful learning and innovative problem-solving skills.”12 we discovered that after students and faculty were placed within the new multidirectional digital environment, both groups became adept at using various online tools to communicate with peers and faculty across campuses. this provided the ability to acquire and convey required knowledge, and recognize preferences for communication, teaching, and overall learning. in this study, students were cognizant that they must take responsibility and ownership for their learning, and educators were conscious of the need to advance or alter their own pedagogical practices. learners and faculty had to actively couple previously acquired knowledge and skills with innovation while ‘negotiating’ competing demands to become master adaptive learners (figure 2). these experiences structured the resulting overarching qualitative themes: constructing a knowledge-based community of practice, responsiveness to diverse learning preferences, and teaching and learning in a multidirectional learning environment. figure 2. negotiating the complexities of a multidirectional digital classroom furthermore, the correlations between the students’ and faculty survey ratings appears to reinforce the focus groups’ findings about developing a knowledge-based community of practice. the characteristics of the adaptive learner were embodied by students at both regional campuses, who rated their overall experience significantly higher than the brew city students. this difference may have resulted from the development of a knowledge-based community of practice for regional campus students who adapted to the new environment and worked closely with each other to learn on their respective campuses. based on the survey data and focus group discussions, the physical absence of faculty teaching in packer city encouraged students to develop their own community of learners to navigate the complex environment of medical school. therefore, the overall positive experience of the multidirectional digital classroom reported by packer city and central city students could have resulted from the opportunity to learn in smaller, more cohesive cohorts of peers. the brew city students, on the other hand, highly valued their interactions with on-campus faculty and being able to ask questions—alluding to the faculty members’ ability to respond to diverse learning preferences. yet all the students valued the ability to interact with the other groups of students, regardless of campus. mcw’s multidirectional digital classroom and the existence of both 3and 4-year degree programs provide a unique setting in medical education and a rare opportunity to evaluate their impact on students and faculty. this study identifies many important findings, but we must acknowledge its limitations as well. first, it is critical to recognize the small sample size. while the opportunity to participate in focus groups was advertised to all first-year medical students at all 3 campuses and to all basic science faculty teaching these students, only a few chose to participate, resulting in the potential of selfselection bias. finally, due to the availability of individual participants, there was natural variance in participation among focus groups and between the study’s first year and its second. a consideration for the future would be to longitudinally follow students from the first to second year to determine whether perspectives change and what further insights can be obtained regarding the learning environment. the reinforced use of best pedagogical practices requires the utilization of pertinent strategies for teaching in a multidirectional digital environment. the increasing interest in 3-year medical school programs and the combined use of synchronous and asynchronous learning makes it imperative that education programs evaluate not only traditional measures of success (student exams and course evaluations) but also diligently and longitudinally analyze perspectives of students and faculty through interviews and focus groups. these real-time data will best identify possible barriers and facilitators within any learning environment. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 type of article conclusion our findings can provide guidance for those who design and facilitate curricula as well as for learners who engage in increasingly new multidirectional digital environments. educators must be mindful of students and their learning needs at all sites, while students need to demonstrate a commitment to lifelong learning with the capacity to successfully navigate complex environments. by mindfully designing this study with qualitative and quantitative methods, including triangulation of various data points, and by ensuring adequate breadth and depth of data analysis, we obtained valuable insights from learners and faculty about this new multidirectional digital classroom in medical education at mcw. this allowed the research team to address the complexity of the overarching research question by obtaining insights from faculty and medical students regarding the multidirectional digital learning classroom, whereas utilizing only qualitative or quantitative methods would have limited our findings. references 1. raymond jr, kerschner je, hueston wj, maurana ca. the merits and challenges of three-year medical school curricula: time for an evidence-based discussion. acad med 2015;90(10):1318-1323. doi: 10.1097/acm.0000000000000862 2. abramson sb, jacob d, rosenfeld m, buckvar-keltz l, et al. a 3-year m.d. – accelerating careers, diminishing debt. n engl j med 2013;369:1085-1087. 3. kauffman m. and ferretti sm. the accelerated physician assistant pathway: a three-year medical school curriculum for physician assistants to obtain do degrees. acad med 2014;89(12):1645-1648. doi: 10.1097/acm.0000000000000307 4. cangiarella j, fancher t, jones b, dodson l, leong sl, hunsaker m, pallay r. three-year md programs: perspectives from the consortium of accelerated medical pathway programs (campp). acad med 2017:92(4):483490. doi: 10.1097/acm.0000000000001465 5. the josiah macy jr. foundation, consortium of medical schools with accelerated pathway programs. http://macyfoundation.org/grantees/profile/consortiumof-medical-schools-with-accelerated-pathway-programs. accessed february 2018. 6. bratton rl and david ak. the university of kentucky’s accelerated family practice residency program. fam med 1993; 25(2):107-110. 7. charmaz, k. (2006). constructing grounded theory: a practical guide through qualitative analysis. thousand oaks, ca: sage 8. charmaz, k. (2000). grounded theory: objectivist and constructivist methods. in n. denzin & y. lincoln (eds.), handbook of qualitative research (2nd ed., pp. 509-535). thousand oaks, ca: sage. 9. wenger e, mcdermott r, snyder wm. (2002). a guide to managing knowledge. cultivating communities of practice. boston, ma: harvard business school press. 10. bandura a. the explanatory and predictive scope of selfefficacy theory. journal of social and clinical psychology 1986;4:359-373. doi: 10.1521/jscp.1986.4.3.359 11. cutrer wb, miller b, pusic mv, mejicano g, mangrulkar rs, gruppen ld, hawkins re, skochelak se, moore de. fostering the development of master adaptive learners: a conceptual model to guide skill acquisition in medical education. acad med, 2017;92(1): 70-75. doi: 10.1097/acm.0000000000001323 12. schumacher dj, englander r, carraccio c. developing the master learner: applying learning theory to the learner, the teacher, and the learning environment. acad med, 2013;88(11):1635-164. doi: 10.1097/acm.0b013e3182a6e8f8 microsoft word student directed free clinic article.docx published by university of minnesota libraries publishing evolution of a student-directed free clinic: two decades of community engagement at a small regional campus william j. crump, m.d.; alyssa s. hounshell, bs; micah b. kaiser, bs; kathleen m. wilmes, bs doi: https://doi.org/10.24926/jrmc.vxix.xxx journal of regional medical campuses, vol. 6, issue 1 (2023) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc william j. crump, m.d., associate dean of the university of louisville school of medicine trover campus (ulsom trover campus) at baptist health deaconess madisonville, madisonville, kentucky alyssa s. hounshell, bs, m-3 medical student university of louisville school of medicine trover campus at baptist health deaconess madisonville (ulsom trover campus) micah b. kaiser, bs, m-3 medical student university of louisville school of medicine trover campus at baptist health deaconess madisonville (ulsom trover campus) kathleen m. wilmes, bs, m-3 medical student university of louisville school of medicine trover campus at baptist health deaconess madisonville (ulsom trover campus) corresponding author: william j. crump, m.d. associate dean, university of louisville trover campus at baptist health madisonville 200 clinic drive, third north madisonville, ky 42071 p. 270.824.3515 f. 270.824.3590 e. bill.crump@bhsi.com all work in jrmc is licensed under cc by-nc volume 6, issue 1 (2023) journal of regional medical campuses original reports evolution of a student-directed free clinic: two decades of community engagement at a small regional campus william j. crump, m.d.; alyssa s. hounshell, bs; micah b. kaiser, bs; kathleen m. wilmes, bs abstract this report summarizes the 20-year evolution of community engagement at a small regional rural campus. the process includes establishing a student-directed free clinic and its transition through the wider availability of medicaid expansion. next came the transition to telemedicine care during the covid pandemic and eventually to a recurring pop-up mobile clinic at a local homeless shelter. invitations from the host community then resulted in conducting health screenings at local food banks with portable clinics planned there as well. at each stage we were directed by community steering committees and advisory councils, and we discuss their roles. we found that it is important to go where and when we are invited rather than making these choices based on our convenience. we provide details of student perspectives, planning, and finances for those who are considering similar activities. background student-directed free clinics have a long tradition. as of a 2007 report, there were 49 medical schools that had at least one student-run clinic. the average clinic had 16 student volunteers a week, and most incorporated preclinical students. most clinics treated both acute and chronic conditions and were usually funded by private grants, with an average annual budget of $12000.1 a 2014 update reported 86 schools with 208 student-run free clinics with chronic care of diabetes and hypertension being the routine.2 the university of iowa recently reported a multidisciplinary student-run clinic that began in a mobile van and developed into rotating sessions at nine fixed locations within a 50-mile radius. continuity was not a priority, with 6% of patients returning for care.3 continuity of student provider was not possible in most of these clinics and was recognized as a deficiency. a recent report summarized the early implementation of telemedicine in these clinics.4 most reports support positive patient satisfaction,5 some lower costs,6,7 and positive student satisfaction.5 history of our free clinic shortly after the regional rural campus began in 1998,8 a few students expressed interest in beginning a student-directed free clinic in the small host town, similar to what they experienced during their first two years of medical school on the urban main campus. by the time these students became comfortable with managing their time on clinical rotations, most were already focused on audition rotations and interviewing for the match, so no sustained effort was established. the host health system had a 40-year tradition of community-based education and community engagement, and some leaders expressed interest in taking the lead for such a student clinic. the clinic and hospital also had a long tradition of providing gratis care to the low income uninsured of the region, so the main purpose of any new clinic would be for the benefit of the students. the regional dean had been involved with studentdirected free clinics at two previous medical schools, including several false starts, and was convinced that doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 6, issue 1 original reports a successful effort would require strong student leadership rather than just that from the health system. when physicians perceived that they were already providing unreimbursed care in their office which was most efficient for them, only a wide-eyed enthusiastic student could interest them in working evening hours precepting them in a much less efficient environment. plans for such a clinic accelerated in 2003 with the arrival on the clinical regional campus of a nontraditional m-3, who in a life before medical school had successfully organized community efforts. he, the regional dean, and an m-4 leader recruited key community leaders to serve on a steering committee. the group included a tax specialist cpa, and within 3 months the new entity was established as a 501(c)(3) that provided tax advantages for contributors. the students did a search of public sources that estimated 6000 uninsured county citizens. we used the financial maximum used by surrounding free clinics of 165% of poverty for family size and required documentation that someone in the household was employed. almost all children in low-income families in our region were covered by medicaid and capacity of local providers for them was adequate, so we limited our care to adults. from the beginning, the students committed to continuity of student provider as much as possible. the steering committee was enlarged to include known local individual and corporate benefactors, and then transitioned to a board of directors. fundraising was very effective with annual golf scrambles and galas, and at the height of activities the clinic budget was $280,000. as the target population found us, we increased from three hours every thursday night and added a full-day tuesday session staffed by a paid aprn. we then hired a full-time executive director, part-time nurse, and a part-time medication assistance advocate. the campus regional dean, a family physician in active practice, served as volunteer medical director. very few visits were for acute care, focusing on longitudinal management of chronic conditions. the clinic used a simple electronic health record. for medications, inexpensive formulary medications at local chain pharmacies and pharmaceutical company patient assistance programs (pap) were used. the host health system provided a brick-and-mortar clinic for $1 per year rent and free basic lab and imaging for those below 165% of poverty. health system subspecialist physicians agreed to see a few consults in their office when the request was approved by the free clinic medical director, and the hospital assisted with getting indigent care application approval for expensive imaging and procedures. each visit was reviewed by the entire class of m-3s twice per month with the regional dean, with a performance improvement focus, as part of “dean’s hour.” the effort evolved into a voluntary longitudinal elective that provided two to four weeks’ elective credit, depending on the time spent by the individual student. in the 18 years since full student involvement began, only one student chose not to be involved. by developing detailed protocols and working with an experienced part-time paid nurse, we were able to spread out visits and actively manage most conditions via telephone. this allowed us to provide longitudinal care for about 1600 patients. with full implementation of the affordable care act in 2014, most of our patients received medicaid coverage. we facilitated their applications and assisted with transitioning their care to a local pcp, many of whom were in our local family medicine residency. in 2015, the clinic board considered closing the clinic but ultimately decided to continue, enlarging the scope to the underinsured. most free clinics in our region ceased operation. the regional dean, a member of the clinic board, advocated for continuing the clinic because of its educational value. many of the formerly uninsured in our region who had incomes higher than the medicaid maximum subsequently enrolled in the state insurance exchange. to minimize their premium, many chose plans that had out-ofpocket costs ranging from $5000 to $12000 per year. health system staff were finding that these patients were not seeking primary care because of the cost, resulting in emergency department visits for medium acuity issues, many resulting in unpaid debt. again, the free clinic board considered alternatives, and ultimately decided to waive the financial screen that formerly was required and see anyone not covered by medicare, with a $10 co-pay for the visit. this still required a financial screen to be done by the health system for free lab and imaging, but removed doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 6, issue 1 original reports one step that could be a barrier to prompt access to care. for patients newly covered by medicaid with needs that couldn’t wait until they could get an appointment with a pcp, we provided transition care. about a year later, with the turnover of some board members, they voted to waive the co-pay entirely. in 2019, the clinic had settled into getting about five new patients per month and caring for 60 longitudinal patients. the staff was trimmed down to just one part-time paid nurse and one thursday evening session with all volunteers, and the budget decreased to about $20000, with greatly scaled down fundraising efforts. the patient volume was adequate for longitudinal training purposes of the eight m-3s based at the regional campus, and many students reported that it was key in their choice of specialty, with almost 50% choosing family medicine and another 25% choosing general internal medicine. when the health system clinics closed to in-person visits because of the covid pandemic in march, 2020, the free clinic did the same. we re-opened in august, but many of our former patients were wary of getting out for any reason. we contacted them all, and for the approximately 30 who did, we used an in-person visit with covid protocol to introduce their new m-3 student pcp, do ecgs to assess for lvh as outlined in our hypertension protocol, and explained the telemedicine option to them. using the same model used by the local family medicine residency,9 the students were trained in telemedicine and each established a dialer account so that calls would appear on the patient’s phone as coming from the clinic. regular clinic sessions were set, and appointments made in the ehr as previous in-person visits were. telemedicine stations were set up in private rooms in the medical school training wing, and the regional dean supervised each encounter and interacted with each patient at the end of the telemedicine visit. the students adapted quickly and became very comfortable with the telemedicine process. in july, 2021, when it was time for the new m-3s to assume the pcp role, the now m-4s completed a “warm handoff” of each patient, often connecting in for a portion of their patient’s first telemedicine visit with the new m-3. we encountered similar problems reported from our residency, with about 30% of patients found not to have video capability on their phones and another 30% having inadequate internet connections to support video.9 when video was not possible, these visits were completed as audio-only telephone visits. funded by the local area health education center, we mailed each patient a high quality scale, automated bp machine, pulse oximeter, and thermometer for a total “home visit” equipment cost of $95. when video was possible, the students learned to have the patients point their phone at the instruments, allowing the vital signs to be listed in the “objective” portion of the visit note. they could also determine if cardiac rhythm was regular by listening as the bp machine beeped with each heartbeat as the automated cuff slowly deflated. basic skin, musculoskeletal, and gross neurological exams could be performed, and a few students demonstrated and then observed the patient doing simple physical therapy maneuvers for common complaints like rotator cuff tendonitis and plantar fasciitis. this telemedicine care has continued to the present, with patients reporting that their needs were being met.10 as happens each year, a few patients became eligible for medicare or got a new job with good insurance coverage, leaving about 25 active patients, resulting in each m-3 acting as pcp for two to four patients. with no personnel costs and much decreased “slip and fall” (general liability) insurance costs, the total budget is now $8000. this is completely offset each year by a grant from the city government, supplemented by student-managed fundraisers of a fun run and a cookout outside the host hospital supported by volunteer campus staff. the regular chart review continues, with ongoing reinforcement of protocol use for hypertension, diabetes, and hyperlipidemia and adaptation as changes occur with new medications available by pap. a staff member of the regional campus has assumed the role of volunteer administrator, assisting with prescription refills and pap forms between visits. at the end of each visit, the student sends a draft progress note to the regional dean who digitally marks up needed changes, the student places the revised note in the ehr, and the dean signs each note, prescription, and lab or imaging request. because of repeated covid waves, the clinic has not resumed in-person visits and is accepting new patients on a limited basis until the team returns to doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 6, issue 1 original reports our brick-and-mortar clinic when the pandemic recedes. history of community cardiovascular screening the regional campus has supported summer pathways programs since 1996, and since 2002, this has included college, pre-m-1 (prematriculation) and post m-1 (preclinical) students in service learning.11-13 during each summer session, students completed a community needs assessment in two adjacent underserved counties including key informant interviews14 and outlined the effort for the next summer. several of the college students returned each summer, providing some continuity to the implementation. the community input highlighted a lack of providers for the school physical exams required before kindergarten and sixth grade, as well as sports physical exams required annually. to address this need, the rising m-2 preclinical students receive an eight-hour tutorial on the physical examination. the larger group including the college students worked in teams led by a preclinical student with each team responsible to prepare for the sessions by researching common responses to history questions and physical exam, and simple lab abnormalities likely to be encountered in this population. the group took the anticipatory guidance script from the previous summer and adjusted it as needed. the physical exam sessions were held in health department facilities in contiguous underserved counties only when we were invited.11 their staff chose the date and time and an experienced nurse worked with each preclinical student in their exam room. the preclinical student progressed from observing to performing the exam early in each threehour session. the students were supervised by the regional dean or another family physician who saw each patient with medical needs. an established referral process through the school-based nurses provided continuing care as needed. the college students were responsible for setting up props in the anticipatory guidance (ag) room. the college student assisted in the exam room and then walked with the school child to the ag room. because they had been present in the exam room, they could provide individualized ag to each child while the parent was in a separate room providing feedback on the process to a staff person. approximately 80 physical exams were completed each summer since 2006. in 2016, leaders of the county that hosted the regional rural campus expressed concern about the high rate of cardiovascular disease (cvd). a panel of informal leaders met with the summer pathways students and together they designed a cvd screening program based on the franklin county maine project that had been reported from a rural county with demographics and socioeconomic profile very similar to the campus host county.15 this led to the formation of a county advisory council with the members shown in the table who established a recurring schedule of student-performed cvd screening at community events, churches, and food pantries.16 early in the process, we determined that to be effective our screening stations needed to be close to where those to be screened were already waiting for another purpose, with food pantries by far the most successful. an individual health risk summary was completed with student assistance, and a finger stick for blood glucose and total cholesterol and a bp check were offered. prior to the pandemic, our goal was have any person screened who had needs and no pcp leave with an appointment time at the next free clinic session as an add-on. the story of an individual patient as described below was subsequently made into a widely distributed short video by the host health system, promoting the value of community screening. perhaps not surprisingly, only about half of the patients directed to the free clinic actually came to their appointment despite it only being a few days hence. we discovered the obvious obstacle that the small van city bus route had a stop near the clinic, but stopped running at 5 pm. to maximize the participation of our working volunteers, we began clinic at 5:00. we met with the city council and plans were underway to extend the bus service hours on the thursday evenings that we had clinic just as we had to stop our in-person clinics because of covid. when the food pantries stopped serving in-house meals and had volunteers deliver the baskets of food to the recipients’ car, removing any organized waiting area, we stopped cvd screening. at the same time almost all in-person community events were paused. we look forward to resuming cvd screening at our doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 6, issue 1 original reports usual community sites when the pandemic has receded. homeless shelter experience just prior to the first wave of covid in spring 2020, we had been invited to do cvd screening in the only homeless shelter in our small town that was managed by the salvation army. the facility provided a warm lunch for the 21 sleep-over residents as well as anyone else in the community who came just for the meal. although small, the cvd screening effort produced almost 60% with abnormal screening values, even if they were under current treatment for diabetes, hypertension, or dyslipidemia. the vast majority listed the name of a local pcp on the risk summary, but most reported no recent visit. this resulted in some frustration among the students, as our protocol only allowed us to urge these patients to see their pcp soon. students learned that the chaotic life that resulted in attending a homeless shelter likely precluded the clients from making and keeping appointments with their pcps who were already too busy. when those at the shelter who had no pcp and had needs requested our care, we scheduled telemedicine visits during our next regular clinic session. as we tried to make our routine follow-up call confirming the date and time, we quickly learned that although most of this population had cell phones, they had limited minutes, no video, and no voice mail. even though at the screening we had given them a card with the date, time, and clinic phone number shown, they rarely would answer our call. this could have been because our services were no longer a priority for them, or an attempt to save their minutes for friends and family, or any of the myriad of social upheavals that they encountered in everyday life. after some discussion at dean’s hour, we decided to launch the “clinic without walls” that had been approved by the clinic board just before the covid pandemic began. instead of scheduling those who needed clinic care, we began providing care on the spot. we took the equivalent of the home telemedicine package that we had mailed to our regular free clinic patients to the shelter. this and a stethoscope provided the essential equipment for a basic primary care visit. when the student had completed the visit, a telemedicine connection was established with the regional dean who acted as supervising physician. the student presented the patient in their presence, and the three agreed on an initial plan. this usually involved basic lab and sometimes imaging, and the city bus had stops at the shelter and host health system clinic lab. after this step was completed, the dean saw the patient inperson at the shelter at a time convenient for all. needed prescriptions were approved and called into a local pharmacy that had a nearby bus stop either using the $4 list or salvation army vouchers. next, we discovered a group of patients at the shelter who had a pcp but either didn’t know they still had medicaid coverage, had health exchange coverage with a high deductible, or simply couldn’t navigate their way through the medicaid application process. we decided to provide them bridge care while connecting them with the contractor working with the host health system to complete the medicaid application process. this required getting beyond the “here’s the contractor’s phone number, call them” approach suggested by the contractor. by including shelter staff and active facilitation by a motivated student advocate, this process was more likely to be successful. this provided a mechanism for students to experience first-hand the social determinants of health and learn the role of patient navigator, the next logical step in our experiential curriculum development.10 the case studies and student comments below give a first-person account of that learning process, and a formal study showed that students reported that even with free clinic care, their patients could not find their way to free local cancer screening procedures and still needed help navigating the health system outside of the free clinic.10 student comments my experience at our free clinic gave me the opportunity to truly take care of patients as my own. it helped me begin to develop my professional identity. it was an invaluable experience that will help me be more prepared for residency. m-4, matched to fm residency working as a student clinic director at the longitudinal free clinic and participating in community cardiovascular screenings allowed me to put what i doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 6, issue 1 original reports had learned into action, educate patients on important health risks, and see firsthand the socioeconomic determinants of health in my patients’ lives. m-4, matched to dermatology residency this experience gave me insight into taking care of patients who face several obstacles to obtaining medical care. my patient lacked transportation, but also was unable to take the city bus because she did not have a car seat for her three small children and nobody to watch them. she did not have finances to pay for medications. i have a better understanding why so many people who lack resources seek medical care in the emergency room. as a medical student, it is important to be able to talk to patients, and often patient contact time in the clinic setting is limited and students do not have time to take full histories on a patient. this experience allowed me to gain confidence in my ability to take a medical history, perform a physical exam, order the appropriate lab work, and choose appropriate medications. this encounter also allowed me to build rapport with a new patient and provide follow up care. m-3, planning an emergency medicine career as we learn in our medical training, much of pediatrics is monitoring developmental milestones, safety concerns, diet, and anticipatory guidance. children are often overlooked in settings such as free clinics because most children are eligible for medicaid. however, with the average pediatrician visit being only 15-30 minutes long, there is still a need for coaching parents outside of the doctor’s office. encountering children in a homeless shelter gives a glimpse into barriers to pediatric care presented by a lack of transportation, lack of reliable income of caregivers, unstable family groupings, and lack of social support. m-3, planning a pediatrics career case studies case 1 prior to the pandemic, a 47-year-old man presented to our cvd screening on thursday afternoon. he was unemployed and uninsured, and had been newly hired for a maintenance job to begin in two weeks. he reported a history of “mild” diabetes and hypertension, but had not been taking medication for “a long time” because of finances. he could not remember if he had ever had his cholesterol checked. his bp was 230/110 and on repeat was 215/105. his random finger stick blood sugar (fsbs) was 210, and his total cholesterol was 220. he had no symptoms, and was given an add-on appointment to our free clinic later that evening. at that visit, his bp was in the same range and his fsbs was 230. his physical exam was unremarkable and he reported no medication allergies. he was given a lab request to be drawn the next morning and instructed not to fill his prescriptions until we checked those results but then to start the medications immediately. he was given prescriptions for lisinopril/hctz of 20/12.5 once per day, metformin 500 mg twice per day and simvastatin 20 mg at bedtime, all available on the $4 list. the next day his lab showed a normal complete metabolic profile except for bs of 216 with creatinine of 0.7, an hgba1c of 8.2, and a total cholesterol of 220 with an ldl of 130 and an hdl of 35. his student pcp called him with the results and suggested he fill the prescriptions, which he did. he was seen for a nurse visit in two days and returned to free clinic a week later. he remained asymptomatic, his bp was 150/95, and fsbs was 140. he was seen again for a nurse visit in four days and a free clinic visit in a week. he remained asymptomatic and bp was 140/85 and fsbs was 120. he presented for his pre-employment physical the next day, and he called us very happy that he was approved to start work on time. he was seen for two more brief free clinic visits before his insurance was in effect, and on the last visit his bp was 132/82 and fsbs 110. we assisted his transition to his new pcp and he again expressed his appreciation for our timely and inexpensive while effective care. case 2 while hosting a cvd screening at the homeless shelter, a 43-year-old woman asked if we could help her get restarted on her medications for hypertension, depression, reflux, asthma, and swelling in her legs. her heart rate was 88 and blood pressure was 154/103 with a large adult cuff, with no thigh cuff available. she reported a height of 5 feet 3 inches and a weight of 300 pounds. after doing a complete h and p, i presented the patient to the supervising physician. we ordered a cmp, cbc, nonfasting lipid panel, tsh, hba1c, urinalysis, bnp, and doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 6, issue 1 original reports urine pregnancy test, which she had done the next day, all normal. she was found to have one more month of medicaid coverage, but she was unaware of this. we started her back on several medications listed at her last primary care visit, which included lisinopril 5 mg, po, qhs, bupropion sr 150mg, po, bid, and famotidine 40mg, po, prn. these were filled with shelter staff assistance. we planned to see her in two weeks at the shelter. case 3 during adult cardiovascular screenings at a homeless shelter, we were informed by staff that there was a family currently residing at the shelter who had children ages five, four, and eight months and the staff was concerned that the mother did not seem to be attentive. the female caretaker was found in fact not to be their mother but their father’s girlfriend. discussion with her and brief interview and physical exam of the children showed some diet, developmental, and hygiene concerns. we reviewed basic hygiene and infant dietary needs. we discussed infant milestones and the importance of tummy time, safe sleep practices, and nasal suctioning with saline drops for runny nose/congestion, as well as ageappropriate calming measures. we confirmed that the children had a local source of care and had wellchild appointments already scheduled and offered to see the children at the shelter or return a call if the caretaker had concerns. table 1: advisory council positions president, city-county economic development director, housing authority co-director, saturday session food bank pastor, prominent black congregation director, weekday food bank president, local community college business liaison, regional jobs program conclusion as our host community health care access evolves, so must our student-directed community-based care. telemedicine and homeless shelter care will likely continue, and portable clinics at food pantries when these resumes will likely be our next addition. the concepts of community medicine and engagement are best learned with sleeves rolled up during service learning. key lessons learned are that community steering committees and advisory councils are necessary and health events need to be where and when suggested by those connected to the target audience. we offer this summary of our journey to others who are considering taking concepts of community medicine into their host communities. references 1. simpson sa, & long ja. medical student-run health clinics: important contributors to patient care and medical education. j of general internal medicine, 2007;22(3), 352–356. doi: 10.1007/s11606-006-0073-4 2. smith s, thomas r, cruz m, griggs r, moscato, b, ferrara a. presence and characteristics of student-run free clinics in medical schools. jama, 2014;312(22), 2407-10. doi:10.1001/jama.2014.16066 3. palma ml, arthofer a, halstead km, wahba jm, martinez da, 2020: service learning in health care for underserved communities: university of iowa mobile clinic, 2019. am j public health. 2020;110(9):1304-1307. doi:10.2105/ajph.2020.305755 4. fabricius mm, hitchcock nm, reuter zc, simon me, pierce rp. impact of the covid-19 pandemic & telehealth implementation in a student run free clinic. j community health. 2021;1-5. doi: 10.1007/s10900-021-01034-8 5. crump wj jr, king ma, matera el, crump wj iii. experience with a medical student-directed free clinic: patient, student, staff, and faculty perspectives. j ky med assoc. 2011;109: 9-14. 6. crump wj, fricker rs, crump am. james, t.e. outcomes and cost savings of free clinic care. j ky med assoc. august 2006;104(8):340-343. 7. crump wj, fricker rs, fisher sm, nair rs. a glimpse of the transition of care from free clinic to medicaid. j ky acad family physicians. winter 2016;87:8-10. 8. crump wj, fricker rs, ziegler ch, wiegman dl. increasing the rural physician workforce: a potential role for small sural medical school campuses. j rural health. 