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August 10, 2014
Doretta Royer 315 464-4833

Study looks at interactions between rural setting and the clinical experiences of students

SYRACUSE, N.Y.— The learning experiences of third-year medical students in Upstate Medical University’s Rural Medical Education (RMED) program and physician assistant students from Upstate’s College of Health Professions are captured through their photographs and vignettes as part of RMED’s Student Photo Research Project.

Through this visual method, the project explored how training in a rural community changed the students’ perspectives of medicine or future practices, and the commonalities across the students’ experiences. Findings from the study, conducted from April to June of this year, may provide ways to enhance Upstate’s RMED Program and to strengthen its Introduction to Rural Health course.

“Each year, a cohort of medical and physician assistant students enter longitudinal clinical training programs set in rural communities across New York State,” said Carrie Roseamelia, associate director of the RMED program. Roseamelia served as the study’s co-principal investigator along with Sheila Singleton-Best, R.P.A.-C., clinical coordinator of the Department of Physician Assistant Studies in the College of Health Professions. “Data suggest that these types of programs are effective in recruiting clinicians to serve rural communities, and internal program evaluations suggest students are highly satisfied with their experiences in rural training. However, our knowledge of how students interact with rural communities during their rotations, and how the rural setting influences their clinical training, is limited. We conducted our study to find these answers.”

The students used the Photovoice method to capture their experiences. Photovoice is a group analysis method that uses digital storytelling, in this instance, to convey their impressions of how their rural medicine experience impacted their lives, what they learned from their experiences, and how their experiences have changed their perspective on medicine. “Photovoice allowed the students to represent their experiences through their own lenses and to express what they might have trouble saying outright,” said Roseamelia.

Altogether, 64 photographs were submitted by 11 RMED students. The volunteer study participants were trained in photography, where they learned of the types of pictures the researchers needed in terms of quality and content. A vignette was required to accompany each photograph. Each student received $50 and a framed copy of his/her favorite picture as a thank you. A photobook of all the pictures and vignettes was given to the clinical preceptor of the student’s choosing.

One of the photographs depicts a restaurant damaged by a flood—damages so intense that it took three years to get it to back to baseline. In the vignette, the student reflects on how obstacles, such as the common occurrence of flooding in rural areas, can impact the lives of residents. The vignette reads:

“Hundreds of homes and businesses were destroyed because of this particular storm. I think as providers in rural areas it is important to remember that our patients have other obstacles besides their health. We have to consider a variety of factors when prescribing them medication and helping them make goals. They might not have insurance, or if they do, maybe they are spending all their money on saving their home from a flood or a winter storm.”

The RMED experience of another study participant, who trained in her rural hometown, is reflected through photographs depicting a canoe on a lake.

The vignette reads in part: “I was able to refresh myself from the intense work of the clinical year by hiking, biking, canoeing and skiing in beautiful surroundings that I know so well. Being able to spend my entire clinical year at several outpatient clinics and one hospital in my hometown in Upstate New York had several advantages.  By the end of the year, I had developed strong professional relationships with several local specialists.  These professional relationships will serve me well as I begin my new career in my hometown.” She says that one of the main strengths of the Upstate program is enabling students to work in one community and thereby building relationships within the medical community.

Once the students submitted their photographs, the research team coded each picture and vignette and associated themes with one another. This exercise guided two focus group sessions with participating students who confirmed, revised and elaborated on the team’s proposed themes

The following themes demonstrate the areas in which training in rural medicine most changed the students’ perspectives and most impacted their lives:

• Participants’ perceptions of others.  Students described specific medical conditions and patient cultures typical in their rural settings, like exposure to harsh climates, accidents, and a prevalent culture of work that keeps patients from seeking medical attention and resistant to rest.

• Environment and Nature. Students described the beauty of the rural setting as a space for personal reflection, relaxation and spirituality; however, they also described rurality in terms of its inaccessibility for patients seeking care.

• Training Environment. As rural trainees, students felt appreciated, part of the team, and given unparallel learning opportunities.  They experienced the true essence of continuity of care as they followed patients from the clinic, into surgery, to the hospital floors, and later back in the clinic resulting in a depth of patient/student interactions and understanding. Continuity of family care, including extended families was not unusual.

• Self Identity. Students described juxtaposition as insiders and outsiders of their training rural communities; they portrayed themselves as insiders in terms of making real connections within the hospital and community, yet illustrated themselves as outsiders through their vignettes as they make assumptions and generalizations of the patients they encountered and their work in trying to “fit in” with their rural communities. For those training in their hometowns, fitting in was much easier.

Roseamelia says that the team will conduct additional RMED studies that will help them to identify ways in which the program can offer further interdisciplinary learning opportunities.

The study’s research team was comprised of Melissa E. Arthur, Ph.D., assistant professor of family medicine and psychiatry at Upstate and director of Behavioral Science, Family Medicine Residency, St. Joseph’s Hospital; Lauren J. Germain, Ph.D., M.Ed., director of Evaluation, Assessment and Research, Office of