2016;32(3):254-259. doi: 10.1111/jrh.12156. epub 2015 oct 30 9. crump wj, nims, dm, hatler dj. mr. watson, come here i want to see you: one rural residency program’s rapid pivot to doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 6, issue 1 original reports telemedicine during the pandemic. marshall j med. 2021;7(2): article 8. doi: 10.33470/23799536.1314 10. parker sr, crump wj. perceptions of social determinants of health in a student-led free clinic: do students see things differently from their patients? submitted for publication, j reg med campuses. 11. crump wj, fisher sm, fricker rs. community service as learning laboratory: a report of six years of a rural community-academic partnership. j ky med assoc. 2014;122:131-6. 12. crump wj, fricker, rs. a medical school prematriculation program for rural students: staying connected with place, cultivating a special connection with people. teaching and learning in medicine. 2015;27(4):422-430. doi: 10.1080/10401334.2015.1077709 13. whittington cp, crump wj, fricker, rs. an invitation to walk a mile in their shoes: a rural immersion experience for college pre-medical students. j reg med school campuses. 2019;1(5). doi:10.24926/jrmc.v1i5.1565 14. brooks rw, martin da, crump wj, et al. community assessment using the key informant method: a snapshot of some rural communities from the perspective of community leaders. j ky med assoc. january 2000;98(4):27-3 15. record nb, onion dk, prior re, et al. community-wide cardiovascular disease prevention programs and health outcomes in a rural county, 1970-2010. jama. 2015 jan 13;313(2):147-155. doi: 10.1001/jama.2014.16969. erratum in: jama. 2015 jun 2;313(21):2185. doi: 10.1001/jama.2014.16969 16. doyle ec, southall wr, edmonson bs, crump wj. a student-directed community cardiovascular screening project at a regional campus. j reg med school campuses. 2021;4(4). doi: 10.24926/jrmc.v4i4x.4299 microsoft word lessonslearnedarticle.docx published by university of minnesota libraries publishing lessons learned: progressing community faculty engagement by considering failures and surprises april heiselt, phd; amanda bassett, mba; helene silverblatt, md; nicole bost, bs z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc april heiselt, phd director, office for community faculty, university of nevada, reno school of medicine, aheiselt@med.unr.edu amanda bassett, mba director of office for community faculty; advancement and alumni relations, university of new mexico school of medicine, abassett@salud.unm.edu helene silverblatt, md executive director, office for community faculty, university of new mexico school of medicine, hsilverblatt@salud.unm.edu nicole bost, bs manager, office of community based medical education, university of colorado, nicole.bost@cuanschutz.edu all work in jrmc is licensed under cc by-nc volume 2, issue 3 (2019) journal of regional medical campuses abstract lessons learned: progressing community faculty engagement by considering failures and surprises april heiselt, phd; amanda bassett, mba; helene silverblatt, md; nicole bost, bs topic: character limit: community faculty (e.g. volunteer, adjunct, clinical) provide medical schools with critical resources to support education and other academic missions. this includes community faculty who serve as mentors, advise career interest groups, and serve on admissions committees. however, recruiting, developing, and retaining community faculty can prove challenging as these individuals serve as volunteers and many teach in busy clinical practices. medical schools across the united states and internationally are reviewing ways to better engage and retain this important group. in this process, lessons have been learned by seasoned directors of offices for community faculty. these lessons have helped them develop an engaged group of community faculty who continue to educate and mentor through targeted activities. this information will prove useful so that other schools and individuals can examine how to not only discuss their failures and surprises, but also how repositioning these failures and surprises can impact feelings of anxiety and stress. being aware of this information can shape next steps when engaging this vital group of individuals. short description: we’ve all tried things that didn’t work. we’ve produced new communication materials, events, and research projects that community faculty did not appreciate in the way we thought they might. we’ve all been there. however, negative findings are rarely reported in academic journals or even to our colleagues, and there appears to be an implicit rule in medical education that one does not admit failure. yet it is often our less successful ventures that lead to in-depth understanding and a way forward. indeed, sometimes our mistakes are more informative than our successes. it is important to focus on stories of mistakes and surprises involving community faculty from across medical education contexts to illustrate how these underpinned learning and progress. by analyzing our findings in relation to the dominant culture within medical education, we can provide guidance on ways for individuals and teams to reposition failures and surprises as opportunities for constructive learning. four questions that were posed to/considered by session participants: 1) why is focusing on failures and surprises critical to ensuring future successes? 2) how can admitting our failures and acting from a growth mindset impact the culture of medical education? 3) have you experienced unexpected results or consequences of a newly instituted program, teaching method, or event and couldn’t figure out what went wrong? 4) what strategies can you use when you experience a failure in order to make changes and get back on course? three take home points from our session: 1) review your assumptions you cannot support people if you do not ask them what they need. when working with constituents think of ways to engage them about how to be meaningful in your interactions. for example, get a broad range of input by conducting focus groups, surveying stakeholders, or creating advisory boards. 2) do not bite off more than you can chew great ideas often need lots of support. ensure the idea is manageable and identify both bottom up and top down ways to execute any new type of program or methodology. 3) there is always more than one way to do things ensure you are engaging stakeholders as you roll out programing or make changes to existing programming. it is critical to seek feedback from all audiences and be flexible in order to have success. microsoft word mountainsand medicinearticle.docx published by university of minnesota libraries publishing mountains and medicine what can medical educators learn from other professionals? darryl potyk, md; john mccarthy, md; mike powers z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc darryl potyk, md, fac; associate dean for eastern washington, university of washington school of medicine, potykd@uw.edu john mccarthy, md; assistant dean for rural affairs, university of washington school of medicine, mccajf@uw.edu mike powers; senior guide & director of guide training, american alpine institute, international federation of mountain guide association, past technical director, american mountain guide association, poowers@earthlink.net all work in jrmc is licensed under cc by-nc volume 2, issue 3 (2019) journal of regional medical campuses abstract mountains and medicine what can medical educators learn from other professionals? darryl potyk, md; john mccarthy, md; mike powers topic: character limit: medical educators are involved in high stakes situations. in the medical setting we diagnose the patient, diagnose the learner(s), and then strategize about how we can help our trainees to refine thought processes, assessments, and actions in order to treat patients appropriately. other professionals engage in similar activities although the setting in which this occurs can be markedly different. rather than protecting the lives of patients, mountain guides must protect not only their client’s lives but their own as well. we explored similarities between these two seemingly disparate professions by reviewing parallel situations that occur at the bedside and in the mountains. scenarios depicting learners and clients in similar situations were shared and real time corrective strategies were discussed with attendees. our mountain guide is mike powers. mike is the director of staff development and senior guide for the american alpine institute. he was one of the first american mountain guides to earn certification from the international federation of mountain guide associations (requiring expertise in all 3 disciplines: rock, alpine mountaineering, and ski). mike has served as the chairman of the american mountain guide association technical committee and director of america’s national guide certification program. he is well known as a master teacher and expert on mountain safety. short description: medical educators are involved in high stakes situations. in the medical setting we diagnose the patient, diagnose the learner(s), and then strategize about how we can help our trainees to refine thought processes, assessments and actions. other professionals engage in similar activities although the setting in which this occurs can be markedly different. rather than protecting the lives of patients, mountain guides must protect their client’s lives but their own as well under extremely challenging circumstances. we will explore similarities between these two seemingly disparate professions by reviewing parallel situations that occur at the bedside and in the mountains with one of the most experienced and respected guides in the country. four questions that were posed to/considered by session participants: 1) group with varied abilities but need to maintain the group’s integrity. examples: inpatient rounds with a strong resident, a weak intern and a great medical student. climbing group that includes novices and to advanced members, but the group needs to advance together. 2) a defensive learner. examples: the medical student is given feedback but responds “i know, i know” but doesn’t integrate the feedback. the mountain guide points out a safety error, yet the client does not change, putting himself and the guide at risk. 3) an entitled learner. examples: an inexperienced student insists on doing a deliver despite being unprepared. a client is determined to summit despite obvious risks. three take home points from our session: 1) medical educators can be somewhat insular in their approach, but this session demonstrated that other professions, even those that are quite removed from healthcare, can provide insight and guidance about how to approach challenging learners and learning environments. 2) establishing expectations combined with active listening early on can reduce the likelihood that some of the difficult scenarios described above will occur. 3) an overarching strategy of facilitated reflection can be extremely useful in overcoming several difficult learning situations. having learners reflect upon and verbalize his or her thoughts, observations, and plans can lead to self-recognition knowledge gaps, preparatory status, and biases. microsoft word newwaysofteachingarticle.docx published by university of minnesota libraries publishing new ways of teaching at the new campus madhavi singh, md doi: https://doi.org/10.24926/jrmc.v2i4.2088 journal of regional medical campuses, vol. 2, issue 4 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc madhavi singh, md; university park regional campus of penn state college of medicine all work in jrmc is licensed under cc by-nc volume 2, issue 4 (2019) journal of regional medical campuses perspectives new ways of teaching at the new campus madhavi singh, md abstract this perspective article shares the experience of my teaching role as a clinical faculty in the newly designed regional campus curriculum of the inaugural class at the university park regional campus of penn state college of medicine. i was thrilled to have our first class of penn state college of medicine at the university park regional campus. from the beginning, the opportunity to be around medical students was an exhilarating idea. for the first time, the knowledge i obtained from hours spent during one and half years of ‘basic science courses’ in dissection hall and physiology labs was going to come in handy. the pages of book of physiology were strolling through my mind, and the anatomy book diagrams were so vividly stimulating my amygdala. while the students were immersed in the clinics right away, as a practicing family physician who practices both inpatient and outpatient medicine, i was in the perfect position to help these young, naïve minds soak up as much as they could. they learned the whole gamut of medicine from the complex physiology of acid-base balance to the basic anatomy of a thumb’s range of motion being reversed. the 12 students, who were all very intelligent, competent, self-dependent, and ready to explore the world of medicine, brought a lot of joy. unlike the traditional system, the firstyear curriculum involved students spending a lot of time in the clinics, seeing every aspect of them function to unique patient interaction. in their didactic session they brought cases from the clinics to learn about illnesses from a to z. here, z is the value-based treatment where they looked up the costs of every medication, procedure, or anything that entailed the treatment plan. their time in clinics interspersed with didactic session slowly started to unfold the magical pandora’s box of medical knowledge. they explored the possibility of getting involved in different research projects at the main campus of penn state university, while also involving themselves in multiple community service projects. every moment of their lives seemed to be filled with enthusiasm. i was going along with this fun ride until i learned that the following year they were to start their clinical rotations. now, i was terrified. how in the world could they learn enough in one year to function during clinical rotations? regardless, i didn’t have any time to waste. game on! i went at it like it was a war to win. while their didactic session tried to cover a lot, i was attempting to run a parallel show from the new age techniques, through emails and social media using what’s app and group me. i created group chats and started to teach many basics, like what an echocardiogram report looks like and how liver function test are different in hepatocellular versus cholestatic disease, etc. at this point one might question how this curriculum is different from the traditional medical education that most of us received. well, the difference here was the story attached to each of these test results, lab values, ekgs, and ct scans – stories of patients who the students would have interacted with created a way to connect the dots of medical complexities. the whole intention of the new/reversed curriculum was to allow students to learn medicine directly from patients. the knowledge gathered directly from patient’s stories has had a deeper impact on their learning, which i felt was the best part of this education model. apart from using the senses vision and hearing in a classroom, interacting with patients bridged many more pathways in their brains, connecting different facets of health and illnesses. additionally, each student connected with patients in different ways depending on their core personalities. so far, the experience of working with the regional campus students has made me ecstatic. while the first class in now finishing up their second year taking different shelf exam, i keep thinking that i wish i was trained with this type of curriculum and wasn’t stuck in the big classrooms, day after day, with no real patient experience for such a long time! microsoft word asimpledisabilitiescurriculumarticle.docx published by university of minnesota libraries publishing a simple disabilities curriculum improves student awareness of disabilities nathan f. bradford, md; nathan gilreath, ms-3; kathy barrington, msm; melissa owens, acume, aamc caa doi: https://doi.org/10.24926/jrmc.v2i4.2092 journal of regional medical campuses, vol. 2, issue 4 (2019) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc nathan f. bradford, md nathan gilreath, ms-3 kathy barrington, msm melissa owens, acume, aamc caa corresponding author: dr. nathan f. bradford; anmed health family medicine residency program; 2000 east greenville street suite 3600, anderson, sc 29621; phone: 864-512-1473 fax: 864-224-8100; email: nathan.bradford@anmedhealth.org all work in jrmc is licensed under cc by-nc volume 2, issue 4 (2019) journal of regional medical campuses original reports a simple disabilities curriculum improves student awareness of disabilities nathan f. bradford, md; nathan gilreath, ms-3; kathy barrington, msm; melissa owens, acume, aamc caa abstract learners sometimes struggle to communicate and empathize with patients with disabilities. possible explanations for this include lack of access and exposure, emotional immaturity, and knowledge deficits. this often leads to a perception that disabilities lie outside the scope of primary care. we constructed a disabilities curriculum and embedded it within our existing third year curriculum. this curriculum is different from others because of the hands-on component in which the students are paired with a patient with a disability with the goal of transitioning patients successfully from pediatric to adult care. the disabilities curriculum also requires the students to listen to a lecture describing the healthcare challenges facing persons with disabilities. in addition, the students view a video showing proper etiquette toward patients with disabilities in medical environments. finally, the students together visit the home of a young person with disabilities. the students complete the validated “medical student attitudes towards persons with disabilities” survey before and after finishing the curriculum (see appendix a). we compare those responses with another institution where the curriculum is not offered. introduction: the proportion of people with disabilities is increasing both in the u.s. and worldwide.1 therefore, the aamc has designated disabilities education as a priority for medical school education.2 their recommendation is that disabilities teaching be integrated into the overall curriculum. suny upstate in partnership with the american association of physiatrists has developed a “disability toolkit” to enable medical schools to incorporate disability teaching.3i one 4year medical school which has implemented many of the ideas presented in the disability toolkit is suny upstate. that effort spans the entire 4 years with different experiences and assignments for students appropriate to their level of education.4 our clinical campus, affiliated with medical university of south carolina in charleston, is located in the upstate of south carolina with a 561-bed hospital in a county of about 125 000 people. we are not aware of a disabilities curriculum followed at any other clinical medical school campus. in our case, we are limited to one year of on-site study, the third year only; therefore, we must integrate our curriculum into the busy third-year clinical schedule. currently, our home institution has a disabilities curriculum involving the first and second years only. learners struggle to communicate and empathize with patients with disabilities for several different reasons. first, they may lack opportunities to interact with and learn about persons with disabilities. since there is usually not a dedicated disabilities curriculum they often lack knowledge about specific disabilities as well as about disabilities in general. often, learners and providers believe that disabilities lie outside the scope of practice for primary care, making access to health care for persons with disabilities more difficult, and over-medicalizing common outpatient problems. furthermore, the student often feels uncomfortable around persons with disabilities. sometimes the patient has a disability involving intellect, speech, hearing, or sight, which directly interferes with communication. at other times a visible disability may distract or distress the learner. in addition, the learner sometimes struggles to show empathy to a patient who has a disability. approaches to improving medical students’ empathy have been tried with varying success.5 we made use of gaps in care for patients with disabilities as an exercise to improve empathy in medical students. one gap in care involves a subset of the disabilities community, youth with special health care needs (yshcn), who are transitioning out of pediatric care to adult care. this transition often does not go smoothly or does not happen at all. this leads to morbidity and unnecessary healthcare expenditures in the form of emergency visits and hospitalizations. therefore, transition for yshcn is considered a priority for the american academy of pediatrics as delineated in its 2011 report.6 medical students have been used for years at our clinical campus as “coaches” for yshcn patients in transition with some success.7 the purpose of the disabilities curriculum is to train physicians who appreciate the challenges facing persons with disabilities, particularly as those patients interact with the healthcare system. we constructed a disabilities curriculum doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports and embedded it within our existing third year curriculum. there are 5 pieces of this curriculum spaced out over the year. those 5 pieces are illustrated in the graph below methods: participants: this study comprises 2 third year medical student cohorts: an experimental group (n=13) with an assigned disabilities curriculum, and a control group (n=20) without an assigned disabilities curriculum. both cohorts are students at clinical campuses of via college of osteopathic medicine-carolinas campus in spartanburg, sc. the study group denoted as “anmed” includes 4 male students and 9 female students with an average age of 25.3, all of whom performed their clinicals at anmed health medical center in anderson, sc. the control group denoted as “spartanburg regional” includes 12 male students and 8 female students with an average age of 26.3, all of whom performed their clinicals at spartanburg regional medical center in spartanburg, sc. curriculum: at the beginning of the year, each student at anmed was assigned a yshcn patient enrolled in the transition project (below). the students participated in a home visit (below). a lecture, “medical care of the disabled patient”, was presented to the anmed students. this lecture is found in the stfm residency resource curriculum.8 on another day the students viewed the video “patient voices”, a series of interviews and vignettes featuring real patients with disabilities encountering the health care system.9 home visit: we partnered with a local organization, family connection of south carolina, which provides support to families of people with disabilities. their physician education awareness program helps providers grow in awareness of disabilities. their representative conducted a group visit for our students to the home of a young person with disabilities. transition project: the yshcn patients were all young people with either an intellectual or a physical disability who were between the ages of 18-21 at the time and therefore transitioning out of the pediatric clinic to the family medicine clinic. we paired each anmed student with a yshcn patient. the medical student attended the patient's last visit at the children's clinic where the patient had been receiving longitudinal health care. the medical student assisted with compiling a medical summary as well as a validated “readiness checklist” developed by gottransition.org, a project of hrsa.10 this checklist is a reminder for the patient and family to prepare for independent living. the student and patient/family chose one competency to develop over the course of the year with plans to revisit the checklist later. the medical student stayed in touch with the patient and family and organized the first visit at the family medicine clinic where the students have their family medicine experience. at that visit, the student was present and assisted the new provider in reviewing the medical history and the readiness checklist. measures: both groups were given the attitudes survey at the beginning of the academic year. the experimental group completed the assigned disabilities curriculum throughout the academic year. at the end of the academic year, both groups completed the attitudes survey again. the validated survey used in this study measures comfort levels treating and working alongside people with disabilities, negative impressions of self-perceptions of people with disabilities, and “conditional comfort” with patients with disabilities. this latter component refers to the difference in a common ambulatory office visit with a typical patient versus a patient with a disability.11 data analysis: the responses on the medical student attitudes towards persons with disabilities surveys were analyzed by 2 different methods. although both methods focused on examining the difference between end of year (eoy) and beginning of year (boy) responses between anmed and the control group, the first method looked at each question individually and the second method grouped the questions into one of 5 categories described by symons, the author of the survey11xi. under both methods, survey responses were translated into a numerical value between 1 and 4. a response of “strongly disagree” received a value of 1, “disagree” a value of 2, “agree” a value of 3, and “strongly agree” a value of 4. six questions on the survey were reverse-scored because a response of “strongly agree” correlated with a more negative attitude towards people with disabilities. the method described above was used to record the responses to all questions, except questions 1 and 2 which required a yes/no response. results: to analyze the effect of a disabilities curriculum on medical students, the responses between the 2 groups from the doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports beginning of the year to the end of the year are compared. we find it most helpful to group the survey statements into the 5 categories mentioned above. we show the comparisons in the graph below by category (graph 1). first, “positive impressions of self-concepts of people with disabilities” is measured by survey statements 5, 13, and 17. “negative impressions of self-concepts of people with disabilities” is measured by survey statements 3, 8, and 11. these 2 groups of statements describe assumptions of attitudes of people with disabilities. the statements gauge how a medical student imagines the way a person with a disability sees himself or herself. for example, when the medical student imagines herself in the shoes of a person with disabilities, does she resent people without disabilities? these types of assumptions are prevalent among the medical community in general.12 the anmed students show a greater improvement in removing these types of stereotypes. next, “working with people with disabilities in a clinical setting” is measured by survey statements 21-19. this group of statements refers to the comfort level in treating people with disabilities. these statements compare a typical office encounter with 2 patients—one with a disability and one without. many learners who encounter such a patient will get distracted or sidetracked by the disability. the improvement in the anmed students in this group of statements is statistically significant (p=0.016). the next group of statements, “comfort interacting with people with disabilities,” is measured by survey statements 4, 6, 7, 9, 12, 14, 18, and 19. these statements assess students’ comfort interacting with persons with disability not only in the healthcare setting, but also in daily life. the anmed students demonstrate greater improvement in this category. the last group of statements, “conditional comfort with people with disabilities,” is measured by survey questions 10 and 15. while these statements show negative results for both cohorts, they are ambiguous. both groups tended to disagree with question 10, meaning that if the patient were not “well-behaved” it would not bother them. for the others who agreed, perhaps their answer shows bias towards persons with disability. however, it would be natural to be uneasy around any misbehaving adult patient! both groups tended to agree with statement 15, that they would be more comfortable if a person with a disability were accompanied by an aide. from the students’ perspective, in some situations it may advisable to have an aide present. graph 1: improvement of scores at anmed health and spartanburg regional on the medical student attitudes towards persons with disabilities survey by question category. discussion: our clinical campus is located in anderson, a community which has less benefits available for the disability community than in charleston, where our main campus is located. years ago, it came to our attention that in our area, people with disabilities in general, and yshcn patients in particular, were being lost to follow-up and using episodic care as opposed to longitudinal care for their health needs. the medical staff was educated about these gaps in health care first. when medical students began coming here for their clinical education it seemed only natural to educate them to take care of people with disabilities. our curriculum is weighted toward actual encounters with persons with disabilities. we rely less on didactic sessions. there are several reasons for this approach. first, caregiver comfort with patients with disabilities has more to do with general knowledge of disabilities than with knowledge of specific disabilities.13 that general knowledge is assessed in the survey used in this project. second, we believe comfort and knowledge of disabilities is more likely caught than taught. the patients themselves are often better at teaching the learner who wants to learn. furthermore, the learner is more likely to be interested in disabilities when he/she forms a friendly relationship with an actual person. finally, the amount of knowledge to become an expert on all disabilities is out of the range of most primary care providers; information pertinent to specific conditions is readily available at the time of contact, and that is a skill worth learning. we want the learners to understand that a receptivity toward persons with disability, not comprehensive knowledge, is the requisite to caring for them. the challenges with the curriculum all arose from the transition project. as in the past, we experienced great difficulty contacting and scheduling the patients; this is one of the reasons for constructing this project in the beginning. in the future we will set up the follow-up visit at the time of the initial visit in order to give the med student and the patient/family a follow-up date. we will also obtain alternate phone numbers for contacting the patients/families. the med doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports students tended to lack confidence in contacting and following the patients, not taking ownership as much as we had hoped; in the future we will tie a grade to the project to motivate the students. the patients themselves made poor choices at times, thus sabotaging their health care. to address that, we would like to incorporate a group visit which might help them process their desires and goals. there are several survey statements which show either similar results in both groups, or negative results in the anmed group. some of these are in the survey category “conditional comfort with people with disabilities”. again, these statements are ambiguous and can be interpreted in different ways, as discussed above. alternatively, the answers suggest that as the students gained more awareness of the complexity of patients with disabilities, they appreciated extra help with the patient visits. these answers are not inconsistent with greater comfort with persons with disabilities. another explanation might be rooted in a difference between the 2 groups which has not been mentioned: the control group reports more “structured experiences working with people with disabilities” (55% as compared with 38%). perhaps more experience may have given the control group less of a perceived need for help from a caregiver. our data show strong benefits of a disabilities curriculum for medical students. our results are convincing in the areas of “working with patients in a clinical setting”, “comfort interacting with people with disabilities”, and “positive impressions of self-concept of people with disabilities.” we believe improvement in this group of statements is due to exposure to persons with disability. therefore, we suggest that the anmed students improved in this category due to their experience with the curriculum. we anticipate that our students will be more accepting, empathetic, and confident treating persons with disabilities not only in the community, but in the office setting. we also expect our students to be able to form differential diagnoses in the office with persons with disabilities that are similar to persons without, with the addition of conditions related to disabilities. that will make them excellent primary care physicians for persons with disabilities. the anmed teaching site is dedicated to training primary care physicians. patients with disabilities represent a vulnerable population in primary care. at the same time, medical schools often do not train students to deal with patients with disabilities. on the contrary, negative attitudes towards patients with disabilities are common in the healthcare setting among students and staff. one of our goals was to counter these assumptions and remove prejudices toward the daily facts of living with a disability. we succeeded in both of these goals. in this way we hope to train physicians who treat patients with disabilities without bias. references 1. kraus, lewis. (2017). 2016 disability statistics annual report. durham, nh: university of new hampshire. 2. integrating disability into medical school curriculum: practical strategies and resources. ioerger, m. french-lawyer, j. turk, m. suny upstate medical university, syracuse, ny. 3. disability integration toolkit, suny upstate medical university, http://www.upstate.edu/pmr/education/toolkit/ind ex.php. 4. symons, a., mcguigan, d., akl, e., a curriculum to teach medical students to care for people with disabilities: development and initial implementation, bmc med educ. 2009; 9: 78. published online 2009 dec 30. doi: 10.1186/14726920-9-78. 5. 5. pederson, r., empathy development in medical education: a critical review, medical teacher, 2010; 32:593-600. 6. american academy of pediatrics clinical report — supporting the health care transition from adolescence to adulthood in the medical home, pediatrics vol. 128, no. 1. july 1, 2011 pp. 182 -200. 7. bradford, n. mulroy, b. “med students as coaches for transition in youth with special health care needs”. society of teachers in family medicine. medical student education conference. phoenix, az. jan 29, 2016. poster presentation. 8. d’agata, et al. medical care for the disabled patient, family medicine residency curriculum resource, stfm.org. 9. jain, sweety (2015). “patient voices” [youtube], lehigh valley health network. 10. gottransition.org a program of the national alliance to advance adolescent medicine supported by hrsa/mchb http://gottransition.org/resourceget.cfm?id=239. 11. symons, et al, the development of an instrument to measure medical students’ attitudes toward persons with disabilities, intellectual and developmental disabilities, june 2012. 12. satchidanand, nikhil, et al, attitudes of healthcare professionals and students toward patients with physical disability, american journal of physical medicine and rehabilitation, vol. 91, no. 6, june 2012, 533-544. 13. the surgeon general’s call to action to improve the health and wellness of persons with disabilities. office of the surgeon general (us) office on disability (us). rockville (md): office of the surgeon general (us); 2005. doi: https://doi.org/10.24926/jrmc.addhere journal of regional medical campuses, vol. 2, issue 4 original reports appendix a: medical student attitudes toward persons with disabilities microsoft word natie americans into medicine article.docx published by university of minnesota libraries publishing native americans into medicine: a program focused on developing representation and diversity in health care mary owen, md; patricia conway, phd; jessica hanson, phd; catherine mccarty, phd; mangan golden, ma doi: https://doi.org/10.24926/jrmc.v5i1.4485 journal of regional medical campuses, vol. 5, issue 1 (2022) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc mary owen, md, director, center of american indian and minority health, university of minnesota medical school, duluth campus, duluth, minnesota patricia conway, phd, research scientist iii, essentia institute of rural health, duluth, minnesota jessica hanson, phd, assistant professor, public health program coordinator, department of public health, university of minnesota duluth, duluth, minnesota catherine mccarty, phd, associate dean of research, professor, department of family medicine and biobehavioral health, university of minnesota medical school, duluth campus, duluth, minnesota mangan golden, ma, research coordinator, center of american indian and minority health, university of minnesota medical school, duluth campus, duluth, minnesota corresponding author: mangan golden, ma research coordinator, center of american indian and minority health, university of minnesota medical school, duluth campus 1035 university dr. smed 182 duluth, minnesota, 55812 218-726-8303 goldenm@d.umn.edu all work in jrmc is licensed under cc by-nc volume 5, issue 1 (2022) journal of regional medical campuses perspectives native americans into medicine: a program focused on developing representation and diversity in health care mary owen, md; patricia conway, phd; jessica hanson, phd; catherine mccarty, phd; mangan golden, ma abstract the center of american indian and minority health (caimh), housed in the university of minnesota duluth medical school, aims to reduce american indian and alaska native (aian) health disparities by increasing the numbers of aian physicians, increasing awareness of aian health care, and conducting aian health-related research. for the past 50 years, caimh has held a summer enrichment program, native americans into medicine (nam), with the goal to increase the number of aian students who successfully matriculate to and graduate from health professions programs. prior to 2018, the program focused on improving math and science aptitude. to respond to persistent aian health disparities, minimal research on aian health disparities, and low aian representation in nearly all health professions, including medical research, caimh changed the nam focus. the program now provides research training and increases aian students’ science and math aptitude through statistics education. caimh teaches skills that enhance students’ standing as applicants to health professions programs and in future careers. the training benefits aian communities by increasing the numbers of tribal members aware of research standards in indigenous communities. the nam curriculum highlights best research practices to use when working with aian communities. introduction american indian and alaska natives (aian) experience higher rates of chronic illness, lower life expectancy, and increased rates of high-risk behaviors than other races.1,2 despite these disparities, health research in aian communities is limited. aian distrust of research and healthcare systems significantly limits the ability to study health interventions in aian communities.3-6 the distrust stems from a consistent exclusion of involvement of tribal members in the development, implementation, and evaluation of research projects in their communities; a history of controversial and stigmatizing research publications regarding aian people; and a lack of tribal oversight of research within aian communities.5,6 one strategy to expand both the involvement of tribal members and the capacity for tribal community-led health research is to increase the number of aian researchers and health care providers with research training. walters and simoni5 state that interest, responsibility, and motivation are enhanced when aian researchers conduct research in their own communities, which facilitates heightened awareness and ability to listen to community-identified needs and minimizes mistrust. research is more likely to have a persistent impact and to be sustained when it is conducted by aian journal of regional medical campuses, vol. 5, issue 1 perspectives researchers, who are more likely to have or to develop long-term relationships with communities with whom they are working.7 stronger relationships can prevent “helicopter research,” in which researchers take information and data from the community and fail to disseminate findings to the community, leading to a lack of meaningful results and understanding of such research. increasing the number of aian researchers and health care providers requires sufficient numbers of aian students interested in and adequately prepared for graduate programs that lead to biomedical research and health professions careers. in 2019, 14% of american indian students who took the american college test (act) college readiness assessment met college readiness benchmarks in math and 13% met college readiness benchmarks in science, compared with 39% and 36%, respectively, of all students.8 only 13% of aian students who completed the act met all three college readiness benchmarks in english, reading, math, and science.8 fifty percent of aian students entering college require remedial coursework.9 in 2016, the 6-year graduation rate for the 2010 entry cohort of first-time bachelor’s degree– seeking aian students was 39%, versus 64% for firsttime white students.10 clearly, increasing the number of aians entering health care and research professions will require additional academic enrichment and support programming for aian students in high school and college. background the center of american indian and minority health (caimh)11, housed within the university of minnesota medical school duluth campus (ummsd), strives to improve the health status of aians by recruiting and educating aian medical students, increasing awareness of aian health, and conducting research with aian communities. caimh’s intensive recruitment and support of aian medical students has contributed to umms graduating the second highest number of aian physicians in the united states.12 as part of the work to train aian health professionals, caimh conducts a summer enrichment program called native americans into medicine (nam) for aian undergraduate college students interested in doi: https://doi.org/10.24926/jrmc.v5i1.4485 pursuing health careers. nam began in 1973 as a way to enhance the academic success of aian undergraduate scholars and prepare them for medical school, with the hope that many of the students would eventually serve aian communities. over the past several decades, nam has recruited and mentored aian undergraduate students as a way to improve some of the academic disparities detailed earlier. the program’s curriculum had focused on academic skills development, particularly in math and science. ultimately, nam is a program that aims to increase aian representation in health professions and research careers and to increase awareness and practice of culturally sound research regarding health in aian communities. caimh revised the nam curriculum in 2018 to focus on aian or indigenous-informed research knowledge and skills and to promote the academic success of future aian health professionals. early exposure to research offers students more varied health-related career opportunities, from research to direct care; both areas will benefit from increased numbers of aian professionals. the new indigenous-informed research curriculum incorporates best practices in research when working with and for aian communities. this article describes the process for recruitment of nam participants, the new curriculum, and important lessons learned from this program. the curriculum spans 2 summer sessions. dr. mary owen, a tlingit physician and director of caimh, teaches native american health. these lessons are similar to or the same lectures she gives to ummsd students during the school year. the rest of the curriculum is collaboratively developed by the nam team, which consists of the caimh research coordinator and ummsd and university of minnesota duluth faculty. collectively, the instructors contribute years of experience in teaching, research, and work with indigenous communities. nam is supported by the university of minnesota library system and information technology (it) department. journal of regional medical campuses, vol. 5, issue 1 perspectives implementation of the researchfocused nam program recruitment of undergraduate and medical students into nam summer program nam recruited students by disseminating flyers and emails through caimh’s network of academic institutions and community partners, as well as through social media (sample flyer available upon request). in addition to changing nam’s focus to research, there were efforts made to develop more focused, rigorous curriculum content; support better team development by improving management of conflict; and more closely monitor students’ progress. one way these goals were accomplished was by limiting program eligibility to college sophomores and juniors. we also required a demonstrable connection to native communities, via a personal essay, because the focus of the new curriculum was aian research methods and connections with tribal communities. these changes resulted in fewer applicants than the previous program; therefore, we decided to accept all applicants the first year. additionally, students are offered a weekly stipend, and on-campus apartments are provided for those who do not live in the area. the first cohort of 17 students participated in the revised nam curriculum at the university of minnesota duluth campus during summer 2018 and summer 2019. each summer session lasted 6 weeks, for a total of 12 weeks over the course of 2 summers. the second cohort of 11 students during summer 2020 and summer 2021 participated virtually due to the covid-19 pandemic, and these sessions also comprised of a total of 12 weeks of programming. more participants were female (n = 20; 71%); participants’ average age was 23.04 (range from 18 to 45). more were sophomores (15; 52%) and attended a public higher education institution (22; 76%; see figure 1). curriculum and implementation curriculum that promotes academic success while teaching aian-focused research skills and methodologies was central to the revised nam program. appendix 1 provides a sample syllabus and curriculum plan. the overall objectives of the nam curriculum were to: doi: https://doi.org/10.24926/jrmc.v5i1.4485 1. enhance aian student skills and academic success; 2. introduce students to qualitative and quantitative research methods; 3. introduce students to indigenous research methodologies; and 4. develop and maintain relationships with aian communities to support nam student learning. to meet the first objective, students completed daily scientific paper readings and written reflections to improve their understanding of western and indigenous scientific methods and writing skills. for objective 2, students received didactic and hands-on lessons in qualitative and quantitative methods, epidemiology, and statistical software. meeting objective 3 included mentoring on research methods focused on principles of community-based participatory research,13 the gold standard for research in and with aian communities.14-16 students were also introduced to both university and tribal institutional review board protocols and completed health insurance portability and accountability act (hipaa) and ethics training as a way to meet objective 4. students presented results of their final research project to a tribal community to maintain accountability to the community and gain experience in presenting their work. throughout the course of the summer program, students worked in small groups, allowing nam faculty and staff to monitor progress and adjust the curricular content as needed. students practiced leadership informally and through rotations in the role of group coordinator, in which they were accountable for group tasks. they strengthened their communication skills by developing social contracts in small groups. finally, participants received individual mentorship throughout the 6-week sessions and following the conclusion of the program. aian health professionals also mentored the students through presentations about their work, cultural values and practices, and academic paths. two first-year aian medical students also mentored the first cohort, teaching them about indigenous-informed research models. faculty from other university of minnesota health, nursing, pharmacy, and veterinary programs, along with external faculty, presented information about programs. cultural programming, which is key to nam, did not change significantly when the curriculum focus journal of regional medical campuses, vol. 5, issue 1 perspectives switched to research. caimh leadership has always recognized that embedding culture in the program is important for promoting aian students’ academic success.17 caimh’s director, dr. mary owen, presented lessons from a ummsd native health seminar series throughout the 6-week course, covering cultural identity, social determinants of health, boarding schools, current events such as missing and murdered indigenous women, and other factors that impact aian health. students met with several aian elders and practiced traditional games taught by a local indigenous organization specializing in this area. covid-19 adaptions a strong sense of community and support was embedded throughout the 6-week sessions, although it was more challenging during the second cohort due to covid-19 pandemic restrictions. the summer 2020-2021 nam program was 100% virtual, pushing faculty and staff to be nimble and adjust how they supported students. laptops were sent to all participants, meeting times were changed to accommodate time zone differences, and mentor meetings were smaller and more frequent. being more creative with forming relationships between students and with the students was necessary. for example, pizza was delivered to each participant’s home for a zoom-facilitated dinner meeting. the nam program sponsored beading sessions and designing t-shirts. the pandemic negatively impacted recruitment of medical students to participate in cohort 2, but nam faculty and staff were able to connect nam students to other students and mentors to facilitate relationships and provide role models. recognizing that students were probably new to the virtual format and feeling the stress of living through a pandemic, the faculty began each week with a check-in and syllabus review. students were also offered the opportunity to provide feedback regularly, and nam faculty made adjustments accordingly. for instance, to reduce students’ time spent videoconferencing, discussion boards were set up for student posts; the students responded that they preferred and needed the virtual interaction. therefore, most of the discussion boards were changed to “in-person” discussions. communication a persistent presence and an investment in student success and well-being are essential, so nam staff doi: https://doi.org/10.24926/jrmc.v5i1.4485 maintained communication with both cohort 1 and 2 students through email and text messaging throughout the academic year and promoted group cohesion through social gatherings via teleconferencing. the contacts during each academic year allowed rapid response to students’ needs during the pandemic; nam program staff were able to fill in the gaps to ensure students did not become lost in the transition to virtual education and to minimize disruption of learning as much as possible. lessons learned the revised nam curriculum was successfully implemented with 2 cohorts over the course of 4 summers; the second cohort’s participation was completely remote. lessons were learned from the sessions with the two groups of students, including regarding recruitment and retention, curriculum development, student support and empowerment, and flexibility. ● recruiting and retaining students. although a 2summer program is a big commitment for students, 12 weeks offered significantly greater opportunity to impact student outcomes. due to conflicting educational and family obligations, 5 students who participated in year 1 of cohort 1 did not return for the second year. four new students joined the group in cohort 1’s year 2. the additional students each brought something unique to the group; ensuring that they were at the same level as students who had been involved the previous year was challenging for everyone. therefore, in cohort 2, caimh decided not to add students to the second year. all cohort 2 students returned for the second summer session. ● curriculum. meeting all of the nam objectives while giving students time for reflection and relationship building requires more than 6 weeks per summer. nam would like to expand the curriculum to include more research basics. additionally, as noted earlier, we had last-minute obstacles that required a change in direction, and, with only 6 weeks each summer, developing alternative plans doi: https://doi.org/10.24926/jrmc.v5i1.4485 journal of regional medical campuses, vol. 5, issue 1 perspectives was challenging. nam has been limited to 6 weeks each summer to accommodate faculty schedules. in future cohorts, we plan to extend the curriculum to 8 weeks, creating a 16-week program over the course of 2 years. by the fifth and sixth weeks, nam students were focused on their final projects and did not necessarily have the mental or emotional energy for additional detailed or difficult conversations. nam staff adjusted the curriculum accordingly after the first cohort and placed difficult lessons and conversations earlier in the 6-week period. students will also receive the curriculum prior to the beginning of the first summer session to alert them to the academic rigor and expectations. incorporating books on indigenous science not necessarily related to students’ research project was a great way to not only teach critical reading but also connect with broader issues and examples of resilience in the greater community. for instance, students in the first cohort read and responded positively to research is ceremony15; therefore, the book became required reading for following cohorts. the second cohort read research is ceremony during the first summer and plants have so much to give us, all we have to do is ask18 in the second summer. that same summer, 2 local aian scholars who wrote children’s books were invited to speak; each student received a copy of the books, providing a muchneeded diversion that was fun and culturally relevant. students told nam staff many times that they had not had opportunities previously to talk with other students and educators about their identity as aian students. ● student support. during the second cohort, developing relationships and community via online curriculum was challenging, but the program did meet this goal. while nam is best provided as an in-person experience, accommodations due to the covid-19 pandemic that forced the program to switch to a virtual format allowed the program to explore online opportunities that may have previously been overlooked. for instance, this change allowed for virtual meetings throughout the academic year and broadened access to aian professionals and mentors. the program will continue to include virtual guest speakers and incorporate virtual connections during the academic year. stages of team development should be considered throughout the learning process and support of students for a cohort model.19,20 tuckman’s five stages of team development—forming, storming, norming, performing, and adjourning—provide one way to think about team development.18 the level of direct oversight needed for teams varies according to a team’s developmental stage. it was important to keep these stages in mind, particularly with cohort 1 and the introduction of new students the second summer, which led to the need to revisit group rules and establish new groups and trust. in the second year of cohort 1, the first 3 developmental stages were revisited during the first few weeks; students needed guidance to move forward and perform together. as with any group, balancing different personalities is a continual process. each summer, students were invited to establish expectations and rules for conflict resolution. conflict still occurred, but student involvement in governing helped smooth the process. meeting the students where they were at was vital, as was focusing on growth potential rather than current academic status and other factors. recognizing individual needs through the application process allowed the nam team to identify and serve students who required more intense support and mentoring while maintaining a cohesive team of students who could meet the program’s objectives. ● student empowerment. too often, cultural knowledge, particularly aian cultural awareness and experience, is not recognized and acknowledged. throughout the 6 weeks, dr. owen, an alaska native physician, held regularly scheduled sessions focused on aian health to educate students about a given aian topic and to empower students by allowing them to share their expertise on the topics. during the discussions, aian students spoke about what they had seen and experienced, shared their frustrations, and voiced their pride in institutions and practices within their communities. for instance, when aian health care institutions were discussed, students journal of regional medical campuses, vol. 5, issue 1 perspectives related their negative experiences and the resiliency-building programs promoted by these same health care clinics or hospitals. small-group discussions worked well to broach difficult yet important subjects such as identity and racism in medicine. these small groups also let students develop their sense of confidence and personal empowerment. ● modeling flexibility. as with all research, flexibility within the curriculum and schedule was key; the development of back-up plans was necessary given that student sessions were only 6 weeks. ongoing conversations with tribal members and leaders facilitated the development of alternative plans and problem-solving. during the first cohort, the visit to a tribal community for data collection was cancelled 2 days before the event, meaning that travel and accommodations were impacted. the caimh director quickly reached out to another community with whom she had an established relationship. as a result, students were still able to conduct interviews for their research project in a different community. the rapid pivot in plan and scheduling was difficult for the students, given the typically regimented structure of classrooms to which they were more accustomed. tension between students resulted from the last-minute change in plans, a reminder to introduce the idea that uncertainties are inevitable in research. throughout the project, nam faculty and staff had frequent check-ins to discuss the projects, setbacks, and solutions. the check-ins were helpful for nam staff as they were also impacted by the rapid changes and needed to model both flexibility and a healthy response to the changes. future directions a robust evaluation plan based on community-based research, utilization of american indian evaluation, and indigenous research principles is needed to better identify components of the program that are more successful and others that need to be revised or deleted.21 measuring whether individual student goals doi: https://doi.org/10.24926/jrmc.v5i1.4485 and midand long-range program goals were reached will inform program development and support the program’s sustainability. development of an evaluation protocol is underway and will be piloted during cohort 3. current academic status and preliminary outcomes suggesting that the program has been successful will be incorporated into the plan. the short-range outcomes achieved by cohort 1 students include the following: • the 2 medical students are in their fourth year of medical school. • one undergraduate student is completing her first year of medical school. • two students have been accepted to medical school. • one student began a biomedical sciences phd program. • three students are completing applications for postgraduate programs (medical and/or graduate school), with one applying for a post-baccalaureate program. the short-range outcomes achieved by cohort 2 students include the following: • one is applying for research positions. • one has been accepted to medical school. • two are applying to medical school. • one is applying to graduate school. students’ qualitative feedback indicated that they had a meaningful and challenging experience. students wrote that they enjoyed “discussions about pathways and discussions about research, especially with dr. owen.” they liked opportunities to ask questions and conduct research, as well as “learning more about indigenous history.” one student wrote, “i enjoyed working with other students on a research topic and meeting/connecting with other indigenous professionals.” another wrote, “i am grateful for how much i have learned! it was an empowering experience to listen and relate to the stories people shared in dr. owen's seminar. i enjoyed our discussion sessions the most.” as part of an award application, one student wrote the following: journal of regional medical campuses, vol. 5, issue 1 perspectives the center of american indian and minority health (caimh) has changed the course of my life in various ways. their two-year cohort summer research program, native americans into medicine (nam), catalyzed my interest in medicine and dedication to work with native american communities and underserved populations. this program enriched my connection with my ojibwe heritage and taught me more about my culture through traditional practices and the significance of indigenous research methods. the friendships and networks i have established throughout nam are irreplaceable. they have touched my heart with their never-ending kindness and support. i could not have asked for a more fulfilling program to engage in as an undergraduate. caimh brought me these research opportunities, career goals, special relationships, cultural reconnection, and a greater sense of identity. i bolstered personal and professional growth that i never would have thought possible. i became so connected with this community that i could not imagine my career in medicine starting anywhere else. i applied to the university of minnesota duluth medical school and was recently accepted into their class of 2025. it is an honor to spend the next chapter of my life surrounded by a community that i trust and that i know will always be here to support me in any way they can. conclusion aian health disparities persist despite numerous attempts by researchers to investigate problems and implement solutions. a long history of limited understanding of and limited relationships with aian communities has resulted in a significant barrier to aian health research. nam addresses the problem by implementing a strategy to increase the number of aian health researchers and health professionals with research experience because they are more likely to serve aian communities and to possess the relationships and understanding needed to conduct trusted and necessary research. nam offers academic enrichment while bolstering the confidence of aian students by immersing them in a program that emphasizes aian culture, research methodologies, and health care. the program exposes students to aian leadership within all of these areas. changing aian health disparities will require more programs doi: https://doi.org/10.24926/jrmc.v5i1.4485 like nam that promote involvement of aian people in their health care solutions by increasing aian student academic success through culture, support, and empowerment. this program could be replicated at other institutions by a non-native faculty member, but only with equal direction and leadership by an aian community or faculty member. before building a program, institutions should have established relationships with the community they are hoping to serve. doing so will help them identify the appropriate partners and community programming to supplement the curriculum for students. additionally, each institution should assess the number and size of cohorts to best meet their funding and faculty resources. nam does not have funding or capacity to run more than one cohort at once. doing so would limit the attention we could give to each student. figure 1. students’ school year and school type references 1. espey dk, jim ma, cobb n, et al. leading causes of death and all-cause mortality in american indians and alaska natives. am j public health. 2014;104(suppl 3):s303-311. doi:10.2105/ajph.2013.301798 2. u.s. department of health and human services. profile: american indian/alaska native. updated january 11, 2022. accessed may 20, 2021. https://www.minorityhealth.hhs.gov/omh/bro wse.aspx?lvl=3&lvlid=62 3. buchwald d, mendoza-jenkins v, croy c, mcgough h, bezdek m, spicer p. attitudes of urban american indians and alaska natives regarding participation in research. j gen doi: https://doi.org/10.24926/jrmc.v5i1.4485 journal of regional medical campuses, vol. 5, issue 1 perspectives intern med. 2006;21(6):648-651. doi:10.1111/j.1525-1497.2006.00449.x 4. lucero j, wallerstein n, duran b, et al. development of a mixed methods investigation of process and outcomes of community-based participatory research. j mix methods res. 2018;12(1):55-74. doi:10.1177/1558689816633309 5. walters kl, simoni jm. decolonizing strategies for mentoring american indians and alaska natives in hiv and mental health research. am j public health. 2009;99(suppl 1):s71-76. doi:10.2105/ajph.2008.136127 6. james r, tsosie r, sahota p, et al; kiana group. exploring pathways to trust: a tribal perspective on data sharing. genet med. 2014;16(11):820-826. doi:10.1038/gim.2014.47 7. baldwin ja, johnson jl, benally cc. building partnerships between indigenous communities and universities: lessons learned in hiv/aids and substance abuse prevention research. am j public health. 2009;99(suppl 1):s77-82. doi:10.2105/ajph.2008.134585 8. act. the condition of college and career readiness 2019. accessed may 24, 2021. https://www.act.org/content/dam/act/secured /documents/cccr-2019/national-cccr2019.pdf 9. national center for education statistics. web tables: profile of undergraduate students: attendance, distance and remedial education, degree program and field of study, demographics, financial aid, financial literacy, employment, and military status: 2015–16. u.s. department of education; 2019. nces 2019467. accessed may 24, 2021. https://nces.ed.gov/pubs2019/2019467.pdf 10. national center for education statistics. indicator 23: postsecondary graduation rates. status and trends in the education of racial and ethnic groups. updated february 2019. accessed may 24, 2021. https://nces.ed.gov/programs/raceindicators/i ndicator_red.asp 11. center of american indian minority health. medical school. published april 9, 2019. accessed october 13, 2021. https://med.umn.edu/caimh 12. association of american medical colleges, association of american indian physicians. reshaping the journey: american indians and alaska natives in medicine. published october 2018. https://store.aamc.org/downloadable/downlo ad/sample/sample_id/243/ 13. israel b, schulz a, parker e, et al. critical issues in developing and following cbpr principles. in: wallerstein n, duran b, oetzel j, minkler m, eds. community-based participatory research for health: advancing social and health equity. 3rd ed. jossey-bass; 2018:31-46. 14. wilson s. research is ceremony: indigenous research methods. langara college; 2019. 15. walls ml, whitesell nr, barlow a, sarche m. research with american indian and alaska native populations: measurement matters. j ethn subst abuse. 2019;18(1):129-149. doi:10.1080/15332640.2017.1310640 16. absolon ke (minogiizhigokwe). kaandossiwin: how we come to know indigenous research methodologies. 2nd ed. fernwood publishing; 2022. 17. sánchez jp, poll-hunter n, stern n, garcia a, brewster c. balancing two cultures: american indian/alaska native medical students’ perceptions of academic medicine careers. j community health. 2016;41:871-880. 18. geniusz wm, geniusz a. plants have so much to give us, all we have to do is ask: anishinaabe botanical teachings. university of minnesota press; 2015. 19. weber md, karman ta. student group approach to teaching using tuckman model of group development. am j physiol. 1991;261(6 pt 3):s12-16. doi:10.1152/advances.1991.261.6.s12 20. tuckman, bw. developmental sequence in small groups. psychol bull. 1965;63(6):384-399. 21. lafrance j, nichols r. indigenous evaluation framework: telling our story in our place and time. american indian higher education consortium; 2009. https://portalcentral.aihec.org/indigeval/book %20chapters/0-intro_contents.pdf doi: https://doi.org/10.24926/jrmc.v5i1.4485 journal of regional medical campuses, vol. 5, issue 1 perspectives appendix 1. student handbook the seven teachings wisdom (nibwaakawin). symb olized by the beaver. to cherish knowledge is to knowwisdom. wisdom is given by the creator to be used for the good of the p eop le. love (zaagi’idiwin). symb olized by the eagle. is to know p eace; is to know love. love m ust be unconditional. you m ust love your self in or der to love ano ther. respect (minwaadendamowin). symb olized by the buffalo. to honor all of creation is to have r espect. yo u must give resp ect if you wish to b e respected. bravery (aakode’ewin). symbo lized by the bear. is to face the foe with integr ity. in theanishinaabe language, this word literally means “state of having a fearless hear t.” to do what is right even when the consequences are unpleasant; th e moral courage to do the right thing. honesty (gwayakwaadiziwin). symb olized by wilder ness man. honesty in facing a situation is to be br ave. always be honest in word and actio n. be ho nest first with yourself, and you will mo re easily be able to be honest with other s. humility (dabaadandiziwin). symb olized by the wolf. to know yourself as a sacred part of creation. to think things through carefully and to know your place. can also be translated as “calmness,” “meekness,” “gentility” or “patien ce.” tru th (dabwewin). symb olized by the turtle. tr uth is to know all o f these things. speak the truth. do not deceive yourself or others.center of american indian and minority health univers ity of minnesota medical school duluth native americans into medicine 2019 student handbook misk waa desi article published by university of minnesota libraries publishing promoting scholarship at regional medical campuses students william cathcart-rake, m.d., michael robinson, ph.d. doi: https://doi.org/10.24926/jrmc.v1i1.999 journal of regional medical campuses, vol. 1, issue 1 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc https://doi.org/10.24926/jrmc.v1i1.999 https://pubs.lib.umn.edu/index.php/jrmc/index dr. cathcart-rake is clinical professor of medicine and dean, university of kansas school of medicine-salina, salina, kansas. dr. robinson is professor of medicine and associate dean for foundational sciences, university of kansas school of medicine-salina, salina, kansas corresponding author: william cathcart-rake, m.d., campus dean, university of kansas school of medicine-salina, 400 south santa fe, salina, ks 67401; email: wcathcart-rake@kumc.edu. all work in jrmc is licensed under cc by-nc volume 1, issue 1 (2018) journal of regional medical campuses original report promoting scholarship at regional medical campuses students william cathcart-rake, m.d. michael robinson, ph.d. abstract multiple regional medical campuses (rmcs) have been established in north america as part of the effort to train physicians in locations geographically removed from the main medical school campus. rmcs may vary in size, geographic location and mission from the main campus, but scholarly activity by faculty and students is expected and should be promoted on all campuses. if the definition of scholarship is limited to research demonstrated by publication, and academic recognition and advancement is largely based on this criterion, faculty at the rmc who fail to participate may be at a disadvantage. thus, in addition to expanding research opportunities at the rmc, it is argued that the definition of scholarship needs to be expanded to recognize the accomplishments of rmc faculty. rmc students must also be introduced to biomedical research principles and provided opportunities to engage in scholarly pursuits. documented participation in scholarly activity may be necessary to make the student more competitive for residency positions. the authors review an expanded definition of scholarship, present an approach to promote faculty and student scholarship, and describe achievable options for scholarly activity on the rmc. north american regional medical campuses (rmcs), also called branch campuses, satellite campuses, or geographically separate campuses, educate an everincreasing number of medical students. proposed characteristics of a rmc include: (1) location more than fifty miles away from the main academic health center or school of medicine campus; (2) delivery of a significant component of medical student education at the site, whether in the basic sciences or clinical years; and (3) a formal administrative and educational relationship with the main campus.1 although separate from the main campus, a rmc does not receive independent accreditation from the liaison committee on medical education (lcme). in 2014 the group on regional medical campuses (grmc) of the association of american medical colleges (aamc) listed fifty-seven medical schools with rmcs and a total of 114 rmcs in the u.s. and canada.2 a survey conducted by the aamc in 2016 noted a total of 115 rmcs, seventy (61%) of these rmcs established since 2010, and over one in ten allopathic medical students (over 9000 matriculants) trained at a rmc.3 cheifetz et al proposed a classification system for rmcs consisting of four models: (1) basic science (years 1 and 2); (2) clinical (clerkships in year 3 or years 3 and 4); (3) longitudinal basic science and/or clinical experiences spanning greater than twelve weeks in one or more courses of study or case areas; and (4) combined (basic science and clinical years are offered in some combination).4 the number of faculty members (tenured or on a tenure track, non-tenured, adjunct-paid and adjunctnot paid) engaged in teaching at rmcs is staggering, exceeding 34,000 in the recent aamc survey.3 the lcme requires that all faculty members have academic appointments, and that each medical school has policies and procedures in place for faculty appointment and promotion (standard 4.3).5 motivations for establishing a rmc vary and include: attempts to address physician shortage in a particular area, a focus on primary care, broadened patient base, and political considerations.1 hopefully, all rmcs strive to create an outstanding academic environment, provide an excellent education for medical students, and reflect positively on the main campus with their dedication to teaching, clinical care https://creativecommons.org/licenses/by-nc/4.0/legalcode doi: https://doi.org/10.24926/jrmc.v1i1.999 journal of regional medical campuses, vol. 1, issue 1 article and scholarship. scholarship may be the one domain that rmc faculty members and students struggle with the most, mainly due to faculty not prioritizing this aspect of medicine. defining scholarship although an rmc may differ in size, geographic location, and mission from the main campus, what constitutes scholarship, and is recognized and rewarded as scholarship, may be identical for both campuses. fincher et al6 observed that the definition of scholarship generally applied by medical schools is unnecessarily narrow—demonstrated only by research, peer review of results, and dissemination of new knowledge. although just as dedicated to teaching medical students as faculty members on the main campus, rmc faculty members may not be inclined to participate in research activities, as their time is consumed by clinical practice and teaching responsibilities. additionally, they may not feel competent and/or may not have the interest to engage in research. unfortunately, if research and publication is of primary importance for recognition and promotion, the clinical faculty at rmcs may be at a disadvantage for academic advancement compared to faculty members on the main campus. likewise, in contrast to the main academic medical campus, basic science research, translational research, and large clinical trials are often not being conducted on rmcs, and students on a rmc may not be aware of or be presented with opportunities to engage in research activities. should or can the academic integrity or prestige of rmcs be judged on research being conducted, publications generated, and grant funding? should or can rmcs be held to the same academic standard as the main campus? although a seemingly difficult task, faculty, as well as students, at rmcs must be encouraged to engage in and be given the opportunity to pursue scholarly activities. how can this be accomplished? redefining or expanding what constitutes scholarship may be an initial step in promoting scholarship on all campuses. boyer expanded the definition of scholarship to include four elements: (1) the scholarship of discovery—typically meaning research; (2) the scholarship of integration—giving meaning to isolated facts, putting knowledge in perspective; (3) the scholarship of application—using knowledge to solve consequential problems—the scholarship of service; and (4) the scholarship of teaching.7 the meanings of these four forms of scholarship are separate, but overlapping. faculty and students at medical schools may engage in one or more forms of scholarship. the truly talented scholar could engage in all four. the scholarship of research may remain paramount, but recognizing and rewarding faculty members who participate in other forms of scholarship, as defined by boyer, may be a constructive advance for both main campus and rmc. glassick’s six criteria (clear goals, adequate preparation, appropriate methods, significant results, effective presentation, and reflective critique) used to evaluate the scholarship of discovery can also be employed to assess the scholarship of teaching.8 faculty members who are excellent teachers and consistently practice compassionate and evidencebased medicine are invaluable assets to the rmc and should be acknowledged. they can be role models, as well as educators. as noted by glick, the best teachers inspire and transform the medical student, and he suggested that faculty portfolios, what he termed “impact maps,” documenting teaching or educational performance be created.9 the impact map charts an educator’s contribution to the education of learners from the development of an innovative teaching method to the actual impact on outcomes. these portfolios can then be used as objective evidence for recognition and reward, including promotion. promoting scholarly activities by faculty at a rmc research is being conducted on rmc campuses, but this is not a universal occurrence. the recent rmc survey found that 78 of 115 (68%) rmc campuses conducted research distinct from the main campus.3 basic science research was conducted on 37 (32%) rmc campuses surveyed, while health service research was conducted on 41 (36%) campuses, education research on 47 (41%), and clinical research on 65 (57%). there was no data detailing percentage of rmc faculty engaging in research. rmc faculty may not find academic advancement reason enough to engage in scholarly activities. in fact, these faculty may have chosen community https://doi.org/10.24926/jrmc.v1i1.999 doi: https://doi.org/10.24926/jrmc.v1i1.999 journal of regional medical campuses, vol. 1, issue 1 article practice to get away from the perceived hassles of the academic medical center. while the “publish or perish” paradigm may be distasteful, they may value the opportunity to participate in the education of medical students. nevertheless, rmc faculty must be informed that the scholarship of discovery is valued by both the main campus and the rmc and is an important characteristic of being an academic physician, complementing both patient care (service) and the education of the next generation of physicians. also, improvement in both medical practice and medical education are rooted in the scholarship of discovery. rmc faculty need to be reassured that the scholarship of discovery is not an impossible task for the busy practicing physician and that there are resources available to assist with completion of scholarly work, such as posters, oral presentations, and papers worthy of sharing with others. there are at least six additional steps that can be taken to encourage rmc faculty to engage in scholarly activity: (1) rmc faculty, who are often quite enthusiastic about participating in teaching medical students and desire to promote their rmc, must understand the importance of scholarship for the integrity and recognition of their local campus. (2) the rmc administration must provide faculty development to assist faculty members who are interested in scholarly activity, but unsure how to start or what project to undertake. faculty education might prompt the disinterested to take up the mantle of scholarly pursuits. providing mentorship may prompt the reluctant scholar to initiate and complete a project. the administration can also provide assistance with statistical analysis and preparation of posters, oral presentations and manuscripts. (3) faculty need to realize that scholarship is not limited to research and, hopefully, the main campus recognizes and values other forms of scholarship, such as service and teaching. the main campus and the rmc should agree on what constitutes scholarship, hopefully embracing a more expanded definition, and set standards for achievement. (4) community members should be informed of the scholarship of the rmc physician faculty. the value of public recognition of the local rmc faculty’s academic achievement should not be underestimated. (5) any financial disincentives for engaging in scholarly activities should be removed, and financial incentives should be considered for faculty engaged in scholarly activities, especially those that include medical students in scholarly projects. the rmc administration should help defray the costs incurred by the design, implementation and analysis of scholarly activities, manuscript preparation and submission, and attendance at local, regional, national or international meetings to present a poster or oral presentation. (6) explore ways to reward and recognize those rmc faculty engaged in various scholarly activities in addition to teaching awards. promoting scholarly activities by students at a rmc providing scholarship opportunities for students attending rmcs is also imperative. longitudinal, indepth curricular programs have been implemented in a number of medical schools to promote scholarship.10, 11 rmcs may not be able to institute such dedicated programs, but all medical students must be introduced to the scientific method as it relates to medicine and be encouraged to explore the rewards and challenges of discovery. the lcme’s https://doi.org/10.24926/jrmc.v1i1.999 doi: https://doi.org/10.24926/jrmc.v1i1.999 journal of regional medical campuses, vol. 1, issue 1 article standard 3.2, published in functions and structure of a medical school, states that “a medical education program [be] conducted in an environment that fosters the intellectual challenge and spirit of inquiry appropriate to a community of scholars and provides sufficient opportunities, encouragement, and support for medical student participation in research and other scholarly activities of its faculty.”5 the canmeds 2005 physician competency framework also emphasizes that scholarly research programs, as a component of undergraduate medical education, allows students the opportunity to develop critical thinking and communication skills and to contribute to medical knowledge.12 students need to realize that inquisitiveness and the scholarship of discovery are integral parts of being a physician and should be informed of scholarship opportunities at the rmc and encouraged to seek out a faculty member who could mentor them through the scholarly activity. murdoch-eaton et al argue that research skills and projects need to be integrated into the medical curriculum early in the undergraduate program.13 chang and ramnanan reviewed the literature on scholarly research by medical students and found that these students perceived their research experiences as positive in terms of stimulating research interest and developing research abilities.14 in order to optimize student research programs, the authors recommended that medical schools increase recognition of student research efforts, promote student-mentor interaction, and allow students to increase the duration of research experiences. finally, in an era of increased competition for residency positions, students must be informed that research or other scholarly activities during medical school may be a prerequisite for securing certain residency positions.15-17 research topics for a rmc research—the scholarship of discovery—is not impossible at the rmc. although rmcs may not have the resources or faculty to engage in basic science research, they may provide ideal environments for clinical, quality improvement, and education research. scholarly activities start with a question. the scholarly pursuit is the search for the answer. all faculty members should be encouraged to develop a list of questions related to their practice, the patients they have seen, or teaching medical students. for example: why did a particular event occur in a particular patient? how can i improve patient care or satisfaction? what unusual results occurred after a particular intervention? how does my care compare with national reports? what can be done to improve the medical education curriculum or its delivery? what have i discovered about teaching medical students or residents that can be shared with peers? answers to these questions can lead to case reports, quality improvement studies, and medical education innovation reports. rmc faculty members can be queried as to potential research ideas, and a list of potential scholarly activities can be compiled by the rmc administrative team. this list can be circulated among all faculty members, giving everyone the opportunity to comment on a project’s feasibility and offer to collaborate on any particular project. the list also needs to be shared with students, giving learners the opportunity to participate in a project of interest. administration needs to provide funds, if needed, to successfully complete and communicate the project. faculty and students can be encouraged to present their findings at a variety of forums and reports may be worthy of peer-review publication. in addition to traditional research projects, rmc faculty can participate in the design and implementation of curricular innovations, assessment methods, and development of course syllabi and assume leadership roles in course delivery—all scholarly activities that can be documented and included in his or her academic portfolio or curriculum vitae. societies that promote research within the institution can also be useful. for example, the university of kansas academy of medical educators and its offshoot, the medical education research interest group, were established to promote educational research at both the main and https://doi.org/10.24926/jrmc.v1i1.999 doi: https://doi.org/10.24926/jrmc.v1i1.999 journal of regional medical campuses, vol. 1, issue 1 article regional campuses and also offer funding for suitable projects. summary promotion of scholarship at a rmc starts with an administration that values and rewards the clinical service and teaching of each faculty member, whether voluntary or paid. faculty members need to be informed that scholarship is not limited to research— that documented excellence in clinical service and teaching are also worthy scholarly endeavors. each rmc should explore alternatives to traditional scholarship (i.e., research) and reward faculty engaged in these activities. development of new teaching methods, modification of curricula to fit the needs of a particular rmc, mentoring junior faculty members, and creating innovative clinical clerkship opportunities and community engagement projects are scholarly endeavors that rmc faculty can consider. however, rmc faculty also need to know that there are a variety of opportunities to engage in the scholarship of discovery, and that such activities can be completed outside the main campus and need not be onerous chores. medical students also need to understand that engagement in scholarly activities is an important component of their medical education and that opportunities for participation in such activities are available. rmcs can be a recognized partner of the main campus in promoting scholarly activity, if the rmc has the will to support such activity and the main campus has the will to embrace the scholarly contributions of the rmc. references 1. mallon wt, liu m, jones rf, whitcomb m. regional medical campuses: bridging communities, enhancing mission, expanding medical education. association of american medical colleges, washington, d.c., 2006. 2. association of american medical colleges. official list of regional medical campuses (as of september 2014). https://www.aamc.org/members/grmc/resour ces/. accessed april 26, 2017. 3. mcowen ks. regional medical campus survey results 2016. presented at: group on regional medical campuses meeting; april 6, 2017; orlando, fl. 4. cheifetz ce, mcowen ks, gagne p, wong jl. regional medical campuses: a new classification system. acad med. 2014; 89(8):1140-3. 5. liaison committee on medical education. function and structure of a medical school. www.lcme.org/publications/2015-16functions-and-structure-with-appendix.pdf. accessed april 26, 2017. 6. fincher re, simpson de, mennin sp, et al. scholarship in teaching: an imperative for the 21st century. acad med 2000; 75:887-894. 7. boyer el. scholarship reconsidered priorities of the professoriate. princeton, nj: carnegie foundation for the advancement of teaching, 1990. 8. glassick ce, huber mr, maeroff gi. scholarship assessed—evaluation of the professoriate. san francisco, ca: josey-bass, 1997. 9. glick th. how best to evaluate clinicianeducators and teachers for promotion? acad med 2002; 77:392-397. 10. schor nf, troen p, kanter sl, levine as. the scholarly project initiative: introducing scholarship in medicine through a longitudinal, mentored curricular program. acad med 2005; 80(9):824-831. 11. green ep, borkan jm, pross sh, et al. encouraging scholarship: medical programs to promote student inquiry beyond the traditional medical curriculum. acad med 2010; 85(3):409-418. 12. frank jr, ed. the can meds 2005 physician competency framework: better standards. better physicians. better care. ottawa, ontario, canada: royal college of physicians and surgeons; 2005. 13. murdoch-eaton d, drewery s, elton s, et al. what do medical students understand by research skills? identifying research opportunities within undergraduate projects. med teach 2010 (3); e152-160. doi: 10.3109/01421591003657493. 14. chang y, ramnanan cj. a review of literature on medical students and scholarly research: https://doi.org/10.24926/jrmc.v1i1.999 https://www.aamc.org/members/grmc/resources/ https://www.aamc.org/members/grmc/resources/ http://www.lcme.org/publications/2015-16-functions-and-structure-with-appendix.pdf http://www.lcme.org/publications/2015-16-functions-and-structure-with-appendix.pdf doi: https://doi.org/10.24926/jrmc.v1i1.999 journal of regional medical campuses, vol. 1, issue 1 article experiences, attitudes, and outcomes. acad med 2015; 90:1162-1173. 15. rinard jr, mahabir rc. successfully matching into surgical specialties: an analysis of national resident matching program data. j of grad med ed 2010; 3(2): 316-321. 16. depasse jm, palumbo ma, eberson cp, daniels ah. academic characteristics of orthopedic surgery residency applicants from 20117 to 2014. j bone joint surg 2016; 98(9):788-795. 17. national resident matching program, data release and research committee: results of the 2016 nrmp program director survey. national resident matching program, washington, dc. 2016. http://www.nrmp.org/wpcontent/uploads/2016/09/nrmp-2016program-director-survey.pdf. accessed april 27, 2017. https://doi.org/10.24926/jrmc.v1i1.999 http://www.nrmp.org/wp-content/uploads/2016/09/nrmp-2016-program-director-survey.pdf http://www.nrmp.org/wp-content/uploads/2016/09/nrmp-2016-program-director-survey.pdf http://www.nrmp.org/wp-content/uploads/2016/09/nrmp-2016-program-director-survey.pdf microsoft word from probation to accrediation article.docx published by university of minnesota libraries publishing from probation to accreditation: successful change management bernadette m. miller, md; michael a. weisz, md; kim johnson; brent w. beasley, md journal of regional medical campuses, vol. 1, issue 2 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc bernadette m. miller, md; program director, internal medicine residency michael a. weisz, md; chairman, department of internal medicine kim johnson; project manager brent w. beasley, md; medical director, internal medicine clinic all authors are affiliated with the university of oklahoma—tulsa corresponding author: dr. brent beasley, schusterman center clinic, 4444 e 41st st, tulsa, ok 74105, (o) 918-619-4400 , (c) 816-6784122, brent-beasley@ouhsc.edu all work in jrmc is licensed under cc by-nc volume 1, issue 2 (2018) journal of regional medical campuses “how we did it” from probation to accreditation: successful change management bernadette m. miller, md; michael a. weisz, md; kim johnson; brent w. beasley, md abstract background in 2015 our residency program located within a regional medical campus was placed on probation. five of the 13 citations were related to the residents’ clinic experience. the resident clinic was encased within a medical culture of chronic opiate prescription management that did not provide a sufficient or balanced ambulatory education for internal medicine residents. objective this paper describes our experience of moving from a residency program within a regional medical campus on probation to full accreditation status over a span of 19 months. methods we used a project management approach with a strong coordinating council designed to empower leaders to effect change in the residency program and the residency clinic. results we were able to create and enact a plan that extricated the residency’s ambulatory clinic from managing a panel of approximately 700 patients requiring chronic monthly opiate prescriptions. the patients were referred to community pain management providers for these prescriptions. we established a policy of providing no chronic opiate prescriptions in the residency clinic. residency acgme surveys from 2015 through 2017 demonstrated improved resident satisfaction. cg-cahps scores demonstrated a temporary decrease in patient satisfaction scores returning to previous baseline after a year. conclusion we employed a project management approach to get our program off probation and change the focus of our residency’s ambulatory practice and re-establish its educational mission. introduction the university of oklahoma tulsa school of community medicine is a regional medical campus focused on training physicians in population-based healthcare management, patient care improvement and patient satisfaction for any clinical setting, whether that be rural or urban. in 2008, several changes were made in our internal medicine residency ambulatory practice. we recognized the volume of patients seen was inadequate to provide an appropriate educational experience. although a sufficient number of patients were scheduled, a high no-show rate led to a low number of patients actually being seen. to address this, we increased the number of patients being scheduled. the volume of patients seen in the resident practice increased, and a large number of new patients had medicaid as their payment source. these patients tended to have a higher prevalence of chronic pain syndromes and psychiatric illnesses. (1) leading up to this time period, chronic opioid therapy became widely promoted as an effective and safe management strategy for the treatment of patients with chronic pain syndromes. (2) in response to what was believed at the time to be an important societal need for physician education, our department of internal medicine developed a pain management specialty clinic and an addiction medicine fellowship collocated in our internal medicine clinic. subsequent policies required more frequent visits for those patients on chronic opiate therapy. this confluence of events led to a large number of patients treated with increasing quantities and strengths of opioids within our residency clinic. the chronic pain patients tended to have a lower no-show rate to ensure their opioid prescriptions were filled. many visits in the resident practice journal of regional medical campuses, vol. 1, issue 2 “how we did it” became focused only on the patients’ pain syndrome instead of addressing other core medical issues. in ensuing accreditation council for graduate medical education—residency review committee (rrc) site visits, the program was cited for “a high ratio of patients with chronic pain”. although attempts were made to address the issue, the volume of patients with chronic pain did not decrease, but actually increased in the resident practice. the residency program was subsequently placed on probation in april 2015 (see figure 1). this article describes our journey from probation to full accreditation status, and the methodology we used to achieve change within our institution. methods the university provided access to a project manager with expertise in change management to address the rrc citations. the first step was to select a steering committee of key leadership, including the department chair, program director, designated institutional official, associate dean of finance, associate dean of curriculum and faculty affairs, and executive director of clinic operations. this steering committee reviewed and categorized the citations and assigned them to four working committees: curriculum, clinic, hospital and sub-specialty, and faculty development and scholarly activity. the steering committee clearly defined the scope and deliverables, and assigned group leads and team members for each working committee. the working committees met regularly throughout each month, tracking the percent complete to the timeline and capturing progress, key decisions, issues and action items in the meeting minutes. the working committee leads presented a progress report to the steering committee on a bi-monthly basis. the steering committee made key decisions and resolved escalated issues as needed. chronic-opiate-requiring patients to address the excessive opiate prescriptions written within the resident clinic, a subcommittee determined the actual number of patients in the resident practice who were receiving opiate prescriptions at that time. resident visits involving chronic opiate prescriptions comprised nearly 50% of the visits early in 2015 and totaled approximately 700 patients. the subcommittee decided to limit the number of chronic-opiate-requiring patients assigned per resident patient panel: zero for pgy-1’s, two to three for pgy-2’s, and no more than five for each of the pgy-3’s. the appropriate number of chronic opiate patients that residents should maintain in their continuity panels to acquire competent opiate prescribing skills was determined through discourse with program faculty, comparison with other clinical practices, discussion by the clinic working group and consensus by the steering committee. finally, we instituted a clinic-wide policy in july 2016 prohibiting prescriptions for chronic opiate therapy in the resident practices. the general internal medicine faculty were also asked to limit their own management of chronic opiate therapy to no more than a handful of patients within their patient panels, and to refer the others and any new chronic-opiate-requiring patients to pain management clinics in the area. all new patients’ medication lists were screened prior to scheduling initial appointments, and new patients were informed that the practice does not manage chronic pain with opiates. those requiring such will be referred to a pain management clinic. based on the decision to limit the number of chronic-opiaterequiring patients in the resident practice, 100 patients were retained in the resident practice and 600 chronic-opiaterequiring patients were transferred to non-resident providers within the practice. this transition occurred between july and december 2016. during that time, two pain management physicians within the department of medicine took on the majority of these patients until their practice reached capacity. the remaining chronic-opiate-requiring patients from the resident clinic were divided among and transferred to general internal medicine faculty practices to assume all care, including continuing the opiate prescriptions until a referral to outside pain management was achieved. to provide residents the needed skill in prescribing opioid prescriptions, the residents were allowed to provide new opiate prescriptions for acute use. the residents were given guidance by faculty preceptors in appropriate practices, including dose and time-limited prescribing per cdc guidelines. survey information we used our program’s acgme yearly resident survey to look for changes in our program’s performance between the time of beginning probation to the year after we were off probation. (3) to look at the potential impact on our patients, we used our group consumer assessment of healthcare providers and systems (cg-cahps) surveys from press ganey. cg-cahps psychometric properties and reliability have been well described. (4-6) statistical analysis we used basic descriptive statistics to summarize the data. bivariate analyses were used to assess differences in responses between sub-groups defined by year. pearson chisquare analyses were used to assess the significance of differences between groups. this was a quality improvement project and was not designed to contribute to generalizable knowledge. for that reason, it did not require review by the institutional review board. results our residency program was placed on probation may 29, 2015. we received 13 citations, 5 of which were related to the residents’ experience in the clinic. on january 13th, 2017 (19.5 months later), our residency program was granted full accreditation with 0 remaining citations. to note, our most recent month of data shows that our resident practice saw 577 patients in may 2017. our resident journal of regional medical campuses, vol. 1, issue 2 “how we did it” practice is fairly well balanced with 48% medicaid, 25% medicare and 18% private insurance (figure 2). figure 3 demonstrates that the percentage of patients in the resident clinic who routinely take two or more chronic opiate prescriptions in the previous twelve months has decreased from 14.5% in february 2016 to 10.6% in march 2017, showing that we have seen some change in the make-up of our population. however, while many of the visits now deal with both acute and chronic pain, our residents are not responsible for writing the patients’ chronic opiate prescriptions. an occasional prescription for acute opiate therapy is written in the resident clinic, but by and large, the nature of our practice and patient expectations around chronic pain has changed dramatically. data comparing our acgme resident surveys from march 2015-2017 are seen in figure 4 below. in 2015, 17% of our residents gave our program an overall “negative” or “very negative” evaluation. in 2016, this decreased to 13%, and by 2017 only 1 resident (3%) gave a “negative” evaluation, and no residents rated it “very negative”. conversely, 41% of residents gave the program an overall “positive” or “very positive” evaluation in 2015, and this increased to 76% by 2017, which was a 35% increase (p=0.054). we compared our cg-cahps surveys between may 2016 and may 2017. to note, our overall composite provider scores have seen little change (p=0.94). however, they demonstrated substantial month-to-month variation, with a five month trend scoring lower than the 80th percentile between july and november 2016 (not shown) when a large number of patients on chronic-opiate-requiring patients were being referred to other pain medicine providers in our community. discussion residency programs are small organizations that are enfolded within their larger departments and enveloped by their governing medical school. changing these programs is exceedingly difficult because of layers of institutional inertia. as kotter has rightly pointed out, the first step to changing an organization is to create a sense of urgency. (7) nothing feels quite so urgent to a residency program director as when the accreditation letter arrives announcing the program is on “probation”. to all involved—the departmental and university leadership, the residents, the teaching faculty— there is a sense of shame: how did we end up in this position? how could we have prevented it? who is responsible for this? it is interesting that so few residencies have written about their experience. we could find only two others. (8,9) our experience of finding our residency on probation mobilized our leadership at the highest level to respond. our dean pledged resources to ensure our success. our department chair made changes in personnel and engaged the project manager to lead the change processes. following along with kotter’s steps in change management theory (7), we created a “guiding coalition” in our steering committee and the various working committees. we developed our “shared vision” and strategies through a collaborative process that included faculty, residents, school of medicine personnel and nursing staff in the clinic and ensured the “communication of the vision” through multiple meetings at all levels. our department chair “empowered” the clinic manager and our clinic medical director to take “broad-based action”. we set “short-term” goals that produced some early “wins”, and we were able to “consolidate the gains to produce more change”. other structural changes to our residency that occurred concomitantly deserve mentioning, as there were many issues beyond only the residency clinic. our inpatient experience was consolidated into one teaching hospital to better support the residency’s educational mission. there was a change in leadership during this time, including the medical school dean, the department chair and the program director. the new dean empowered the designated institutional official to drive change in all the residencies on campus, including ours. our new department chair was empowered to hire more faculty, improving the faculty-toresident ratio, and allowing faculty focused time to teach. we also had several limitations. our electronic health record made obtaining patient level data difficult. the volume of referrals required to move the patients to pain management practices in the community taxed our referral office greatly. difficult conversations with the patients on opiates as they were transferred to other providers brought a great amount of stress to our office staff and providers for a number of months. while we delivered one large group session on dealing with difficult patients to our staff when the policy was first enacted, we should have prepared a plan of helping them with the stress and the emotional turmoil on an ongoing basis. additionally, we could have done a better job of educating our patients about the planned changes and their expected impact. we sent an introductory letter and had signage, but we could have provided ongoing updates, as people often receive when there is “reconstruction” interruption. in essence, we were reconstructing the clinic. we suspect the amount of change and the dissatisfaction with our new policy and its communication had a direct impact on patients’ willingness to recommend the clinic, sense of the provider’s respect for them and belief about the amount of time the provider spends with them. in conclusion, we used a project management approach to change the focus of our residency clinic. we created policies to guide the reassignment of patients on chronic opiate therapy to outside providers and reestablished a focus on general internal medicine within our residency clinic. the residents’ experience in clinic has contributed to their improved satisfaction with the residency. patients’ experiences during this time were variable, and those receiving chronic opiate prescriptions were often frustrated with the change. our resident clinic saw a slight journal of regional medical campuses, vol. 1, issue 2 “how we did it” decrease in volume for a few months that quickly recovered as more general internal medicine patients found that we now had access for their routine problems. after the change, the tenor and make-up of our residency patient encounters provided a more satisfying and diverse experience for the residents and the faculty. figures figure 1: timeline of events in our residency accreditation figure 2: demographic make-up of the resident clinic, july 2016 figure 3: rolling average of patients with more than 2 chronic opiate pain prescriptions in the residents’ clinic in the last 12 months figure 4: acgme survey: residents' overall evaluation of the program bibliography 1. edlund mj, martin bc, devries a, fan m-y, braden jb, sullivan md. trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: the troup study. the clinical journal of pain. 2010;26(1):1-8. 2. joranson de, gilson am, dahl jl, haddox jd. pain management, controlledsubstances, and state medical board policy: a decade of change. j pain symptom manage. 2002 feb;23(2):138-47. 3. “resident/fellow and faculty surveys.” acgme. accreditation council for graduate medical education. web. accessed 13 july 2017. 4. press ganey associates, inc. medical practice survey psychometrics report. south bend: press ganey associates, inc; 2010. 5. press ganey associates, inc. guide to interpreting calculation of scores. south bend: press ganey associates, inc; 2010. 6. hays rd, shaul ja, williams vs, lubalin js, harris-kojetin ld, sweeny sf, cleary pd. psychometric properties of the cahps 1.0 survey measures. consumer assessment of health plans study. med care. 1999;37(3 suppl):ms22– 31. journal of regional medical campuses, vol. 1, issue 2 “how we did it” 7. kotter, john p, and holger rathgeber. our iceberg is melting: changing and succeeding under any conditions. new york: st. martin's press, 2006. print. 8. kirk se, howell re. practice-based learning and improvement for institutions: a case report. j grad med educ. 2010 dec;2(4):633-7. 9. fassler s, dobkin ed, horowitz s, morejon o, reilly p, civetta j. lemonadefrom lemons: a program response to rrc-determined probation. curr surg. 2000 jul 1;57(4):373-376. microsoft word being there article.docx published by university of minnesota libraries publishing "being there" building productive scholarly teams across distance and over time denise kay, cayla r. teal, gerald crites, andrea berry, larry hurtubise, elissa hall, mohammed k. khalil journal of regional medical campuses, vol. 1, issue 2 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc denise kay, phd, ma; educational/counseling psychology; assistant professor, medical education; executive director, longitudinal curricular themes; co-director, interprofessional education program; university of central florida; college of medicine cayla r. teal, phd, ma; associate dean for evaluation and assessment; research associate professor; texas a&m college of medicine gerald e crites, md, med; professor of medicine; augusta university/university of georgia medical partnership andrea berry, mpa, director; faculty life; co-director, geriatric and principles of palliative care longitudinal curricular theme; instructor, department of medical education; college of medicine; university of central florida larry hurtubise, ma; associate director, center for faculty development; adjunct associate professor; the pediatric academic association ; nationwide children’s hospital; the ohio state university department of biomedical education and anatomy elissa hall, ma ; assistant professor; associate director for curriculum and education technology; mayo clinical college of medicine and science mohammed k. khalil, dvm, msed, phd; clinical associate professor; director of the academic success program; department of biomedical sciences; university of south carolina school of medicine greenville corresponding author: denise kay, phd, ma; 6850 lake nona boulevard, orlando, fl, 32827; 407-266-1186; denise.kay@ucf.edu all work in jrmc is licensed under cc by-nc volume 1, issue 2 (2018) journal of regional medical campuses original report "being there" building productive scholarly teams across distance and over time denise kay, cayla r. teal, gerald crites, andrea berry, larry hurtubise, elissa hall, mohammed k. khalil abstract in response to the projected shortage of physicians and the needs of traditionally underserved communities, medical schools are opening regional medical campuses (rmcs). however, faculty members on rmcs face unique professional development issues, such as lack of access to distant university resources and colleagues. at the same time, access to user-friendly technologies that support virtual communities, asynchronous and audio/visual synchronous communication, screen share features and inexpensive artifact storage has expanded. the authors explored the viability of using these technologies to establish and maintain a virtual community of practice (cop) for medical educators. we use tuckman’s four stages of group development to describe the evolution of our virtual community and provide tips for building virtual cops. each current member of the community completed a short answer survey modeled after brookfield’s critical incident questionnaire. we include applicable quotes that highlight members’ experiences in the community from charter members and members who joined the community later in the formation process. technologies can support productive virtual communities and prescribe them as viable options for addressing the unique needs of faculty at rmcs or for faculty who could benefit from establishing a cohesive, productive professional network beyond their home institution. keywords: community of practice, web 2.0, group development, virtual communities, virtual groups, professional network. introduction “being on a rather isolated regional campus, at an institution that has not had a strong educational research program, i was instantly interested in the group and how i could learn about using distance collaboration techniques to help round out my research community.” one outcome of the association of american medical colleges (aamc) recommendation to increase student enrollment in undergraduate medical training1 has been to boost student enrollment in already established programs and/or expand current training programs to regional sites.2 while deploying a regional campus model is not without challenge, positive reports of student performance and noted journal of regional medical campuses, vol. 1, issue 2 original report additional benefits suggest that regional campuses represent a viable option for increasing student enrollment and addressing physician shortage needs.2-4 the aamc group on regional medical campuses (grmc) recently defined regional campuses as “campuses of medical schools at which a portion of pre-clinical or clinical education of medical students occurs...on a campus that is separate from the main medical school.” 5(p. 1141) though associated with the main medical school site, the mission of rmcs is unique to their setting. curricular resources are often different from the main campus and delivered by a separate faculty located at the rmc.6 faculty at rmcs are busy, fulfilling multiple roles with varying levels of interest and experience in research.7,8 still, faculty in academic medicine are expected to demonstrate scholarly productivity.7,9,10 however, research productivity for regional campus faculty can be suppressed due to lack of time, inadequate research infrastructure and inherent difficulties with providing faculty development to regional sites.7,8 in their investigation of associations between faculty productivity and personal and institutional variables, bland and colleagues described the association between high faculty productivity and being in a department where there are clear expectations regarding faculty research.9 this association is problematic for faculty at rmcs where teaching is often the primary focus for faculty recruitment and development, and there is little to no focus on research.2 however, bland and colleagues also reported a negative association between high productivity and belonging to a well-developed network within a department. in contrast, they reported associations between high productivity and regular communication with an active professional network of colleagues outside of the institution, suggesting the potential for increased faculty productivity through participation in active professional networks beyond one’s institution. futurists predict that in time, one outcome of the increased use of new technologies is the erosion of the boundary between a ‘real’ and a ‘virtual’ self. if these technologies are mastered, they will allow for virtual interactions that nearly mimic those we experience in ‘real’ time. they can challenge the barriers of distance that have historically limited consistent access to professional relationships beyond one’s institution. we, the authors, represent medical education professionals who attempted to harness these technologies to establish and maintain a virtual community of practice (cop). a cop is “a set of relations among persons, activity and world, over time and in relation with other tangential and overlapping communities of practice.” 11(p. 98) cops are characterized by “sustained mutual engagement in practice, pursuit of a joint enterprise, and a shared repertoire of resources, experiences, stories, and tools.” 12(p. 32). driven by our mutual interest, we formed collaboration at a distance for medical educators (cd4me). charter members and subsequent members of cd4me include physicians, psychologists, faculty developers, professional educators, basic scientists and student affairs professionals in academic medical institutions representing both allopathic and osteopathic programs in eight states across the aamc southern, central and western groups on educational affairs. the purpose for authoring this manuscript is to provide our experience with cd4me as an outlet to overcome time and distance barriers for scholarly collaboration and provide tips for faculty members at rmcs who wish to establish similar collaborations. the evolution of cd4me sustainable, productive group relationships are rarely spontaneous phenomena. they require time, effort, attention and commitment. tuckman described group formation as a sequential process that includes four stages: forming, norming, storming and performing. he noted that the purpose, duration and tasks associated with a group could impact how it experiences the four journal of regional medical campuses, vol. 1, issue 2 original report stages.13 tuckman’s stages of group development accurately depict our own experiences in developing cd4me and have adopted it as the framework for describing our evolution as a productive virtual team. we integrate applicable statements from cd4me members who voluntarily reflected on their personal experiences of the group via a short answer survey modeled after brookfield’s critical incident questionnaire.14 this exercise allowed members to consider the cd4me interactions that inhibited or disinhibited their personal commitment to or engagement with the group. based on the lessons we learned, we provide tips for building a virtual community of practice which can be used by professionals on rmcs to expand opportunities for collaboration, scholarship and community. forming: in forming stages of development, group members work to determine their place in the group, understand the patterns of behavior particular to the group and obtain direction from group leadership.13 the cd4me group originally formed as a result of one author’s (gec) aamc southern group on educational affairs (sgea) member-at-large project that explored web-based solutions for establishing peer-to-peer networks. the seven authors from six sites are the current membership of cd4me. three of the authors are charter members of the group, and the remaining members joined in subsequent years. since our inception, the total membership included up to eight (representing seven sites) and as little as five (representing four sites) members. cd4me’s original purpose was to explore the viability of building a sustainable virtual community of practice that would allow medical educators to participate in both simple (idea/resource sharing) to complex (scholarly pursuits) collegial interactions. the initial task of cd4me was to identify preferred technologies that would afford optimal authenticity for group interactions. in selecting the technology, it was important to utilize solutions that were not ‘institution specific’ and were accessible by anyone, anywhere and at any time. under the initial leadership of gec, the first agenda was to determine frequency of meetings and a regular day and time to meet. this was somewhat complex given the varied schedules and time zones of cd4me members, but the group eventually identified a regular time each month for meetings. in order to anchor the meeting time in group members’ schedules, calendar invites for the year were sent to all members. in initial meetings we explored various online collaboration tools, such as screen sharing, using the chat and additional features that allowed members to express their personalities. these activities introduced spontaneity and humor early in our group interactions, characteristics our group have embraced and sustained over time. from a charter member: “i suggested that we use google hangout for its convenience (no need for institutional support) and cost (free) and ability to support video calls as the centerpiece of the collaboration technologies. the first several monthly meetings consisted of getting to know each other, figuring the nature of our shared interests, and getting comfortable with the technology.” from a member who joined later: “i’ve always spent a great deal of time in relationship building before asking to be part of something, and here, it was quite the reverse. i was suddenly going to “belong” to a group of folks i didn’t really know. given my circumstances in my institution, however, i felt like i had to try something new. i wasn’t sure how to go about it; how to mix the business with the fun, over the internet,…but i gave it a shot.” journal of regional medical campuses, vol. 1, issue 2 original report storming: in this stage, the group attempts to define their structure, roles, rules and evidence of short and long-term productivity. individual beliefs, opinions and preferences are challenged. effective group process requires consistent negotiation related to equity in verbal space and group member interaction. though typically unobservable, group members may experience friction as a result of participating in these group processes. however, if group dynamics proceed appropriately, the level of internal conflict is assuaged by both the benefits of and commitment to the projected purpose of the group.13 since the goals of cd4me were yet to be firmly established, early cd4me meetings seemed directionless at times as group members shared their reasons for considering membership in the group, their professional interests and what the potential promise of the group held for them personally and professionally. group members still deferred to gec for direction and purpose, and different members frequently introduced redirects to refocus the dialogue on what we wanted to accomplish in a meeting or as a group. from charter members: “early on, we, as a group, violated the rules of group formation and process for distance groups. i generally do not recommend that you try this, but for several months, early in the group process we did nothing but meet, play with avatars and addons, and talked in an unstructured way about our challenges and ideas. i was worried that an online “greenhouse group” would fail, as some of the literature suggests that distance/virtual groups should have a clear direction and roles assigned early, less risk the group disbanding. we didn’t heed this advice. we couldn’t because, early on, we had no clear idea why we were doing what we were doing.” norming: cohesion is the primary characteristic of group development at this stage. group members are able to manage the interpersonal and group dynamics in ways that contribute to productive group interactions. group members regularly participate in meetings and correspondence, actively contribute to the group discourse and commit to tasks that reflect their interest or identified group needs. consistent attendance, member participation, productive meetings, meaningful contributions and timely completion of assigned tasks builds trust in the group’s ability to optimize the distributed intelligence of the group, function effectively and build momentum. this fosters creativity and continued engagement in group endeavors.13 for cd4me, a consistent core of group members regularly participated in meetings and other correspondence. as different members of the group recommended projects, we determined viability, set goals, delegated tasks and deadlines, established commitments and went to work as a group. these steps influenced group norming as more firm roles were established regarding leadership, and the process of virtually managing projects was determined. specific technologies supported the group’s development at this stage. cd4me formed an online community to create a virtual space and build a member network. the group also created project specific cloud-based folders, which afforded members the ability to synchronously view and edit work products. the need to keep a running record of group goals, decisions, delegated tasks and deadlines became evident at this stage to keep the group’s energy focused between and during meetings. an online document was created for cd4me to serve as a running record of such items, and two group members spontaneously took the lead in capturing this critical information during meetings. from charter members: “... early on, even though i proposed the group, i predominately served as the logistical (techie) and meeting coordinator role. this did create problems, journal of regional medical campuses, vol. 1, issue 2 original report but i believe that it did allow others… to eventually step into the leadership void and take over when we had specific initiatives to complete.” “when it became clear that i could not find a time to move the cd4me meeting to suit everyone else’s calendars, i suggested that i continue to participate asynchronously. during the last few virtual meetings before i left the video environment, i began to experience what i was soon to be losing: comradery, connectedness, collectiveness, and better understanding (through verbal and nonverbal communication). i truly believe that the video presence using real time audio and motion video helps with building understanding through enhanced communication, enculturation, and commitment that i never experienced through asynchronous emails or teleconferences.” from members who joined later: “immediately joining the group i volunteered to take notes (on google docs) so i could get to understand the dynamics, get to know each person, and learn about the topics being discussed.” “it is always effective when team members know exactly what they need to do by certain due dates. it is very helpful to assign each member certain tasks to be completed by the agreed upon due dates.” “that shared interest has been more than enough to bridge the gap between us, and to help me get through the times when i didn’t know if i was fitting in. it took about 4-5 months, but i finally figured out how to contribute in what felt like meaningful ways to me.” “stepping up to lead a portion of one project and feeling like i was contributing to the group through service and action. i do not need to be lead all of the time as it is distributed it was more the feeling of pulling my weight to give back to the team. “ performing: unity, interdependence and productivity are the distinguishing feature at this stage of group development. the group completes tasks together in sub-groups or as independent members. leadership and group roles are flexible depending on the group’s goals, resources, deadlines, member interest and availability. group members enjoy a sense of belonging and identify as members of the group.13 cd4me has been an active, productive, working group for four years. despite time differences, job changes and shifting personal and professional values, the group continues to meet regularly to select meaningful projects, define workable plans of action and achieve selected goals. different group leaders emerge and group members step into different roles depending on the shifting group agendas. members of cd4me have benefitted professionally from the productivity of the group. to date, the scholarly activity of the group includes one publication, three presentations at regional conferences, three presentations at national conferences and a successful attempt to present at multiple regional conferences simultaneously (see appendix for a complete list). the benefits for members of cd4me are not limited to the tangible professional achievements; all members enjoy the benefit of connecting with professionals beyond their local circle that cd4me affords. this has been especially valuable to cd4me members who have limited access to like-minded professionals in their local professional setting. for these members, cd4me ameliorates professional isolation by providing a sense of belongingness to a meaningful professional group. from charter members: “the things i’ve noticed that i enjoy with the group are the humor, group members’ commitment to the kinds of things that sustain a group, such as regular attendance at meetings, completing delegated tasks within established deadlines and the group’s ability to process tangible and intangible elements of group process productively.” from members who joined later: journal of regional medical campuses, vol. 1, issue 2 original report “(the group) working together to accomplish goals, accepting roles, affirming email about projects (i’m in!) laughing at my jokes.” “i also like when members bring up new references, concepts, models that impact or are relevant to our work.” building a successful virtual, collaborative and productive professional network we assert that cd4me is a model of a successful virtual, collaborative and productive network. cd4me members have established a record of collaborative scholarship attained through active participation in our virtual community. we are working on new projects and discussing expanded membership. in this section, we share three factors we have identified as contributing to our longevity and success: 1) the characteristics of our members, 2) the effective management of group dynamics and processes and 3) our ‘virtual presence’. member characteristics: persistence, flexibility and conscientiousness are the primary member characteristics that cd4me associates with our success. as members, we have persisted through the processes of virtual group formation. we learned new technologies and navigated the transitions of new members joining the group and members temporarily or permanently disengaging their online presence. cd4me members are able to flexibly adopt either leader or follower roles depending on personal goals and the needs of the team. high levels of ego strength translate to a limited need to be right, to lead or to have one’s own way in processes and decisions. these characteristics allowed us to successfully navigate the conflicts that occurred when the virtual community’s goals were not aligned with our individual institutional goals and missions. cd4me members are conscientious, realistic and honest with themselves and the team regarding what they can contribute to a team project given other commitments and deadlines. they practice and maintain the values of personal ownership, agency, follow-through and collective achievement in their virtual relationships. group dynamics and processes: we recognize that effective processes for one group may not be effective for another group. however, members of cd4me agree that our productivity is a result of the group’s values including a collectivist perspective, flat or flexible hierarchies and a shared sense of purpose. since virtual cop members are not in the same organization, their roles must be constantly renegotiated. cd4me members view our group as a flexible team of equals. the function of membership is to serve group needs, goals or deadlines. this requires acceptance and flexibility with decision-making processes, shifting authority and variability in group members’ responsibilities or role assignment, in task delegation and work effort. focus on long-term tasks, like a literature review, or more immediate tasks, like preparing a conference proposal, creates a shared sense of purpose that generates sustainable momentum. all members need to be willing to take a leadership role. this can occur organically, as it did for cd4me, or more formally. virtual presence: as individuals increasingly engage in virtual interactions, the boundary between a ‘physical’ and ‘virtual’ self grows increasingly blurry. most cd4me members had not met face to face until presenting cd4me generated scholarship at a professional conference. we had to select and co-manage a co-owned virtual space so that the sustainability of the group would not be overly dependent on any one member and/or the features of, or accessibility to, any one institution’s technologies. our primary interactions are via email, text, our online community, video conference, online documents and folders. all cd4me members had to learn how to use the technologies needed to access and operate in a virtual world and to synchronize our interactions with a variety of communication and collaboration tools including audio, video, chat, screen sharing and document editing, as well as access from a variety of journal of regional medical campuses, vol. 1, issue 2 original report hardware. we use chat to share links to resources without disrupting the primary conversation. screen sharing enables all members to synchronously view the artifacts under discussion. while one or two members may take the lead in online document editing, all members are able to edit and view edits of artifacts under discussion in real time. cd4me meetings are most productive when all members have audio access to the meetings. since all cd4me members have access to resources of interest to cd4me projects, members who join a meeting using only audio can access artifacts under discussion in our cloud-based folder. cd4me meetings are less productive when members have only video access. while they can see the artifacts under discussion, they are dependent on the chat feature for sharing their responses, ideas and feedback, making the process cumbersome and time consuming. cd4me members have learned that archiving the synchronous components of cd4me interactions and applicable artifacts is critical to maintaining momentum from meeting to meeting. having one or more members consistently serve as the group scribe ensures that important decisions, task delegation, deadlines and goals are recorded on a shared document that all group members can access as needed. this is especially useful if group members have missed a meeting and provides a reference point in cases when the group purpose or focus derails during a meeting. discussion lack of resources and faculty isolation are barriers to medical education research and scholarship on university campuses. isolation can negatively affect faculty development since there is limited intellectual stimulation, education, formative feedback from peers and motivation derived from momentum generated with peer collaboration.15 these factors can be particularly debilitating for rmc faculty who may experience unique isolation as a result of distance from the main campus and comparatively different curricular missions, roles and resources from faculty at the main campus. some of the cd4me members have or are currently working on regional campuses. some have experienced isolation due to geographic separation from professional colleagues. other members have unique scholarly interests that make it difficult to establish effective collegial collaborations at their home institutions. our experiences suggest that virtual cops can serve as replacements for or supplements to productive professional relationships at one’s home institution. virtual cops can potentially address both faculty productivity and faculty development concerns for rmcs, especially when the mission, curricular resources and faculty are different from the main campus. as the cd4me group formed, members experienced challenges communicating with powerful but more complex media, establishing clear common goals, establishing an online culture and clarifying individual roles. once these were established, the group’s productivity and satisfaction increased and helped sustain its growth and prevent departures. as members subsequently joined, their integration was enhanced and accelerated since group goals, norms and roles were better established. one area of future scholarship regarding online collaborative communities is better elucidating how the interface of technology and human interaction hinder or help sustain such collaborations. one fact is certain: since the evolution of web 2.0 technologies and social media, collaborations such as cd4me are becoming viable substitutes for face-to-face interactions. the feeling of ‘being there’ establishes a social presence and helps foster both commitment and belonging. as one cd4me member wrote: “from 2002-2005, i participated with an online distance master’s program that predominately used asynchronous message boards and the rare online meeting using audio only and uploaded slides. i found the commitment of students insufficient to maintain meaningful discourse and i really did not feel i was part of a group. i never saw them in action so they never seemed real to me. after i joined cd4me, i feel like i am part of a team of colleagues whom i really enjoy working with and journal of regional medical campuses, vol. 1, issue 2 original report i have a strong sense of responsibility to them. i can see them, watch them, and read their ideas in real time. i appreciate who they really are and what they are all about. the experience has changed my views about working across time and distance barriers.” journal of regional medical campuses, vol. 1, issue 2 original report references 1. association of american medical colleges. aamc statement on the physician workforce. 2006. http://www.aamc.org/download/55458/da ta/workforceposition.pdf. published june 15, 2006. accessed december 7, 2017. 2. norris t, coombs, j. house p, morre s, wenrich m, ramsey p. regional solutions to the physician workforce shortage: the wwami experience. acad med.2006;8:857862. 3. fogarty j, littles a, romrell l, watson r. hurt m. florida state university college of medicine: from ideas to outcomes. acad med.2012;8:1699-1704. 4. cathcart-rake w, robinson m, paolo a. from infancy to adolescence: the kansas university school of medicine-salina: a rural medical campus story. acad med. 2017;92:622-627. 5. cheifetz c, mcowen k, gagne p, wong j. regional medical campuses: a new classification system acad med. 2014;89:1140-1143. 6. whitcomb m. new and developing medical schools: motivating factors, major challenges, planning strategies. http://macyfoundation.org/docs/macy_pub s/new_and_developing_schools_part2.pdf. published july 2013. accessed december 2017. 7. eder m, pierce, j. innovations in faculty development: study of a research assistance unit designed to assist clinicianeducators with research. south med j. 2011;104:647-650. 8. kichler k, kozol r, buicko j, lesnikoski b, tamariz l, palacio, a. a structured step-bystep program to increase scholarly activity. j surg educ. 2014;71:e19-e21. 9. bland c, center b, finstad d, risbey k, staples j. a theoretical, practical, predictive model of faculty and department research productivity. acad med 2005;80:225-237. 10. simpson d, fincher r, hafler j, et al. advancing educators and education by defining the components and evidence associated with educational scholarship. med educ. 2007;41:1002-1009. 11. lave j, wenger e. situated learning: legitimate peripheral participation. ny: cambridge university press; 1991. 12. mckenna a, johnson a, yoder b, guerra r, pimmel r. evaluating virtual communities of practice for faculty development. j fac dev. 2016;30:31-39. 13. tuckman b. development sequence in small groups. psychol bull. 1965;63:384399. 14. brookfield s. becoming a critically reflective teacher. san francisco: jossey¬bass; 1995. 15. gruppen l. improving medical education research. teach learn med. 2007;19:331335. journal of regional medical campuses, vol. 1, issue 2 original report appendix cd4me publications/presentations hurtubise l, khurma a, hall e. leveraging technology to build a community of practice at a distance workshop presented at the ohio state university 11th annual conference on excellence in teaching & learning may 4, 2017, columbus, ohio. kay d, hurtubise l, teal cr. effective strategies for distance collaboration. skills workshop presented at the 2016 generalist in medical education 36th annual meeting, november 10, 2016, seattle, washington. hall e, hurtubise, l. (2016). collaborate-innovatedisseminate: the generalists in medical education 36th annual meeting. med. sci. educ.26:263. hurtubise l, crites g, souza k, crow s, berry a, mckenzie s, kay d, gaines j, hall e. new strategies to collaborate, innovate, and disseminate at a distance. 2015 generalists annual meeting, november 8, 2015, baltimore, maryland. hurtubise l, crites g, souza k, crow s, berry a, mckenzie s, kay d, gaines j, coschigano p. aamc small group virtual collaborative – wgea, grmc, and sgea – web based collaboration in medical education. 2015 aamc southern group on educational affairs annual meeting, april 23, 2015, charlotte, north carolina. crites ge, kay d, gaines jk, berry a, mckenzie s. technologies that facilitate distance collaboration brief: a state of the technology (as of october 2014); icollaborative. 2015 jan. available at: https://www.mededportal.org/icollaborative/reso urce/3887 gaines j, mckenzie s, berry a, kay d, crites g. scholarly collaboration at a distance: tools available for and the potentials of web-based solutions for peer-to-peer networking. aamc southern group on educational affairs annual meeting, march 14, 2014, miami, florida. microsoft word seeking education article.docx published by university of minnesota libraries publishing seeking education, equity, and diversity (seed): the learning experience, cultural humility, and intention to effect change crystal r. ackles, m.ed., michael e. anders, ph.d. doi: https://doi.org/10.24926/jrmc.v6i2.4879 journal of regional medical campuses, vol. 6, issue 2 (2023) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc crystal r. ackles, m.ed.; program manager, chief medical office, university of pittsburgh medical center michael e. anders, ph.d.; educational development, academic affairs, university of arkansas for medical sciences corresponding author: crystal ackles, m.ed. acklescr@upmc.edu 412-647-0505 all work in jrmc is licensed under cc by-nc volume 6, issue 2 (2023) journal of regional medical campuses perspectives seeking education, equity, and diversity (seed): the learning experience, cultural humility, and intention to effect change crystal r. ackles, m.ed., michael e. anders, ph.d. abstract introduction health care work cultures that embrace diversity, equity, and inclusion (dei) foster innovations, synergy, and appreciation for differences. to promote dei, health care systems have encouraged professional development on cultural humility, which is awareness of one’s values, beliefs, and social position, given the current cultural context while mindful of history. the national seed project (seeking educational equity and diversity) is a professional development program that prompts reflection and perspective shifting about workplace culture and systemic change. however, reports that examine the seed learning experience and the participants’ intention for behavior change are lacking. the purpose of our study was to examine: (a) the seed learning experience, (b) how personal views can foster cultural humility, and (c) the impact of seed on intentions to effect change. methods a purposive sample of eight (n = 8) faculty and staff from a seed cohort at an academic health science center, with regional programs, participated in in-depth interviews to explore their personal views of how to foster cultural humility in health care and the impact of seed to prompt intentions for behavior change. the investigators conducted a thematic analysis using an inductive, iterative method. independently, they read each transcript and created codes for each comment. subsequently, they compared findings, developed a coding frame, and grouped codes into potential themes. they then individually applied the coding frame to the data and considered themes. finally, they built consensus on codes and synthesized codes into themes. results thematic analysis indicated the participants had a profound learning experience, which prompted them to develop cultural humility by re-framing cultural experiences and resolving to become more proactive about dei in the workplace. they found small group discussions were insightful and provocative. these discussions led to new perspectives and behavior change or intentions for behavior change. our analysis generated three themes: (1) connecting with diverse perspectives, (2) developing new perspectives, and (3) being proactive with advocacy and new strategies. conclusion health care professionals and organizations can use our findings to encourage professional development that potentially stimulates behavior change, the ultimate goal of professional development, related to dei. future studies should examine the impact of this professional development within their organization and in the delivery of health care. introduction it is vital for diverse people to work together effectively in health professions. a work culture that embraces diversity, equity, and inclusion (dei) fosters innovations, synergy, and appreciation for differences.1 diversity is the presence of differences, while equity is systemic fairness, and inclusion occurs when diverse people fully participate in organizational decisions and development. when a sense of connection exists between people in a diverse workplace, there is a sense of belonging and people strive to meet common goals. building foundational awareness of multiculturism, inclusive of diverse groups who maintain their identities, leads to knowledge about related institutional structures, policies, and practices.2 professional development can potentially shape norms, values, beliefs, and common practices among health professions, faculty, and staff.3,4 in light of ongoing appalling social injustices and health journal of regional medical campuses, vol. 6, issue 2 perspectives disparities in the u.s., a pressing need exists for professional development that prompts health care professionals, educators, and staff to reflect on and have meaningful discussions about dei and, ultimately, change their behavior.5,6 health care systems are one of the largest community assets and can serve as agents for change to address systemic biases, which are unfair health organization policies and practices that adversely affect underrepresented or marginalized groups.7,8 for example, health care teams may lack the diversity of the patients they serve, therefore, their cross-cultural communication may suffer. health care systems can also encourage professional development on cultural competencies, to promote knowledge about the values, beliefs, and behaviors of certain cultural groups and tailoring professional and clinical encounters accordingly.9,10 the national seed project (seeking educational equity and diversity) is a professional development program that provides an educational framework for reflection and perspective shifting about workplace culture and systemic change.11 seed explores cultural humility and dei in communities, institutions, and schools. cultural humility is awareness of one’s values, beliefs, and social position, given the current cultural context while mindful of history.12 however, published reports that examine the learning experience in seed and the participants’ intention to change their behavior are lacking. therefore, the purpose of our study was to examine the following: (a) the learning experience in the seed program from the lens of health care faculty and staff, (b) perspectives of participants and how their personal views can foster cultural humility in health care settings, and (c) the impact of seed on the participants’ intentions for implementing strategies to effect change in their setting. methods setting: the setting was an academic health science center, with regional programs (area health education centers), in a rural, southern state. participants: a cohort of 32 faculty and staff, including some (three faculty, one staff) from the regional programs (area health education centers), participated in the seed seminar series. to recruit a purposive sample, all participants received an invitation asking them to volunteer to participate in a semi-structured interview at the conclusion of the seminar series. procedures: the seed program consisted of eight monthly professional development peer-led seminars in the fall, 2020 – spring, 2021. due to the covid-19 pandemic, seed used a virtual videoconferencing platform (zoom video communications, inc.). seed seminars featured large group forums combined with small group breakout sessions, which offered an opportunity for engaging dialogue. under the auspices of the division of dei at our institution, seed facilitators consisted of four trained faculty and staff from family and preventative medicine, veterinary medicine, and the center for health literacy. the principal investigator (ca), with training in qualitative research, conducted in-depth, semistructured interviews, each approximately one hour long, via videoconferencing (zoom video communications, inc.). the videoconferencing software generated transcriptions of recordings of the interviews. the investigators took steps to minimize biasing the participants during the interview. the pre-interview briefing sought to create a safe environment for and emphasized the importance of the participants being candid by saying, “what you truly think is important. feel free to speak your mind. there are no right or wrong answers. all your comments, positive or negative, are helpful. not everyone sees things the same way. it is good to have many points of view.” moreover, the facilitator (ca) maintained a neutral outlook during the interviews. measures: the investigators developed an interview guide with open-ended questions for in-depth exploration of how the personal views of the participants can foster cultural humility in health care settings and of the impact of seed to prompt their intentions for change management at our institution and the seed facilitators. see table 1. along with input from the division of dei at our institution, the theory of planned behavior, which served as the basis for the social injustice scale, served as conceptual frameworks for many of the questions.13,14 the central concept of the theory of planned behavior is journal of regional medical campuses, vol. 6, issue 2 perspectives one’s stated intention to act predicts future behavior.13 qualitative analysis: we conducted a thematic analysis using an inductive, iterative method outlined by braun and clarke.15 the two investigators independently read each transcript and created codes for each of the participants’ comments. subsequently, the investigators compared findings, developed a coding frame, grouped the codes into potential themes, and assessed data saturation.16 the investigators then individually applied the coding frame for the data, and considered themes.17 next, the investigators met to build consensus on codes, synthesized codes into themes, and identified illustrative quotes. finally, we conducted respondent validation, in which some respondents assessed whether the analysis was representative of their views. throughout, the investigators used analytical memos to record decision points.18 to address the potential influence of the views and beliefs of the first author (ca), who was a participant in the seed cohort, on the analysis, the second reviewer (ma) was a neutral investigator from the educational development department who prompted ca to objectively examine her assumptions about seed. table 1: interview guide • tell me about your experience in the seed program. • please discuss the most helpful aspects of the seed program. • please discuss any suggestions you have for improving the program. • self-reflection welcomes awareness to learning and understanding different experiences. what have you learned about yourself through the seed experience? • tell me about an experience when you felt your rights to something or someone were oppressed? can you share a time you experienced a ‘privilege moment’? • how has seed influenced the way you envision social injustices? how has the seed experience challenged you? • from your seed experience, discuss how you are more proactive, the same, or less proactive in challenging inequality, social injustice, inequities? why? • based on your experiences with others’ views of oppression, privilege, or social injustices, how did you receive or struggle with different perspectives? • the word diversity can take on many definitions, depending on the context in which it is used. how do you define diversity, inclusion, and equity? • how has diversity, equity, and inclusion showed up in your workplace? • how has systemic oppression or privilege shaped your identity? • after your seeds experience, would you recommend this program for new employees? why or why not? • tell me about your seed project experience and its effect on your future professional practice. ethics: our institutional review board determined this study was not human subject research. journal of regional medical campuses, vol. 6, issue 2 perspectives results eight (n = 8) faculty and staff volunteered to participate in an interview. see table 2. review of the participants’ responses revealed similar themes. the investigators were confident they achieved a thorough understanding of the participants’ experiences in seed, because analysis revealed data saturation or a close approximation of it was evident in redundant themes.16 table 2: characteristics of the participants (n = 8) thematic analysis of the transcribed interviews revealed three predominant themes: (1) connecting with diverse perspectives, (2) developing new perspectives, and (3) being proactive with advocacy and new strategies (table 3). see table 4 for illustrative quotes of each theme. table 3: themes and codes table 4: representative quotes of themes discussion qualitative analysis of the interviews indicated the participants had a profound learning experience, which prompted them to develop cultural humility by re-framing cultural experiences and resolving to become more proactive about dei in the workplace. in particular, they found small group discussions were insightful and provocative, even “intense,” and desired more of this format. these discussions often led to new perspectives and intentions for behavior change. our analysis generated three themes: (1) connecting with diverse perspectives, (2) developing journal of regional medical campuses, vol. 6, issue 2 perspectives new perspectives, and (3) being proactive with advocacy and new strategies. the first theme was connecting with diverse perspectives. participants were faculty and staff from diverse health care professions and work settings as well as diverse ethnicity, race, gender, sexual orientation, and religious views. the seed curriculum challenged each of these participants to cultivate his or her perspective and knowledge about social injustice through stirring poetry, mini-documentaries, tedx talks (www.ted.com), videos, and music. participants then related their unique perspectives and knowledge to their workplace environment, including normal day-to-day work routines, interpersonal dynamics, how one’s culture shows up in the workplace, and an expanded definition of diversity. differences and commonalities surfaced, as participants examined diversity, equity, and inclusion through the lens of peer discovery. virtual breakout rooms provided a space for small groups, with six to eight participants each, in which participants were able to engage with the curriculum and each other emotionally, behaviorally, and cognitively. there, they were able to candidly express opinions, reflect, and formulate strategies for behavior change. the participants valued the intimate, in-depth connection with people who had diverse perspectives. connecting with diverse perspectives led to the second theme, developing new perspectives. participants recognized differences and commonalities with each other and colleagues as well as patients in their work settings. many participants exhibited cultural awareness, or understanding differences between people from other backgrounds. through historical social context in the curriculum, seed enhanced their awareness of implicit or unconscious bias, which had manifested with race, gender, and cultural differences. participants also embraced the challenge of self-reflection, which seed identified as the “4 ws”: (1) what is it that i am feeling? (2) why do i feel this way? (3) when does this feeling occur? and (4) where does this feeling occur? some expressed an understanding of the difference between equality, giving people the same resources and opportunities, and equity, allocating resources and opportunities needed for equal outcomes. others recognized the difference between acceptances of imposing social injustice, because it is consistent with a social convention, versus hardened perspectives developed by previously experiencing the brunt of social injustice. they shared childhood and parental guidance leading up to adult experiences. for the first time, some participants looked at oppression with a privilege lens, based on demographics and socioeconomic status. the “ah hah” moment occurred when participants recognized life experiences had shaped their perspectives about privilege versus oppression. indeed, because their life experiences differed, some participants accepted uncertainty about how to respond to them. rather, they resolved to try to listen and try to understand them. the last theme was being proactive with advocacy and new strategies. upon reflection about diverse backgrounds and experiences of people in their workplace, they resolved to speak against social injustices, micro aggressions, and biases that arise in day-to-day activities. faculty expressed motivation to embrace difficult conversations with students and prompt them to self-reflect. self-reflection on the part of future health care professionals could lead to advocacy and change to strengthen diversity, equity and inclusion in health care. some even spoke of action they were already taking to build diversity in their workplace. while our study findings support that of others, our methods and findings are novel in important ways. hutchins, et al., conducted a qualitative analysis in faculty from outside of health care who participated in an online course that focused on cultural competence.19 cultural competence largely involves promoting knowledge about the values, beliefs, and behaviors of certain cultural groups and tailoring professional and clinical encounters accordingly. in contrast, cultural humility, the focus of seed, is both an interpersonal and intrapersonal approach, because it calls for individuals to learn from others’ experiences, while being aware of their own engrained enculturation. nevertheless, their findings revealed themes similar to those of our study. these themes were learning through dialog, heightened self-awareness, empathy, and improved self-efficacy to be proactive against unconscious bias, micro aggressions, and privilege.19 unlike our study, both journal of regional medical campuses, vol. 6, issue 2 perspectives their course discussion and their qualitative data came from asynchronous online discussion forums, which may have limited responsive exchanges between participants. an interdisciplinary workshop for health professions faculty, too, focused on cultural competency.20 their study findings demonstrated improved knowledge, skills, and attitudes. themes from a qualitative analysis of field notes taken during the workshop related to improving clinical practice and teaching.20 another faculty development course for medical school faculty sought to raise their awareness of unconscious bias and, thereby, prompt self-discovery and future behavior change.21 based on a qualitative analysis of in-depth interviews of the participants, the investigators concluded the course was moderately successful.21 kumagai, et al., used interactive theater.22 similar to seed, the intervention featured small group discussions focused on social justice. at long-term follow-up, participants reported behavior changes. in an educational intervention that featured movie clips to prompt discussion and reflective writing, participants’ evaluations demonstrated the discussions helped them reflect on their own attitudes about race and diversity.23 o’connor, et al., targeted only nursing educators, but similar to the seed approach and our study findings, their dei educational intervention featured small group activities, and participants perceived an improvement in self-efficacy.24 other studies addressed implicit bias and racism in clinical practice, which differed from the broader target group in seed and our study.25,26,27 our study was novel, because it provided an in-depth qualitative evaluation of a dei educational intervention for both faculty and staff at a health science university. our study has several limitations. in the analysis, the investigators thought they had a thorough understanding of the perspectives of the study participants, reaching data saturation or close to it. however, it is possible interviewing more participants could have further enhanced their understanding and expanded the themes. further, most of the participants were female. their perspectives may have differed from that of males in the seed cohort and in health care settings. the ratio of females (n = 7, 88%) to males (n = 1, 12%) who participated in an interview was similar to that of the seed cohort, which had 27 females (84%) and five males (16%). however, compared to medicine faculty nationally, in which females make up 45% of assistant professors and 35% of associate professors, our study had overrepresentation of females.28 our study also had overrepresentation of african americans (12.5%) compared to the proportion of african american faculty at the university of arkansas for medical sciences faculty (5%) and medical faculty nationally (3.6%), but the sample size was small.29,30 another limitation was the primary investigator was a participant in the seed program and facilitated the interviews as well as participated in the analysis. to minimize biasing the participants’ responses, the investigator took great care to create a safe environment for them to speak freely, as outlined in the methods section. to offset this investigator’s potential bias in the analysis, the second reviewer was a neutral investigator who strived to ensure objectivity. further, the virtual format of the seed program may have inhibited the participants’ engagement. however, many of them highly favored the small group discussions, which the breakout rooms in the platform made possible. further, their responses were rich. finally, the participants’ expressed intentions for behavior change, including advocacy, being proactive in the face of social injustice, and prompting students to self-reflect, may not translate to real future behavior change. still, some participants described significant behavior changes they already made. conclusion health care professionals and organizations can use our findings to encourage professional development that stimulates behavior change, the ultimate goal of professional development, related to dei. future studies should examine the impact of this professional development within their organization and in the delivery of health care using quantitative methods and a comparison group. acknowledgements we are grateful to the division of diversity, equity, and inclusion at the university of arkansas for medical sciences (uams) for support and feedback, and we are grateful to tricia edstrom, director of education for graduate medical education in regional programs at uams for her support and guidance. journal of regional medical campuses, vol. 6, issue 2 perspectives references 1. shaw-taylor y, benesch b. workforce diversity and cultural competence in health care. journal of cultural diversity. 1998; 5(4):138140. 2. sotto-santiago, s. , poll-hunter, n. , trice, t. , buenconsejo-lum, l. , golden, s. , howell, j. , jacobs, n. , lee, w. , mason, h. , ogunyemi, d. , crespo, w. & lamba, s. (2022). a framework for developing antiracist medical educators and practitioner–scholars. academic medicine, 97 (1), 41-47. doi: 10.1097/acm.0000000000004385. 3. hutchins d, hode goldstein m. exploring faculty and staff development of cultural competence through communicative learning in an online diversity course. journal of diversity in higher education. 2021; 14(4):468479. doi: http://dx.doi.org/10.1037/dhe0000162 4. grant s. diversity in health care: driven by leadership. frontiers of health services management. 2010; 26(3):41-44. 5. lewis ld, steinert y. how culture is understood in faculty development in the health professions: a scoping review. acad med. 2020;95(2):310-319. doi: 10.1097/acm.0000000000003024. pmid: 31599755. 6. sabatello m. cultivating inclusivity in precision medicine research: disability, diversity, and cultural competence. journal of community genetics. 2019; 10:363-371. 7. betancourt jr. organizational change management for health equity: perspectives from 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perdomo j, tolliver d, hsu h, he y, nash ka, donatelli s, mateo c, akagbosu c, alizadeh f, power-hays a, rainer t, zheng dj, kistin cj, vinci rj, michelson cd. health equity rounds: an interdisciplinary case conference to address implicit bias and structural racism for faculty and trainees. mededportal. 2019;15:10858. doi: 10.15766/mep_23748265.10858. doi: 10.15766/mep_2374-8265.10858 27. white-davis t, edgoose j, brown speights js, fraser k, ring jm, guh j, saba gw. addressing racism in medical education: an interactive training module. fam med. 2018 may;50(5):364-368. doi: 10.22454/fammed.2018.875510. 28. xierali im, fair ma, nivet ma. faculty diversity in u.s. medical schools: progress and gaps coexist. association of american medical colleges 2016; 16 (6). 29. university of arkansas for medical sciences, division for diversity, equity and inclusion. 2020-2021 annual report. https://ddei.uams.edu/about-us/annualreport/. accessed on october 3, 2022. 30. american association of medical colleges. data and reports. https://www.aamc.org/data-reports. accessed on october 3, 2022. microsoft word leadership succession at regional medical campuses article.docx published by university of minnesota libraries publishing leadership succession at regional medical campuses – what incoming leaders might want to know from their predecessors gerry cooper edd; mark awku mb; dema kadri md doi: https://doi.org/10.24926/jrmc.v1i3.1270 journal of regional medical campuses, vol. 1 issue 3 (2018) z.umn.edu/jrmc all work in jrmc is licensed under cc by-nc gerry cooper edd, associate dean, schulich school of medicine & dentristry – windsor campus, windsor, ontario, canada mark awku mb, chb, frcp(c), faap, professor (paediatrics), schulich school of medicine & dentistry – windsor campus, windsor, ontario, canada dema kadri md, resident (family medicine), schulich school of medicine & dentistry – windsor campus, windsor, ontario, canada all work in jrmc is licensed under cc by-nc volume 1, issue 3 (2018) journal of regional medical campuses original report title leadership succession at regional medical campuses – what incoming leaders might want to know from their predecessors gerry cooper edd; mark awku mb; dema kadri md abstract succession planning and changeover between outgoing and incoming leaders within medical education is an important but largely neglected topic (rayburn, grigsby & brubaker, 2016). the paucity of literature is even more apparent regarding leadership transitioning at regional medical campuses (rmc). with this paper, perhaps one of the first to inform this topic, we hope to bridge this gap by assembling the shared perspectives of an administrator, senior faculty member, and a learner from the same rmc. specifically, this work will focus on the following two questions: • based on our collective experiences, what are the critical issues facing an incoming rmc dean? •are there practical strategies which might assist an incoming rmc dean with the leadership transition process? this commentary is the result of our collective experience at western university’s windsor campus, a 10-year-old regional medical campus of the schulich school of medicine & dentistry located in southwestern ontario, canada. we make the assumption that rmc’s encountering leadership transitions are adequately funded, in this way incoming deans can properly attend to effective leadership succession processes. this paper might be of particular interest to those who are personally transitioning as new rmc deans or who will soon take on such a leadership role. we have no conflicts of interest to declare. introduction succession planning within academic medicine has been described as “a strategic and rationale approach to maintaining a vital organization by promoting successful leadership transitions” (rayburn et.al. 2016, p.465). many academic health centers and medical education programs appear to be poorly prepared for the challenges associated with leadership renewal. it has been reported that, increasingly, executive positions within academic medicine are being filled by interim leaders and that the rates of turnover of academic leadership positions are becoming more frequent (grigsby, aber & quillen, 2009). considering that this situation could be accelerated over the next decade given the high numbers of academic leaders who will approach retirement (cain, felice, ockene, milner, congdon, tosi & thorndyke, 2018), it is clear that immediate attention to succession planning efforts would be prudent. rmc’s that anticipate leadership change in the near future may want to pay particular attention to this issue and the comments which follow. we propose to commence this discussion using our rmc as a mini-case study and thus provide the aligned perspectives of a soon-to-retire rmc dean, a senior faculty member (awuku, 2018), and a learner who graduated from the md program who is now nearing the end of her first year residency training at the rmc. the schulich school of medicine & dentistry’s windsor campus is a collaborative effort between western university (schulich medicine is the faculty of medicine at western university) and the university of windsor (host of the windsor rmc). a formal multi-year affiliation agreement between the two universities is approved at the level of the university presidents. it takes roughly two hours to drive from the main campus in london, ontario to the rmc in windsor, ontario (canada’s southernmost city journal of regional medical campuses, vol. 1, issue 3 original report across from detroit, michigan) along the international canada/usa border. the windsor campus can be described as a vibrant “combined model” rmc (cheifetz, mcowen & gagne, 2014) where basic sciences/pre-clinical studies occur in the first two years, followed by clinical training in years three and four. currently there are 38 students in each of the four undergraduate medical education years, and as of the 2018 convocation roughly 240 physicians have graduated where the majority of their training was within the rmc (cohorts from the first two years were 24 and 30 students). the windsor campus also supports a range of postgraduate residency training across a variety of specialties including fulltime trainees in family medicine and psychiatry (psychiatry was a new program in 2016, so it will be a few years before it reaches ‘steady state’). the academic program is enabled by a skilled group of approximately 350 adjunct faculty members, the vast majority of these medical educators are active physician clinicians. the role of an exceptionally welcoming local community cannot be overemphasized. both the city of windsor and the county of essex have been incredibly supportive of this rmc along with many local organizations (cooper & awuku, 2018). despite the tremendous growth and quick maturity experienced by our rmc, there continues to be developmental issues of significant importance which campus leadership must keep a close watch over. these areas are thought to be critical enough that they would apply to many other rmc’s. for this reason and given the absence of a wider conversation about this topic, we offer our advice in the hopes that it will stimulate an examination of leadership succession by the rmc community. we also hope that our experience will benefit any rmc that is or will soon undergo a leadership transition so that disruptions to the core areas of education, research, and clinical programs will be minimized. rmc leadership transition: critical issues and practical strategies doi: https://doi.org/10.24926/jrmc.v1i3.1270 just as grigsby and colleagues advocate that medical school department chairs should have a leadership succession strategy given the increasing rate of retirements of this cohort and the possibility of unforeseen events (grigsby et.al., 2009), so should those responsible for regional medical campuses. making anticipatory plans for when leadership of the rmc needs renewal, whether that be of a temporary nature or more permanent, can help avoid the chaos that oftentimes is associated with these kinds of transitions (rayburn et.al, 2016). in examining the windsor campus, our assessment of the areas of greatest importance requiring the incoming dean’s attention results in the identification of the following domains: • faculty engagement • learner health and academic performance • community engagement • campus culture • resource leveraging • rmc leadership sustainability these areas are not distinct from one another. in fact, there is considerable overlap. that being said, each of these domains will be explored in greater detail incorporating our collective perspectives in addressing critical issues and practical applications associated with the transition to new leadership. as a basis for our discussion, we have focused on two questions throughout the remainder of this paper: • based on our collective experiences, what are the critical issues facing an incoming rmc dean? • are there practical strategies which might assist an incoming rmc dean with the leadership transition process? we cannot say definitively that these domains will be applicable to all rmc’s, or that our approaches will prove to be consistently effective. still, we strongly believe that our success has been closely connected to the approaches presented journal of regional medical campuses, vol. 1, issue 3 original report below. despite their simplicity, these approaches may provide the reader with some new ways of thinking about opportunities created in the leadership transition process. faculty engagement many will be familiar with pareto's law which essentially states that 80 percent of the effect can be explained by 20 percent of the cause. we have generally found this to be true, but it is especially true in distributed medical education and within rmc's. regional medical campuses exist in large part because of faculty's willingness to impart their knowledge and mentorship with future physicians. we cannot have a successful medical education program without excellent teachers, preceptors, and mentors. rmc’s may find that faculty are often in diminished quantities in communities which are newer to academic medicine. as a result, many rmc's rely on a relatively small number of faculty to support the bureaucratic necessities associated with a medical campus – pareto’s ‘20 percent’. moreover, this is a model that simply is not sustainable in the longer term. for this reason, faculty engagement must be high on the rmc dean's radar and as an ongoing priority. attention will need to be given to broadening the base so that the rmc will not be as reliant on a small number of contributors. this way, the workload will be shared by a larger group which will create greater routes for academic leadership opportunities within the professoriate. it might be helpful to consider faculty engagement from a more holistic perspective: how are faculty recruited to your rmc? how easy is it to get them a faculty appointment and/or teaching assignment? how do you ensure that your educators are good at what they do and are focused on continually improving? what keeps your faculty corps motivated, and how will you address problems when they occur? regarding the efforts to recruit and retain faculty, much of this work might be handled by the main campus, but there is a great deal that can be done locally to improve the process by adding a personal touch. for example, we have found success doi: https://doi.org/10.24926/jrmc.v1i3.1270 through having exploratory meetings with prospective applicants, sharing an on-boarding manual specific to the local rmc, holding an annual welcome event, distribution of branded swag, and periodic appreciation events (especially ones that are inclusive of families). one of the more successful approaches at the windsor campus included a calendar featuring photos of members of our faculty, learners, and staff. these were produced locally at a reasonable cost with our brand prominently displayed. afterwards these were distributed to faculty, where many readily displayed their calendars within their office/clinic environments and with considerable exposure to their patients. incoming deans might want to consider instituting regular check-ins with faculty members by asking them: how are things going and how can we be of help? additionally, consider advocating that the main campus department leaders also engage in this kind of practice with their distributed faculty members. perhaps this is something that you can do collaboratively with department chairs within your medical school. make sure to enquire about faculty’s satisfaction regarding continuing professional development opportunities: are these available locally and are these conducted live/in person or via distance education? your regional faculty might appreciate the opportunity to participate in training conducted at the main campus if this can be accommodated from remote locations, and even better if it can be archived for use by the faculty member at a later time that might be more conducive to her schedule. reassure faculty that some of the best medical educators started out feeling inadequate, that there are excellent training events and it is possible to become proficient at evaluating a learner’s clinical performance. in short, not everyone is a born teacher, but that does not mean one is not destined for excellence. next, the incoming dean might examine if rmcbased faculty are encouraged and supported regarding their efforts at scholarship. do they have access to research support, and are they helped to attend national medical education conferences? journal of regional medical campuses, vol. 1, issue 3 original report perhaps some form of mentorship would be helpful for those faculty who have not been as active lately; perhaps they should be encouraged to attend a refresher workshop offered by more seasoned faculty. some mentorship programs are formal and quite rigorous, while others might be as simple as connecting the more experienced educator/leader with less experienced colleagues. celebrate all forms of scholarship in the form of an inventory that reads like a reference section. survey your faculty members repeatedly for any publications, authorship, posters, and/or presentations and add these to the list. make sure the list is widely shared and celebrated so that your team will aspire to see their scholarship efforts included therein. if there are differences in the status of distributed/regional faculty compared to main campus faculty, this might require your attention in resolving. at a minimum there should be a level of mutual respect which exists amongst the broader professoriate. as the new rmc dean, you may need to advocate amongst your main campus academic peers that distributed faculty members should be invited routinely to participate in important academic decisions regarding curriculum, residency matches, and/or faculty departmental business. you may need to ensure that relevant policies speak to this inclusion. ongoing efforts may also be needed with main campus departmental chair/chiefs in terms of the faculty appointment and renewal process. the rmc should have representation on main-campus based faculty appointment and promotion committees if these have oversight of your educators. if not, this could be a fruitful area for investigation. regardless, it will be important to have these chair/chiefs physically visit your rmc at least annually. develop these relationships as they will be key when you need to resolve a problem or launch a new innovation and your primary form of speaking is via electronic methods of communication. the incoming dean will also want to know if there is a process by which rmc faculty can be rewarded and/or recognized for their contributions (e.g. doi: https://doi.org/10.24926/jrmc.v1i3.1270 academic promotion, peer recognition, increasing level of responsibility/leadership, and/or faculty appreciation events). some schools may have a local rmc-based awards program, some schools may have this centrally and some might have access to both. indeed, there may be benefits to having numerous mechanisms for recognition, but it is critical to at least have some means for this. to be sure, faculty will want feedback even if their performance does not merit formal recognition such as an award; they will want to know how their performance is being evaluated and they will be keen to want to improve their skills as an educator. ensuring there is help for faculty along this path is one of the most important things we can do as the rmc dean. be cognizant of the fine line between sending information that faculty need to successfully accomplish their objectives and over-saturating their mailboxes. some might want to consider having differential routes of communication where more ‘generic’ information is distributed through vehicles like newsletters and more critical information will come from administration via a specific/direct email account, text, or cellphone call. finally, be mindful of differences in funding provisions where they exist between rmc-based faculty and those from the main campus (e.g. practice plans). there are no absolutely correct answers here as there is no “one-size-fits-all” funding model for rmc’s. however, being aware early of sensitive issues like this could save you a great deal of time and effort. learner health and academic performance generally speaking, rmc's are smaller versions of main campusus and are much newer. this often provides rmc’s with a natural opportunity to be more nimble and innovative (carter, cooper & johns, 2016). learners initially might be apprehensive if they believe they are missing out when it comes to academic functions, however, they will soon discover that they can benefit from a more personalized style of medical education. afterwards, they are more likely to explain that journal of regional medical campuses, vol. 1, issue 3 original report their rmc affords them an opportunity for "greater hands-on exposure and experience". they will appreciate that the rmc dean regularly meets with their local representatives, has an open-door policy, and knows most if not all learners by name (as do the faculty and staff). students perform better when they have a sense of belonging (levett-jones, lathlean, maguire & mcmillan, 2007), which is a strength of many rmc’s with their smaller class size and tightly knit community. it is important to continue to encourage the collegiality that exists within rmc’s and to encourage students to interact with one another as well as with the community in which they are training. it might be helpful to provide your students with a list of mentors willing to have student observers or research assistants as a means of facilitating their engagement early on. some rmc's experience academic success through their learners’ accomplishments almost immediately while other rmc's might take longer before successful outcomes emerge. either way, celebrate the successes that do occur and try to build on these so that they will be more likely to be repeated. positivity breeds positivity and success breeds success (luthans, lebsack & lebsack, 2008). to the extent possible, try to create an atmosphere where those who belong to your community genuinely aspire towards significant outcomes. one of the important conditions for success is that learners need to be healthy. specifically, they need to be mentally well-supported (rotenstein, ramos, torre, segal, peluso, guille, sen and mata, 2016). part of this will involve your vigilance regarding risk as well as your team’s efforts to create a conducive learning environment. we recommend that you pay special attention to these issues prior to the arrival of new learners. for example, how are new students initially welcomed and oriented to your campus? have you taken precautions to ensure their safety, as well as minimizing any reputational damage that could result from over-zealous orientation practices (see for example: cooper, ellaway, tithecott, bere & piccinin, 2014)? as the saying goes, you only get one chance for a first impression, and the rmc dean can help guide the doi: https://doi.org/10.24926/jrmc.v1i3.1270 newest learners through this exciting yet daunting process. capturing key performance criteria such as learner feedback/evaluations (clerkship rotations, grades, graduate surveys) is also something new deans may want to be mindful of; best too if you can assemble this data so as to be aware of trends as well as current activity. consider if your campus’ residency match statistics are comparative to the main campus and other rmc’s, if possible. chronical learners’ participation with research (for example, track the number of funded projects, posters/presentations, and so on…) and include these in the scholarship inventory like the one you have created for your faculty members (or perhaps combine all scholarship efforts into a single inventory). as the rmc dean you may need to champion your campus’ awards/recognition program(s). by promoting learner involvement, you will encourage them to make nominations (make it easy to nominate and several reminders to do so; track how many participate with this process each year). offer to assist the learners, especially the newest ones, to hold social events that integrate amongst the years and/or campuses. help them to get acquainted with and to participate on various academic committees and support their efforts to give back to the local community (e.g. fundraisers, charities). be mindful of the opportunities that exist at the rmc which are not necessarily available at the main campus, and vice versa. for example, at our rmc we have a very close proximity and working relationship with the faculty of nursing, and thus great inter-professional educational (ipe) opportunities (cooper, inayatulla, patrick, & sbrocca, 2015). these opportunities may vary from site to site but assess where you have natural advantages and leverage them to the greatest extent possible on behalf of your rmc. does the formal curriculum provide opportunities for learners from different campuses to integrate? some have suggested that this may have unique benefits if accomplished early on (ellaway, cooper, al-idrissi, dubé & graves, 2014). to what extent journal of regional medical campuses, vol. 1, issue 3 original report can you facilitate the transportation to such activities at the other campus, accommodate timeoff requests, or allow students to attend some curricular activities at the other campus? this might be an area where donors might be willing to assist, especially if it is associated with specific events such as research presentations or unique events that are part of the school’s culture and tradition. remain aware of the kinds of professionalism issues that occur within your rmc, their frequency (trends will be important to watch for), and how they are dealt with. it will be important that there is a consistent approach between campuses regarding how these issues are addressed and when indicated remedial efforts; frequent contact with and a conducive professional relationship to the respective academic leader(s) is quite important. it will be important for you to document these, even with brief process notes as needed. give careful consideration to proactive healthpromotion policies and activities as well as riskavoidance strategies. for example, if your students will need to travel to the main campus for components of their training, is there a policy regarding travel during the winter months or inclement weather? finally, be mindful of the need for good contingency plans that speak to things like bad weather or other catastrophes (best too that these should be aligned with the main campus). for example, what happens if one campus is forced to close because of a local storm but the other campus is unaffected? community engagement it is not unreasonable to conclude that many rmc's were created to address physician shortages in a given geographic area, and that their presence is a fairly recent phenomenon. the association of american medical college’s (aamc) group on regional medical campuses (grmc) data suggest that 61 percent of all rmc's have been established since 2010 (mcowen, 2017). these two facts contribute in a major way towards understanding why local host communities are so supportive of the rmc's presence. this is important and should doi: https://doi.org/10.24926/jrmc.v1i3.1270 be capitalized on; it is also something that you should emphasize with main campus-based medical education leaders. connection to the community can result in curricular opportunities, increased interest from potential donors, new ways of teaching, supporting learners, and potentially recruiting these same learners as faculty. there are many ways to build and enhance relationships between the local community and the rmc but maintaining positive professional relationships with all stakeholders cannot be emphasized enough. in addition to learners, these stakeholders are likely numerous, including the main campus decanal team, local hospital and community agency leaders (especially those where your learners train), local academic/faculty leaders, staff, volunteers (standardized patients, proctors), and local media. in this regard, we have found it beneficial to involve the school of medicine’s dean in local activities whenever possible. indeed, this might be made easier by exploring if there are any personal connections the dean and/or other senior decanal school leaders have to the rmc community and leverage these. should you develop signature events for your rmc, you might consider providing complementary tickets to key community supporters/donors and/or try to involve them in the school culture somehow (e.g. newsletter mailing list, guest lecture, focus group). other novel ways to engage the local community in your school’s mission could involve invitations to promising local high school students to visit the rmc or teddy-bear clinics for younger children, perhaps from underprivileged backgrounds. if you can solicit medical learners’ participation in the running of such events, not only will the event be more successful, but you will also have medical students who are honing other skills while giving back to their communities. we recommend that the incoming dean maintain a monthly log of activities that advance your rmc’s mission; no accomplishment is too small. afterwards, these can be distributed as updates to your key stakeholders (this can also be an opportunity to educate them about the process of journal of regional medical campuses, vol. 1, issue 3 original report medical education – also a good way to begin the donor recruitment process). these updates can also be useful in routine reporting to one’s supervisor or various academic committees, and they will serve as a wonderful narrative account of your rmc’s journey. these monthly logs can also be used to track the number of learners, faculty, and staff who nominate peers for awards as well as those who are receiving awards – we maintain a list of faculty members who are recognized beyond the local level (provincial/state, national, international). this list has proven its value many times over; the trick is to create it early and to routinely update it. similarly, if you have an awards program, we think it worthwhile to recognize every nominee with an individualized communication (email, letter) thanking them for their contributions. we also suggest that it could be beneficial to maintain a chronological folder with media clippings and evidence of other outcomes that illustrate how the rmc is achieving its mission. you might even want to consider the creation of a time capsule since these could provide the rmc with some special opportunities down the road (e.g. learner research posters, student life videos, manuscripts, photos, publications roster). campus culture there is a good chance that the rmc you are associated with is a relative newcomer to the medical education landscape. it might be helpful to learn as much as you can about the specific origins of your campus in addition to how rmc’s came to be and their connection to social accountability mandates. there are several excellent historical commentaries, and these will provide a wonderful context for your efforts (for example: ramsey, coombs, hunt, marshall & wenrich, 2001). with regard to your rmc, what were the drivers that led to the creation of your campus? who were the champions, and do they continue to play a role such that you might be able to mobilize them for support? have events leading to the creation of your rmc been chronicled? sometimes there might even be consultant reports that speak to doi: https://doi.org/10.24926/jrmc.v1i3.1270 developmental issues within the rmc; these too can provide you with important information. most rmc leaders likely want their campuses to be known as exceptional places to learn and work. as you become familiar with your campus you might check your own impressions of how close this describes the situation or how much effort you expect that it will take to get your rmc there. have you experienced your rmc to be a safe, respectful and inclusive center for learning? is there a ‘cando’ attitude present where members of your administrative team in addition to the faculty and learners feel empowered and that there are no limits to what can be accomplished? if not, what steps might you be able to take to eventually lead toward such a culture? who can you rely upon to help move the rmc into this direction and what can be done to best empower their efforts? telling your rmc’s story is very important. do you have members of your local team to assist with this function, or will the work be taken on by colleagues at the main campus? if the latter, you may have to educate them about the nuances of your community and thus what stories are important to your local stakeholders/citizenry. it might also be helpful if you can showcase your rmc in other organizations’ newsletters, and even better if you are able to discuss projects that you are collaborating on. in our experience when we have held special events, we have benefitted a great deal by having access to a photographer who can ensure high quality pictures of the event and those in attendance. afterwards, there can be multiple purposes for these photos (for example, making into posters to adorn the walls of your campus, local health care organizations, and/or physician offices and afterwards sending electronic files of the pictures to key stakeholders and potential donors). it might be prudent to consider in advance if you need to arrange for consent forms regarding the eventual use of these images. signature events are a wonderful way to build a campus culture while at the same time reinforcing and responding to community issues. these provide you with an opportunity to showcase your connection to your community and what makes journal of regional medical campuses, vol. 1, issue 3 original report your rmc a special place. at the windsor campus we always begin the academic year with a meet & greet event welcoming all newcomers to our rmc ‘family’ (including faculty, staff, and learners). more recently, we also used this as an opportunity to capitalize on recent efforts towards encouraging inter-professional education (ipe) and thus extended a welcome to include other health discipline learners. if yours is a newer rmc, you might consider what opportunities exist to celebrate the first graduates (‘charter class’) of your rmc. this is a very special moment in time and a particularly important event to involve the host community. in our case we had the benefit of being able to plan several months in advance and had a community-based committee assisting us, leading to special newspaper and magazine supplements, special events hosted by community partners, historic gifts to the charter class, and a convocation ceremony that included the presidents of the main campus (western university) and rmc’s host university (university of windsor). it might be helpful to also think about your learners as future alumni and begin that relationship early while they are in your presence; learners and their family members are also potential donors – if not now, perhaps at a future time. it is best to get them feeling as though they are a member of the rmc family. they will also be great ambassadors within the community. if it is possible, consider establishing an rmcspecific awards program where the awards will be more meaningful to members of your campus than similar awards that might be hosted by the main campus. this way, you are also able to better define the criteria of the award. be sure to recognize all who are nominated with a personalized letter from the campus dean. in order to showcase these awards, we strongly advise that you host an annual awards banquet. at the windsor campus, we hold this at the same time we celebrate the graduating class’ accomplishments. this is also an opportunity to determine an appropriate name for the event (e.g. celebration of excellence) or to possibly name it doi: https://doi.org/10.24926/jrmc.v1i3.1270 after a special donor. every effort is made to have our dean play a prominent role at this event (for example, all award recipients are photographed with the dean prior to the formal banquet, photos are later sent to award recipients along with our thanks). making this available to the local community may have additional dividends in terms of relationship building with prospective donors. feedback that we received regarding faculty and staff appreciation events caused us to consider having some of these where members of the team can also involve their families. before you realize how quickly time has elapsed since your grand opening, you will need to begin preparations for an anniversary milestone; whether it is at year 5, 10, or 25, this will be another chance to involve your local community and the media. leveraging resources ideally, as the rmc dean you will have some discretionary funding for special local projects. if this is not the case, then perhaps a local donor might be a reasonable solution to provide you with this flexibility. consider yourself to be a farmer: always planting seeds in the hopes that ‘fruit’ will result at some future time. nurture the seeds to the extent that you can, and continually look for ways to connect your campus to the local community and vice versa. as you tell the story of your campus, be sure that this story includes all who contribute to your campus: volunteers, standardized patients, exam proctors, and administrative assistants within clinics who arrange for the preceptor’s time, to name a few. the more inclusive you can be with this, the better the opportunity for a wider community of support. keep these stakeholders connected to your rmc through whatever mechanism works: social media, newsletters, certificates of merit, old fashioned open houses, or even hand-written letters of thanks. a research colleague once shared an interesting story regarding community engagement and it is worth repeating here. while checking out of a hotel in a small rural community served by a rmc, when the front-desk clerk learned that the doi: https://doi.org/10.24926/jrmc.v1i3.1270 journal of regional medical campuses, vol. 1, issue 3 original report departing customer was associated with the rmc they began singing the praises of the school and thanking him for helping to solve the physician shortage. when he said that he was a researcher and not a teacher, it made no difference to the hotel clerk: they saw this person as an important part of their healthcare because of the affiliation to the rmc (dubé, schinke, strasser & lightfoot, 2014). one never knows where there are quiet sectors of support, so it is best to know ahead of time that your local community is invested in the success of your rmc; invite them to contribute to the rmc’s mission and to celebrate their affiliation no matter how insignificant. rmc leadership sustainability in order for us to be as effective as possible and for the longest duration, we must take care to maintain a healthy balance in our own lives. while it is true that we are medical educators, even if the vast majority of our time might be spent on administrative matters, our actions, judgements, and demeanor may have a much wider reach than we realize. all the more reason to ensure we are at the top of our game; we educate our administrative teams, our faculty, and our communities in addition to our learners. in short, we are role models and given the stake our communities have in our work, our sphere of influence can be quite extensive. with that, our leadership role is often reduced to a few areas that might be surprising: cheer-leader, relationship counsellor, farmer, and strategist. some of the best teachers and sources of inspiration and support are colleagues who have similar roles at other rmc’s. they often provide creative ways to look at an issue as well as a means of stimulating curiosity and inventiveness. for those new to rmc leadership roles, it is recommended that they find ways to connect with this community of like-minded individuals. there is a growing network across north america and perhaps one place to start would be the group on regional medical campuses (grmc: https://www.aamc.org/members/grmc/about/). it is also recommended that incoming rmc deans carve out time periodically within their schedules to work on special projects that they enjoy. perhaps this will be writing, conducting a research study, or participating in a special assignment. whatever the task, it will help to recharge and approach regular assignments with new energy. another strategy that might help would be to restrict the checking of email to certain times of the day or by declaring some email-free ‘vacation’ periods. as you are doing these things, consider how you might be preparing your colleagues to take your place when the appropriate time comes. of course, the decision will likely fall to your superior, but that is not to say that you cannot have influence on who might be considered as your successor. there are many excellent resources on being an effective leader but not too many of them advocate that such success follows one who micro-manages. therefore, give your subordinates latitude to demonstrate what they can do and help mentor them as the need dictates. doing so you can add one more aspect to your job description: coach. being a good coach is probably intuitive to most, but it needs to be stated as part of this conversation too. it is a good reminder, especially as one climbs into a new rmc leadership role. discussion as we crafted this commentary, the need for more empirical data regarding leadership metrics within rmc’s became increasingly apparent. nearly 40 percent of medical schools responding to a 2016 north american survey (93 percent response rate) reported having an rmc (mcowen, 2017). these campuses together account for over 9100 medical students and over 34 000 faculty members (ibid.). in short, the lack of data regarding rmc leadership succession affects many stakeholders. for example, a discussion like this would be much better informed if we had a better understanding of the average length of service for rmc deans, what their qualifications are, and if they tend to be replaced by applicants from within the rmc, as is the case with medical journal of regional medical campuses, vol. 1, issue 3 original report school department chairs (rayburn et.al. 2016). in the past, the aamc’s biennial survey collected data about rmc governance, but perhaps it should expand in the future to also include information about leadership and succession practices. it would also be helpful to know of others’ experiences with regard to those domains that are of greatest urgency requiring action when a new rmc dean arrives. learning of these issues might lead to a resource manual that could aid new deans and expedite their transition process with greater efficacy as opposed to relying on a single case study like that provided here. likely, such action would have the effect of broadening the domains cited within this paper in both depth and breadth. one way to illustrate this point is to consider the points we raised regarding faculty engagement and rmc leadership sustainability: others might choose to begin the process of leadership recruitment at a very early stage, right after the new rmc dean’s arrival. others have highlighted the distinction between “interim” and “acting” deans (grigsby et.al. 2009); perhaps this also needs some discourse within the rmc leadership transition conversation. finally, it might also be worthwhile to begin to consider rmc’s risk exposure to the effects of retirement, certainly amongst its leadership, but perhaps more broadly as well (faculty and staff). as mentioned earlier, we are not sure if these domains will be applicable to all rmc’s or that our approaches will prove to be uniformly helpful. that said, we believe that success associated with our rmc has been connected to the approaches as we have outlined above. the strategies are simple but will require careful and sensitive attention to local circumstance. in doing so, these approaches may provide the new rmc dean and others with some novel ways of thinking about opportunities created in the rmc leadership transition process. summary three distinct voices from a single rmc have endeavored here to assist new rmc leaders with their transition. the perspectives include a campus doi: https://doi.org/10.24926/jrmc.v1i3.1270 dean nearing retirement, an accomplished faculty member, and a graduate of the medical education program. here, they have combined to address questions related to critical areas needing attention and practice strategies that have proven helpful in doing so. while these three perspectives are aligned, each adds something unique to the conversation. it is hoped that those who are new rmc deans or who will soon take on such leadership roles will benefit from our collective experiences and eventually build on them for those who will follow. we also hope that these observations will help to stimulate a larger overdue discussion regarding leadership transition processes within regional medical campuses. references awuku, m. (2018). the practical pocket guide for medical educators: the abc’s of teaching medical students and residents. north charleston, sc: createspace. cain, jm., felice, mf., ockene, jk., milner, rj., congdon, jl., tosi, s. & thondyke, le. (2018). meeting the late-career needs of faculty transitioning through retirement: one institution’s approach. academic medicine. 93(3): 435-9. doi: 10.1097/acm.0000000000001905 carter, l., cooper, g. and johns, a. (2017, september). a closer look at regional medical campuses. [letter to the editor]academic medicine. vol. 92, no. 9: 1221. doi: 10.1097/acm.0000000000001841 cooper, g. & awuku, m. (2018). campus overview: schulich school of medicine & dentistry, windsor campus. accepted for publication within: flanagan, m. et.al. group on regional medical campus textbook. pennsylvania state university (in press). cooper, g., ellaway, r., tithecott, g., bere, p. and piccinin, l. (2014). making the most of orientation: transitioning new medical students and managing the risks associated with traditional orientation approaches. workshop presented at the 2014 journal of regional medical campuses, vol. 1, issue 3 original report canadian conference on medical education, ottawa, canada. also published in: medical education, 48 (s1), may 2014. [available online at: https://www.proreg.ca/events/ccme/archive_2014 /schedule_abs.php?id=98451 ]. cooper, g., inayatulla, s., patrick, l. & sbrocca, n. (2015, december). fostering ipe at a regional medical campus: how necessity was our mother of invention. (accepted for presentation at the group on regional medical campuses spring meeting – march 2016, washington, dc). cheifetz, c., mcowen, k. & gagne, p. (2014). regional medical campuses: a new classification system. academic medicine. 89 (8): 1140-1143. doi: 10.1097/acm.0000000000000295 dubé, t., schinke, r., strasser, r. and lightfoot, n. (2014). interviewing in situ: employing the guided walk as a dynamic form of qualitative inquiry. medical education research. 48: 1092-1100. doi: 10.1111/medu.12532 ellaway, r., cooper, g., al-idrissi, t., dubé, t. and graves, l. (2014). discourses of student orientation to medical education programs. medical education online, 19: 23714 [online at: http://www.med-edonline.net/index.php/meo/article/view/23714]. doi: 10.3402/meo.v19.23714 grigsby, rk., aber, rc. & quillen, da. (2009). commentary: interim leadership of academic departments at u.s. medical schools. academic medicine. 84(10): 1328-9. doi: 10.1097/acm.0b013e3181b6b1bb levett-jones, t., lathlean, j., maguire, j. & mcmillan, m. (2007). belongingness: a critique of the concept and implication for nursing education. nurse education today. 2007;27(3):210–18. doi: 10.1016/j.nedt.2006.05.001. doi: https://doi.org/10.24926/jrmc.v1i3.1270 luthans, k., lebsack, s. and lebsack r. (2008). positivity in healthcare: relation of optimism to performance. journal of health organization and management. 22 (2): 178-188. doi: 10.1108/14777260810876330 mcowen, k. (2017). regional medical campus survey data. presented at the group on regional medical campuses spring meeting, orlando, fl. ramsay, p., coombs, j., hunt, d., marshall, s. and wenrich, m. (2001). from concept to culture: the wwami program at the university of washington school of medicine. academic medicine. 76 (8): 765-775. rayburn, w., grigsby, k. and brubaker, l. (2016). the strategic value of succession planning for department chairs. academic medicine. 91 (4): 465-468. doi: 10.1097/acm.0000000000000990 rotenstein, l., ramos, m. torre, m., segal, b., peluso, m., guille, c., sen, s. and mata, d. (2016). prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. jama. 316(21):2214-36. doi: 10.1001/jama.2016.17324 microsoft word jrmc_4554.docx geneviève maltais lapointe ma, research analyst, institutional data & analysis, brandon university, lapointeg@brandonu.ca kim lemky phd, school of business and leadership, aurora college, klemky@auroracollege.nt.ca pierre gagne md, msc, frcp(c) founding regional dean, campus de l’université de montréal en mauricie, québec. pe.gagne@gmail.com jill konkin md, professor, family medicine, faculty of medicine & dentistry, university of alberta, edmonton ab dkonkin@ualberta.ca karl stobbe md, clinical professor, department of family medicine, michael g. degroote school of medicine, mcmaster university, saint catharines, ontario stobbek@mcmaster.ca gervan fearon phd, president, george brown college, toronto, ontario gervan.fearon@georgebrown.ca corresponding author: kim lemky phd, school of business and leadership, aurora college, bag 9700, 5004-54th street, yellowknife, nt, x1a 2r3 klemky@auroracollege.nt.ca cell number : 204-441-0032 fax : unavailable all work in jrmc is licensed under cc by-nc volume 6, issue 1 (2023) journal of regional medical campuses original reports a step-by-step process for assessing the economic impact of regional medical campuses in canada geneviève maltais lapointe ma; kim lemky phd; pierre gagne md; jill konkin md; karl stobbe md; gervan fearon phd abstract background: regional medical campuses create positive economic impacts in rural communities and small cities. they increase educational capacity, medical services, and address the shortage or maldistribution of physicians in these areas. our paper answers the question: how do you assess the economic impact of a regional medical campus? methods: the canadian input-output model and the simplified american council on education model are adapted to assess the economic impact of an individual regional medical campus using a step-by-step process. the models are tested using data from three canadian medical schools and their regional campuses. results: a comparison of the two models found similarities with data requirements. however, the canadian inputoutput model calculations use north american industry classification system multipliers thus calculations are more complex. the outputs in this model result in a single number for each economic category. the simplified american council on education model, in contrast, applies a single multiplier of 1.5 to all categories, which results in a single number output for each category and a cumulative total of all impacts by summing outputs. conclusion: both models successfully assess economic impacts of regional medical campuses. the step-by-step process allows administrators and others to understand the limitations of each model, but also facilitates an inhouse economic assessment. the authors provide guidance on choosing the best model. introduction regional medical campuses (rmcs), i.e., instructional sites that are distinct from the central/administrative campus, are areas of growth in medical education in canada and elsewhere.1-3 a call to action by the american association of medical colleges (aamc) in 2006 led to a recognition that strategies are needed to address the maldistribution of physicians.1 the benefits of rmcs include reducing physician shortages outside of large urban centres, and strengthening medical facilities in underserved areas.1 rmcs also diversify student training to meet the needs of diverse cultures, communities, and locales.4-6 rmcs help to meet social accountability mandates and expand the teaching capacity of medical schools; furthermore, these new medical education opportunities create positive economic impacts in the regions where they are located.1, 4 doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports canada responded to pressures to increase the number of physicians practicing in rural areas and to diversify medical education beyond large urban centres by increasing medical educational capacity. these strategies include increasing the number of rmcs, but also developing opportunities for training medical students outside of major urban areas. enrollment into canadian rmcs on specific campuses increased substantially, from 152 students in 20051 to 1700 in 2020.2 opportunities are also available to hundreds of students at dozens of locations that support approximately a year of longitudinal integrated clerkships (lic).3 currently, all medical students in canada train off the main campus at some point during their training.4 these rmcs may fall into four different models: basic science, clinical, longitudinal, or combined.1 some medical schools increased class sizes at main campuses and other medical schools created new rmcs.1-3 areas of concern identified by the group on regional medical campuses (grmc) (a working group that is part of the aamc) include: a) pedagogical success, b) quality of medical practice, c) health care access and d) local economic development.5 measuring the impact of rmcs improves our understanding of how to increase their positive outcomes through education and as economic drivers.5, 7 a literature review identified four major themes focused on rmcs: workforce, social accountability, rural medical education, and rural versus urban settings.1 there is a gap in research on financial and local economic impact of rmcs or distributed medical education.8 economic impact measurement and analysis of regional medical campuses provides information required for decision-making for government, educational, and regional partners. this data helps to support the securing of needed investment and increases to operating budgets.8 as well, economic information accounts for the spillover benefits extending beyond students graduating from the program. rmcs have significant public and community health benefits and regional development benefits, beyond any monetary amount tabulated in this paper.1,2,4-8 these benefits warrant further study, and the authors recognize that the economic impact analysis shared in this paper only partially captures the benefits, but is still essential in assuring the development and perpetuity of rmcs. the purpose of this paper is to explain and demonstrate, using data from several medical schools, the application of two methodologies to assess the economic impacts of rmcs. the authors’ previous review of models used for measuring and assessing economic impacts of rmcs8 formed the basis of the choice of these two models. in that study, given the availability of data, the models determined most suitable to assess rmcs are the canadian inputoutput (i-o) model and the simplified american council on education (ace) model (two input-output models). the information included here provides a guide for rmc program administrators and others to choose a model to assess their economic impact. the data used to test the two models came from three canadian rmcs, covering a range of programs from an individual campus to a longitudinal clerkship. literature review few publications exist that measure the economic impact of rmcs for the canadian context. the canadian studies found in the literature include a canada-wide study measuring the economic impact of medical education and health science partners,9 another specific to the northern ontario school of medicine and its rmcs10 and an unpublished document regarding healthcare in a rural manitoba region.11 this paper builds on the authors’ previous publication and recommends creating an accessible and reliable method to measure the economic impact of distributed medical education through the rmc to provide information for regional and rural community development, policy development, and return on investment.8 these new rmcs not only increase capacity to existing medical programs, but also generate economic benefits in smaller centres and can help boost small community economies. measuring the impact of rmcs is complex. surveys of key community leaders, the business community, and university managers provide insight into social, health, and other qualitative impacts.10-11 economic impact surveys collect quantitative data on spending by students, faculty, staff, and visitors; however, it may be difficult to find an adequate sample of participants who also keep meticulous records of all doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports aspects of spending over the years of study. other spending data collected on graduates captures the impact of former students who remain in the region after graduation. in this paper, we assess the two main models used by post-secondary institutions to measure economic impact, adjusted for a single program. the model data includes estimates of spending by students and visitors found on websites, and institutional financial records.8 the facilities used for training in rmcs range from a full regional medical campus with fit-for-purpose buildings in a mid-size city to a single clinic in a small community (longitudinal integrated clerkships).1 programs may include classroom teaching and video conferencing from the main campus. students complete their medical training for their undergraduate degree at a regional medical campus, or take a portion (i.e., eight weeks to a full year) of their training at a facility distant from the main campus at a clinic, hospital, or public health unit in a rural community. given the challenges of measuring economic impacts of diverse programs, researchers instead focused on key economic impact variables common to each program: students, visitors, and institutional spending; alumni and potential research impact. economic assessments of rmcs need to focus on their location, i.e., small and mid-size cities, community-based, and rural programs.1 this requires a range of data to evaluate, understand, and be useful in decision-making. economic information provides valuable input into continuity and the impact of a change to these programs. choosing an economic model to assess rmc one of the challenges to assessing the economic impact of rmcs is the diversity of programs, e.g., longitudinal integrated clerkships, shorter rural medicine placements, and complete regional medical campuses.1 the canadian medical education journal published an evaluation of models with the potential to assess the economic impacts of rmcs.8 the study found that universities apply either the simplified ace model or the canadian i-o model to assess universitywide impacts in canada.8 the economic impact reports provide specific information on university impacts, but they do not provide detailed information on how to gather data (and challenges to finding it), economic impact calculations, or the importance of using these calculations (outputs) in decision-making.8 furthermore, none of the studies applied the two models specifically to an rmc, an individual smallscale program, or a subset of their university programming. additionally, the recent expansion of rmcs in canada limits the scope for statistical techniques involving econometric (regression) analysis. the basis for the inclusion of these two models to assess rmcs in canada are: a) their use in determining university-wide impacts, b) their use of critical economic variables needed to evaluate a university’s impact (institutional spending, student spending, and visitor spending) for the canadian i-o model and additionally alumni and research impact for the simplified ace model, c) their replicability, d) the likely availability of data (either in-house or easily accessible from a reliable third party, e.g., statistics canada) to run the models and, e) the variety of outputs or results produced by the models, providing a broad range of information for stakeholders to include in their evaluations or decision-making processes.8 model overviews input-output models use regionand industryspecific multipliers to estimate how much of an initial investment (i.e., the direct effect) is re-spent by its suppliers across different industries (i.e., indirect effect) and by employees of the firm and its suppliers (i.e., induced effect). “the canadian i-o model was developed to determine the economic impact of an initial investment (or adjustment) in the economy of a predefined area by tracking how the investment recirculates within the economic area depending on the interdependencies of a region’s industries.”12 the total economic impact of the investment on the local economic area comprises the sum of the direct, indirect, and induced effect.12 the multipliers provide a measure of the interdependence between an industry and the rest of the economy (table 1). doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports table 1: terminology for the economic impact economic term definition direct economic effect initial investment and spending indirect economic dollars that are re-spent by supplier induced economic effect dollars that are re-spent by the employees and the organization multiplier a value estimated as the impact above the actual spending, the ace model uses 1.5,13 provincial or national multipliers are ~2 indicating that the impacts are greater at the larger spatial scale9 leakage spending outside the region that cannot be counted as an economic impact locally, smaller communities have greater leakages than large spatial areas e.g., province or country10,14 data required to apply the canadian i-o model includes institutional spending, student spending based on enrollment, and an estimate of visitor numbers and their corresponding spending. the size of the industry multiplier allocated to a specific spending category depends on the change to the economy attributed to it. this enables a calculation of the overall impact of a university or university program. outputs are a result of a calculation that includes the impact of that industry on gross output, gross domestic product (gdp) basic price, labour income, job creation, and indirect taxes. studies using multipliers based on industry standards and averages are comparable within the same industry sector or with other sectors. typically, measurements span a one-year time frame and thus use annual data.12 the simplified ace model requires the same raw data as a canadian i-o model, but includes both alumni and research impacts. instead of using a specific computed multiplier based on its impact on the industry sector for each category of spending, a single multiplier, in this case 1.5, is multiplied to each spending category. thus, to calculate outputs, each of the sums of the five different spending categories, e.g., institutional, student, visitor, alumni, and research impacts, is multiplied by a single multiplier to measure the total economic impact on a community.13 other researchers assess research impact separately, but alternatives to measure this at a small scale are limited, thus the authors apply a 1.5 multiplier to research impact. several research groups note that the multiplier should decrease as the size of the city decreases to account for larger leakages in smaller communities. smaller communities offer less retail and services, thus it is necessary to purchase items in larger population centres.9,14 multipliers should generally remain less than two unless applied at a state or provincial level.9 incorporation of data into decisionmaking is by separate outputs for each category of spending. summing the five separate outputs for a single cumulative number representing the impact of the whole rmc is also an alternative. cumulative assessment of the economic impacts of rmcs nationally is possible with this model. overview of variables the two models use economic variables that provide the most complete economic assessment of the rmc program: student spending, visitor spending, institutional spending; and for the simplified ace model, additionally, alumni practicing in the region and research output. using a representative set of variables at a point in time is essential to assess the most comprehensive and accurate economic impact of rmc. it is also challenging due to the following: a. the variety of rmcs, b. the array of (governmental, for-profit, and not-for-profit) organizations and individuals who contribute to and/or benefit from an rmc program which render the gathering of institutional spending more complex, c. the potential lack of data (e.g., financial, logistical, programmatic) that outlines specific allocation of funds to the rmc due to the interconnection of budgets with the main medical campus, and d. the models currently rely on provincial and national multipliers and focus on a university as a whole; thus, for smaller centres, economic impacts of local, regional, and portions of institutions requires the use of estimates by researchers. doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports student, visitor, and institutional spending are variable through time because the development and operation of an rmc is ongoing and non-linear. figure 1 conceptualizes six stages of rmc development. these stages may overlap: stage 1: creation of the rmc via an initial proposal, partnership, and/or funding, capital cost; stage 2: construction of necessary infrastructure, e.g., classrooms, labs; purchasing supplies; and recruitment and hiring faculty/staff; stage 3: implementation of training; this is the start of the first cohort of students for each year (pre-med to year 3 or 4). training costs associated with each year of medical school differ; stage 4: this stage recognizes the growth and evolution of the program to full capacity (all cohorts) and ongoing maintenance of the program and infrastructure; stage 5: alumni the first cohort enters into residency. a sound teaching environment for medical students implies being in touch with residents. this can be done locally through one or many family medicine training units (fmtu) created in conjunction with the rmc or be part of mandatory or optional clerkship in residency training program for the main campus taking part locally at the rmc. for example, general surgery residents belonging to the main campus program can be sent to spend three months training at the rmc as part of their educational pathway during their five years training. ultimately, those residents can become part of the workforce as practicing licensed physicians, as exposure to the reality of the rmc increases the likelihood of attraction and retention (alumni impacts); this likelihood is even stronger for the fmtu, as time spent by the residents is maximal. administration of this post-graduate program requires an increase in infrastructure and an added layer of instructors, leaders, and administrators; and stage 6: creation of a post-graduate or residency program increases the attraction of a newly created environment. the appeal of a newly created dynamic and promising academic environment can increase the capacity of attraction of newly graduated family medicine and specialists of a region long before rmc students graduate from their rmc academic program. maturity of an rmc occurs once residents graduate and settle in the community and/or become faculty. administration of this post-graduate program requires an increase in infrastructure and an added layer of instructors, leaders, and administrators. researchers recommend measuring economic impact during maximum undergraduate enrollment (i.e., include all student cohorts of the medical program). measurements at earlier phases in the development process result in wide variations because of capital costs (i.e., infrastructure development varies from renovating an operating room to constructing an entire medical school). a measurement at the inception of the program would only include a partial measurement of the student body, staff, and faculty. measuring when all student cohorts are present results in the assessment of the whole program. the economic impact is calculated for a single year for both models. doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports figure 1: stages of development of a rmc program and the variables included in the two economic impact model method the methods section comprises a review of the data required for the models, calculations, and subsequent output. tables included below provide readers with examples of the data analysis. data collection requires collaboration with the institution and the rmc coordinator to ensure the collection of the appropriate detail of data. additional data from an independent third party may be required to complete data collection of yearly spending (e.g., a student or graduate website). the following sections describe how to a) obtain the data for each of the five variables, b) estimate annual spending and c) assess the economic impact using both models at each geographic level (provincial and regional). a table following each section provides a summary of the data required and how to format it. the model requires all data from a single year. for example, operating expenditures for the 2015-16 fiscal year requires student enrollment numbers for the 2015-16 academic year. undergraduate student and resident spending data collection information and data required to assess learner spending: 1) number of undergraduate (students) and postgraduate learners (residents) enrolled in the rmc; 2) the duration of the study period (in months) for each year of the program; 3) average monthly spending for learners; and 4) yearly salary earned by residents. the rmc administration (or an equivalent administrative body) stores information on both the number of learners enrolled in the program and duration of the study period in the region for each year. it also gathers information on the number of residents in the program per year. doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports resident numbers include full-time equivalent (fte), or estimates of residency placement length. the average monthly student expense estimate uses the information found on provincial student loan program websites, the institution’s website and/or the student union website (table 2). table 2: average monthly spending for an undergraduate student in the waterloo region15 spending category monthly spending housing $485.00 utilities $75.00 food $350.00 cell phone & high-speed internet $150.00 transportation $400.00 entertainment $250.00 retail and miscellaneous $150.00 total average monthly spending $1,860.00 residents likewise would potentially have similar spending patterns, albeit they have salaries. the professional association of residents of ontario (paro) website lists salaries for residents.16 resident salary data is also available nationally on the canadian resident match service caarms organization.17 the salary depends on the year of residency and program. spending calculation the total number of undergraduate students multiplied by the number of months spent in the region and the average monthly expenses for each spending category provides an estimate of the yearly student and resident spending (table 3). the model assumes that all learners are renting instead of living at home. multiplying the fte for each year of residency with the appropriate salary provides an estimate of resident spending. simplified ace model output using the simplified ace model, the sum of spending in each category is multiplied by 1.5.13 this calculation repeats for each spending category. the data required for the calculations includes institution, student, and visitor spending (as with the canadian io model), as well as alumni impact and research impact. all data is multiplied using the multiplier of 1.5. the number of alumni practicing in the rmc region comprises two categories: general practitioner and specialist. many rmc administrators keep track of where their alumni practice. however, crossreferencing the list of all graduates with a physician directory is an alternative method to finding the location of alumni.18 further, the alumni may leave the region and return after completing their residency or, if the opportunity is available at the rmc, complete their residency locally. other residents from the main campus may complete part of their residency at the rmc and stay after completion. the national physician database and national health expenditure database by the canadian institute for health information contain payment data per physician, by specialty, and by province or territory.18 the authors recommend applying the same multiplier of 1.5 to research dollars procured at the institution each year as per the simplified ace model. a commonly used method applied to larger institutions tends to exaggerate impact for small institutions.19 this simple multiplier accounts for the hiring of graduate students and the purchase of software and equipment as a conservative method to estimate research impact. canadian i-o model output the canadian i-o model links each spending category to the most appropriate statistics canada industrydefined multiplier (table 3) to assess the impact. the doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports multipliers comprise three broad categories: business, government, and non-profit institutions serving the household sector. the north american industry classification system (naics) forms the basis of the disaggregation of the business sector multipliers by industry and the government sector multipliers by function.20,21 application of the lowest possible aggregation level avoids overestimating the economic impact of the spending categories. table 3: classification of student spending by statistics canada industry-specific multipliers for ontario20,21 spending category i-o multipliers ontario coefficient code title gross output direct & indirect housing (rent) bs531100 lessors (landlord) of real estate 1.4135434802 utilities bs220 utilities 1.3275880175 food bs445000 food and beverage stores 1.4319196251 cell phone & high-speed internet bs517000 telecommunications 1.4224332046 transportation – gas bs447000 gasoline stations 1.4008403673 transportation – car maintenance bs811100 automotive repair and maintenance 1.4432209024 entertainment bs719 arts, entertainment, and recreation 1.5246111266 retail and miscellaneous bs453000 miscellaneous store retailers 1.5136241074 resident spending gs622000 hospitals 1.3800731490 to capture the socio-economic effect of additional medical staff (even if training) within the region, researchers linked the gs622000 hospitals multiplier with resident spending. for each spending category, there are 12 different coefficients, four categories of coefficients (e.g., gross output, gdp basic price, labour income, and jobs), and three types of impact in each category (i.e., direct; direct and indirect; direct, indirect, and induced). adding together the taxes on products and taxes on production for each industrydefined multiplier results in a calculation of indirect taxes. the authors calculated the multiplier for each impact category (gross output, gdp basic price, labour income, jobs) and output type (direct; direct and indirect; direct, indirect, and induced) to yearly spending categories. the calculation resulted in twelve different components of the provincial economic impact. scaling down the effect of the provincial multipliers simulates a regional impact.15 the labour force survey (lfs) formed the basis of the estimation of a region’s labour force.21 the regional share of employment by industry calculation employed table 282-0125, available through the canadian socioeconomic information management system (cansim). this estimated the percentage of the provincial economic impact attributed to the region.22 for example, in 2015, 27,900 people worked in the industry classified as code 22 – utilities in the province of québec and 1700 in the region of mauricie, pq. thus, the mauricie region’s share of employment for the utilities industry is 6.1%. therefore, calculating the regional economic impact requires multiplying the provincial economic impact by the share of employment for each industry, e.g., 0.061 for utilities. visitor spending data collection visitor spending is determined using four variables: 1) an estimate of the number of casual visitors each learner attracts to the region; 2) an estimate of the number of days and/or nights each visitor spends in the region; 3) the average spending per day and/or night per visitor; and 4) the distribution of visitors spending across categories. doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports researchers base these numbers on the literature for similar locations and/or verified the information by consulting rmc administrations. the number of visitors per learner ranges from 2-11 per student. some tourism departments (e.g., ontario, manitoba) publish regional statistics on visitor numbers and spending. these statistics may also include visitor type and purpose of travel. statistics canada travel survey of residents of canada (tsrc),23 provides equivalent information for other provinces and measures the size and state of canada’s tourism industry. spending calculations multiplying the estimated number of visitors per learner by the total learner enrollment determines the total number of casual visitors to the region generated by the presence of the rmc. multiplying the total number of visitors by the number of days spent in the region and the average spending per day results in the total spending in the region. finally, the distribution of spending by category includes the total spending by expenditure type of all visitors in the region or province (table 4). table 4: rmc visitors spending by expenditure type* itemized visitor spending in region total spending for all visitors to the region* distribution of spending breakdown of total rmc visitor spending public transport $1,163,000 0.5% $129 vehicle rental $4,120,000 1.7% $457 vehicle operations $48,119,000 20.3% $5,338 local transport accommodation $3,721,000 $44,369,000 1.6% 18.7% $413 $4,922 food & beverage $91,193,000 38.4% $10,117 recreation/entertainment $13,500,000 5.7% $1,498 retail/other $31,353,000 13.2% $3,478 total visitor spending $193,169,000 100% $26,352 total rmc visitor spending $26,352 *the rmc location is anonymous; however, the numbers are factual the canadian i-o model links each visitor spending category to the most appropriate statistics canada industry-defined multiplier (table 5). the provincial and regional economic impact calculations use the same methodology as for student spending. the provincial economic impact uses the statistics canada multiplier. scaling down of this multiplier by share of employment results in the regional economic impact. table 5: classification of visitor spending by statistics canada industry-specific multipliers spending category i-o multipliers code title public transport bs48a000 other transit and ground passenger transportation and scenic and sightseeing transportation vehicle rental bs532100 automotive equipment rental and leasing vehicle operations bs447000 gasoline stations local transport bs485300 taxi and limousine service accommodation bs721100 traveller accommodation food & beverage bs720000 food services and drinking places recreation/entertainment bs719 arts, entertainment, and recreation retail and miscellaneous bs453000 miscellaneous store retailers doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports institutional spending data collection institutional spending includes operating and capital expenses of the rmc at a specific point in time, using year-end financial data provided by the university finance department. all expenses, regardless of who incurred or paid for them, are included. for example, the hospital where learners complete their residency might encounter costs directly related to the program. the capital expenses that occur during the creation stage of the program are not included to avoid inflating the annual economic impact. building costs are one-off expenses, versus the other variables that provide yearly impact. operating expenditures include but are not limited to: salaries (academic), salaries (staff), benefits, travel, supplies and consumable expenses, major renovations, rent/utilities, internet, property taxes, preceptor payment, and scholarship and bursaries. capital expenditures include research equipment, library book acquisitions, capital equipment expenditures, and other capital fund accounts. spending calculation calculating the operating expenditure and capital expenditure separately allows a nuanced interpretation of the result. the sum of institutional spending represents the total dollar amount spent in the province. the percent of provincial spending that remains in the region provides the regional spending estimate. discussions with the finance department or other individuals in the rmc with appropriate knowledge determines the different spending categories and the regional percentage. categorizing university vendors by their geographical location provides the percentages of spending locally, regionally, and provincially. the final numbers result from prorating the initial spending based on the percentage spent in the region and summed to calculate the total regional spending (table 6). table 6: example of prorated spending categories total % spent in region $ spending in region salaries (academic) $ 1,262,000 90% $ 1,136,000 salaries (support) $ 690,000 90% $ 621,000 benefits $ 386,000 0% $ 0 travel $ 70,000 25% $ 17,000 supplies and consumable expenses $ 212,000 80% $ 169,000 rent/utilities $ 161,000 100% $ 161,000 preceptor payments $ 382,000 80% $ 305,000 total $ 3,165,000 $ 2,412,000 % of total expenditure in the region 76.2% the provincial economic impact of institutional spending (operating and capital) uses gs611300 university multiplier. the regional impact calculations require dividing the sum of regional operating or capital expenditures by the sum of provincial operating or capital expenditures. this calculation determines the percentage of total provincial expenditures in the region. the provincial impact requires scaling down the impact by multiplying by the percentage of expenditures in the region. results the following five tables illustrate the calculations using data from a single rmc for both the simplified ace model and the canadian i-o model. the authors use the same variables at the rmc level as used when applying these models at a university level to assess yearly economic impact. simplified ace model the simplified ace model assesses a cumulative impact in each area of impact, e.g., institutional, students, visitors, alumni, and research. a second option using this model is to sum these numbers to doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports obtain an overall cumulative impact i.e., a single value (tables 7 and 8). given that most of the spending takes place at the regional level, except for university operations, the provincial impact is about the same as the regional impact using this method. table 7: simplified ace model economic impact output at the regional level* spending in the region multiplier total impact in region undergraduate students $1,375,136 1.5 $2,062,704 residents $1,453,166 1.5 $2,179,749 out-of-town visitors $26,352 1.5 $39,528 university operations $2,601,758 1.5 $3,902,637 capital expenditure $22,410 1.5 $33,615 practicing graduate $10,953,366 1.5 $16,430,049 research impact 1.5 $0 total impact $16,432,188 $24,648,282 * to ensure anonymity of the rmc, its location is anonymous; the numbers are factual table 8: simplified ace model economic impact output at provincial level* spending in the province multiplier total impact in the province undergraduate students $1,375,136 1.5 $2,062,704 residents $1,453,166 1.5 $2,179,749 out-of-town visitors $26,352 1.5 $39,528 university operations $3,427,288 1.5 $5,140,932 capital expenditure $22,410 1.5 $33,615 practicing graduate $10,953,366 1.5 $16,430,049 research impact 1.5 $0 total impact $17,257,718 $25,886,577 * to ensure anonymity of the rmc, its location is anonymous; the numbers are factual. canadian i-o model the output for the canadian i-o model, in contrast to the simplified ace, results in a single number for each economic category (these cannot be summed). it is also possible to calculate impact by geographical region by estimating the regional impact (table 9) and the provincial impact (table 10). these calculations result in a more conservative economic impact; however, calculating impact over a variety of economic indicators may be more useful to decisionmakers. for example, the model calculates the number of jobs created by the rmc and taxation information. table 9: canadian i-o model output at the regional level* initial spending $2,828,302 $26,352 $2,601,758 $22,410 $5,478,822 direct, indirect & induced impact learner spending visitor spending university operations capital expenditure impact in region total gross output $507,615 $5,094 $3,983,696 $34,313 $4,530,718 total gdp basic price $305,227 $2,872 $2,888,509 $24,880 $3,221,488 doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports total labour income $195,887 $1,623 $1,688,578 $14,544 $1,900,632 total jobs 4 0 26 0 30 total indirect taxes $28,795 $241 $129,993 $1,120 $160,148 *to ensure anonymity of the rmc, its location is anonymous; the numbers are factual. table 10: canadian i-o model output at the provincial level* initial spending $2,828,302 $26,352 $2,601,758 $22,410 $5,478,822 direct, indirect & induced impact learner spending visitors spending university operations capital expenditure impact in province total gross output $4,973,185 $48,049 $5,247,711 $34,313 $10,303,259 total gdp basic price $2,986,961 $25,507 $3,805,025 $24,880 $6,842,372 total labour income $1,859,859 $15,082 $2,224,358 $14,544 $4,113,844 total jobs 37 1 35 0 72 total indirect taxes $293,944 $1,926 $171,239 $1,120 $468,229 *to ensure anonymity of the rmc, its location is anonymous; the numbers are factual. the model also calculates the personal income tax generated through the labour income (table 11) by multiplying by the ratio of personal income tax for the province and the dollar amount of compensation of employees. the table 384-0040 “current account – households, provincial and territorial, annual available” through the canadian socio-economic information management system (cansim)” contains multiplier data.21 table 11: personal income tax generated by the additional labour income created* total labour income ratio personal income tax ontario $4,113,844 22.8% $937,956 *to ensure anonymity of the rmc, its location is anonymous; the numbers are factual. discussion although many rmcs have very complicated funding formulas, adapting models that dozens of universities use to assess economic impact (and thus a familiar context), should assist both main campus and rmcs to document spending in a manner that will facilitate applying these models in the future. the models could be applied prior to establishing an rmc by using estimates of rmcs that are going to be emulated, or these models can be applied post construction. further, developing a model to measure spending and calculating economic impact for the region served by rmcs is potentially a less time-consuming and less costly option for rmc administrations than a survey of educators, students, visitors, and graduates.15 it provides a much simpler model requiring input from fewer information sources (e.g., the university, tourism associations, and statistics canada). however, bringing awareness to administrators of these data needs for evaluating an rmc’s economic impact prior to developing new rmcs facilitates data collection. administrators could more easily set up excel worksheets to ensure that spending categories are recognized at the onset of the program. it would also be possible to verify these spending estimates by conducting surveys for each group of spenders to verify spending. this type of research requires ethics review and random sampling of a group of spenders, and it may be difficult to ensure the anonymity of the participants. it also depends on the goodwill of participants to record or share private information. doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports the economic impact calculations for rmcs include two models and three steps: a) data collection, b) spending calculations, and c) analysis of outputs. data collection the data inputs are similar for both models. however, obtaining the data required for an analysis may be a challenge. awareness of the data needs, the format required, and the fiscal year will reduce the data gathering time. upon completion of the first economic impact calculations, subsequent data collection will be easier, which will facilitate year-overyear comparisons of impact. institutional spending: university financial departments record rmc and the main campus medical program expenses separately; they typically supply a detailed breakdown of financial data for a specific fiscal year. however, it is possible that the rmc financials are quite closely intertwined with main campus financial data, and it may be difficult to separate out the rmc expenses. it may not be possible to attribute costs solely to the rmc or solely to the parent university. as an example: 1. main campuses video conference most preclinical courses to the rmc site. as a result, the full cost of these courses is difficult to separate between the main campus (physical classroom and instructor) and the rmc (physical classroom at rmc, video conference and it equipment) or smaller sites for the lic. in these cases, the budget for the course may be recorded under that of the main campus; 2. employees may hold joint positions administratively, therefore allocation of a portion of the salary to the rmc depends on the percentage of their duties needed for the remote campus. potential multiple and changing roles with the development of these programs may complicate this allocation of resources. many partnerships and funding formulas finance the rmcs, e.g., other organizations and levels of government, and a wide variety of programs under the umbrella of rmc, ranging from a clinic not administered under the university umbrella at the university of alberta, to an entire campus (e.g., l’université de montréal en mauricie in trois rivières, pq). consequently, institutions need to record all the spending precisely (table 12). researchers recognize the complexity of gathering comprehensive financial data. ideally, all expenses should be included in the analysis, regardless of who incurred or paid the expense, and partnerships need acknowledgement. for example, the province may pay the preceptors directly, and the university will not have a record of the dollar amount within their financial statement. if financial statements of partner organizations are available, this will improve the accuracy of economic impact calculations. table 12: operating expenditures-extract from economic impact of univ. de montréal en mauricie paid by categories udem salaries (academic) udem salaries (support) ciusss salaries ciusss travel cost udem supplies and consumable expenses ciusss rent/utilities udem internet ramq clerkship/preceptor payments … etc. … etc. udem : université de montréal ciusss : centre intégré universitaire de santé et de services sociaux ramq : régie de l’assurance maladie du québec24 doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports the rmc administration reviews and verifies numbers as data collection nears completion. they verify that data are accurate and representative of spending. gathering all the necessary financial data and the level of detail to have a meaningful economic assessment requires the commitment of the university as a whole. gathering data in a reasonable time period is facilitated by the support of university executives. if the data are incomplete, it may be necessary to either estimate the data or leave the data out. an alternative option would be to examine other rmcs of similar size and location where data are more easily obtainable and estimate their impacts. if data is inadequate to complete an economic assessment, the worksheet will help the rmc identify data gaps early in the study. student enrollment: institutional spending uses a fiscal year for recording and reporting financial information. student enrollment, in contrast reports for an academic year that spans across two different fiscal years. determining the numbers of students and the number of months they study in the region is a way to match the financial data. however, this is complicated, and most of the time not feasible. if student spending represents a whole year of data, even if the end and start date do not coincide with the fiscal year, it is still representative of the economic impact of students for one year of the program. spending calculation as data are not always available from the same source, collection of multiple categories of data occurs simultaneously. verification of spending occurs by postal code or company names to determine its geographic location. the percentage of spending broken down by geographic location might require proportional scaling, for example what percentage of the spending occurs in the local region, in the province, and outside of the province (or nationally). this step is essential to allocate economic impact of the rmc to the region versus spending outside the region. average monthly spending for undergraduate students at many institutions is available online. however, the average monthly spending may not be available for new rmc students located in smaller cities and rural areas. spending based on the averages for the main medical campus may result in an overestimate or an underestimate. the rmc administrator could verify, with students, that estimates are reasonable. output due to the nature of the data available through the cansim tables, interpreting data requires consideration of two factors. first, the calculation for share of employment is at a higher aggregate level than most of the spending categories, i.e., resident spending utilizes the hospital [62-2] multiplier. however, the share of employment uses the health care and social assistance [62] industry which encompasses four other industries: ambulatory health care services [62-1], hospitals [62-2], nursing and residential care facilities [62-3] and social assistance [62-4].18 the region used to assess the share of employment may encompass a larger area than is ideal for the rmc’s economic impact because of grouping small regions with neighbouring regions with similar economic characteristics. these two factors will tend to overestimate the regional impact. each model calculates a unique output. the simplified ace using only one multiplier is much easier to calculate; however, the results provide limited overall economic data for each category. a single number output enables universities to make sweeping statements about the impact of their program. the size of the multiplier, e.g., 1.5, is not adjusted to the size of the region. however, its simplicity results in frequent application to university settings. further to this, repetition of calculations yearly is unnecessary unless there is a major change in institutional spending, student or visitor numbers, alumni, or research. the multiplier remains the same for all elements of the model. a benefit is the overall summative number; a decision-maker can state that a particular rmc impacts the local economy by eight to nine million dollars per year. it does not account for leakages out of the economy; for example, the northern ontario school of medicine researchers state that since leakages are greater in smaller cities, they require smaller multipliers. using a standard multiplier of 1.5 on a region of 100,000 people may exaggerate the economic impact.9 doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports the canadian i-o model, in contrast, uses multipliers built on industry averages. multipliers exist only at the provincial or national level; they do not exist at the regional level. thus, to diminish the overestimation of economic impact in a smaller region, the researchers adjusted the provincial impact to the population size. this information is valuable to local decision-makers; it includes not only the impact on total gross output, gdp basic price, and on labour income, jobs created, and potential indirect taxes, but also impacts calculated by the data category and by different economic parameters. these numbers are not cumulative; however, they provide decision-makers with valuable information in each of these broad categories. a further benefit of this output is its comparability to other industries that use the statistics canada i-o multipliers. both models provide practitioners with information for decision-making. individual application provides results for different variables. calculations for both models provide a broader understanding of the potential economic impacts of rmcs. a limitation of both models is that they each measure for a specified academic year. if significant changes occur to a program, the economic assessment for that year requires updating. statistics canada updates its multipliers every four years to current economic conditions (linked to naics); the simplified ace model, in contrast, consistently uses the same multiplier regardless of the year. economic information resulting from this analysis is invaluable in the decision-making process for several reasons. it provides (1) a benchmark of current economic impacts of an rmc by collating student, visitor, and institutional spending into economic models, and (2) a quantitative analysis of an rmc, which includes additional information to qualitative data that may already exist. these data are comparable to other industry sectors, providing decision-makers with an understanding of investment in medical education versus other sectors of the economy. different stakeholders have an interest in completing these analyses and incorporating the resulting data. they include the rmc administrators, the main medical campus administrators, government officials, city and community decision-makers, not for profit groups, and philanthropists or other funders. medical schools use these data when they approach funders, e.g., government and philanthropists. substantial investment occurs in these programs. it is therefore of the utmost importance for faculties of medicine and their affiliated healthcare facilities to be socially accountable toward the populations they serve. governments face tough investment decisions, and evidence-based data are needed to make the best choices. creation of the l’université de montréal en mauricie rmc occurred in 14 months; it was urgently needed to increase the number of physicians in the region,25 thus addressed a critical need for more practicing physicians. this rmc faced significant challenges in receiving the necessary financial support even though it was addressing the population’s needs. one of the issues was identifying which ministry in government held the responsibility to finance this rmc, health or education. alternatively, a third party, e.g., a different ministry with special funds to promote economic diversification from the traditional dying industries such as paper mills in regions like the mauricie, could have subsidized the creation of the regional medical campus if an economic study showed some clear economic impact to the region. as the rmcs become established, there is an expectation that research will increase. a survey study identified the importance of establishing research agendas at the rmc planning phase to ensure resources and funding needs are identified and that research is incorporated into the rmc mandate.6 the medical faculty at rmcs are uniquely situated to study rural regional issues and methods to improve primary care to the populations that they serve. more research is required into the role of researchers at the main medical campuses who collaborate with the regional medical campus faculty, and vice versa. if research dollars are procured for these research endeavours, this data can be incorporated into an economic model. although publications on rmcs’ research output are limited, a recent research project on the michael g. doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports degroote school of medicine students documents research participation amongst three cohorts of medical students.26 the researchers state that two barriers to research participation identified are students’ perceptions of both inadequate time and access to projects; however, additional limitations include inadequate education in research methodology and appraisal of scientific literature.26 despite this, survey results state that 70.4% of students do participant in some type of research project. both returning alumni from undergraduate medical programs and alumni from the main campus or residents moving to rmcs to continue their specialist training are integral to the region to address the health needs of the local population. research suggests that 50% of physicians trained in rural areas return to these areas upon graduation, for not only the quality of care, but to address the specific health challenges faced in smaller cities and rural populations.27 further, access to specialist treatment locally ensures that travel is not a limiting factor in getting access to health services. rmcs may further develop to provide essential medical graduate education in different areas of specialty. the vast richness and diversity of rmcs is a result of each being created according to different local and regional needs, challenges, and opportunities. increasing educational opportunities thus increases the attraction and retention of physicians locally. the present article broadens the scope and benefits in investing in various forms of rmcs as an economic stimulus. measuring the return on investment using an indicator such as the retention of medical professionals could also enhance community buy-in and appeal to private business investors. the models are applicable regardless of the size of the rmc, e.g., a full medical campus or an lic. a limiting factor for using the models would be getting enough data to run the models. it may be a challenge to separate spending on a clinic or operating room from overall hospital or health spending in a region. for those facilities providing a dual purpose, percentage of time using the facility for education of undergraduate or graduate medical students versus a regular treatment room may be the only way to attribute costs. if the local undergraduate or residency programs address the maldistribution of physicians locally, this is a net gain for the region. the analysis provides a mechanism for incorporating rmcs into regional economic development strategies and extending the role of the rmc beyond the traditional domain of solely rural health care provision. a multi-year approach to rmc investment and development is required to understand the full impact. the research, student, and population health benefits of rmcs are important, but beyond the scope of this economic impact analysis. the social value of rmcs is broad and represents a significant and increasing development in canadian medical education and health services provision. table 13 itemizes the benefits and limitations of each model. table 13: benefits and limitations of economic impact models i-o model (statistics canada) simplified ace model benefits standard set of industry multipliers comparable to other industries using similar model provides impacts in economic terms on job creation simple model using a set multiplier (1.5) for all categories of spending assesses longitudinal impact of education and research result is a single number for each category of spending or a cumulative number allowing for easy interpretation limitations multipliers are not estimated at the regional (local) level and need to be estimated by percentage of spending may underor overestimate the impact due to the simplistic nature of the multiplier, typically there is greater leakage of spending out of doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports underestimates the impact since it does not include alumni and research as variables results are for several different economic variables which complicates the interpretation no cumulative number that is easily understandable by decision makers smaller communities, thus multiplier should be smaller no impact provided on job creation table 14 provides a summary of impact category, data requirements and source of information for each type of category needed in the two models. table 14: summary of impact category, data requirement and source impact category data required student impact § number of full-time undergraduate students per year § duration (number of months) of each year § number of residency students per residency level § duration (number of months) residency or full-time equivalency § average spending per category § residency salary per year § share of employment by naic codes for each expenditure category (higher aggregate) visitor impact § average number of annual casual visitors § average dollar amount spent per person per visit § length of stay (number of days) per visitor § total spending by expenditure type § share of employment by naic codes for each expenditure category (higher aggregate) operations impact § spending (dollar amount) per operating category § percent of regional spending per category capital impact § spending (dollar amount) per capital category § percent of regional spending per category practicing graduate impact medical student influence on solving challenges associated with creating a new regional medical campus. § number of graduates practicing in the region by family medicine and specialist § average clinical payment conclusion the benefits of rmcs are multiple: they address the maldistribution of physicians and/or provide better medical services in smaller communities and city centres. research also demonstrates that exposure of medical learners to rural practices increase the likelihood of choosing to practice in a rural area, be it the same one or a new one, potentially impacting similar communities geographically distant from the rmc. stakeholders involved in hosting, investing, creating, or administrating rmcs for these institutions need to be able to speak more broadly to the benefits of rmcs and include quantitative economic data in their decision-making. doi: https://doi.org/10.24926/jrmc.v6i1.4554 journal of regional medical campuses, vol. 6, issue 1 original reports this paper provides both the rationale and the stepby-step process for calculating the economic impact of rmcs using two different models. it gives direction on conditions needed for applying either model. use of either model will depend on who the users of the information are. with the detailed outputs of the canadian i-o model, stakeholders can access different types of information, e.g., jobs created, impact on indirect taxes, as well as implications to gdp. further to this, it is easier to calculate impacts at various geographical scales, e.g., regional, provincial, and national. the benefit of the simplified ace model is the breakdown of impacts by spending, and the calculation of a cumulative number. decision-makers may find it easier to include this single number in decision-making rather than the detailed breakdown of the canadian i-o model. however, providing numbers, such as the increase in jobs and impact on taxes, are useful to others. these models were both tested with real rmc data. however, it is important to note that the economic benefits of any size of campus can be estimated from using estimates of spending by the university on an rmc. thus, although our research is retrospective on most of the spending, it is possible to forecast spending and thus economic impact of future rmcs. it is possible that this data combined with the needs of the underserved community will provide decisionmakers with an understanding of the impact of an rmc in the area and a solid estimate of future economic impacts. the simplified ace model is a relatively easy model to apply as it requires only the data from the university and a standardized multiplier; it provides a single usable economic impact but may overestimate the impacts in smaller communities. the canadian i-o model requires extra steps to apply but provides a richer set of information for decision-makers. the next steps for economic assessment of rmcs are to: a) build a national and/or international database from economic assessments of rmcs to be able to gain an overview of rmc economic impact nationally and internationally b) increase the use of these models while ensuring there are checks and balances in place to ensure consistent usage, and access research funds to enable collaboration amongst rmcs to conduct a more in-depth study of economic impacts involving surveys and/or discussions with local decision-makers c) conduct workshops to garner the opinions and experiences of deans of rmcs on how to improve the models and an understanding of other types of impacts d) collate the processes that resulted in the decision to increase medical education for each type of rmc across the country, and e) develop an online resource with various case studies so that users understand the 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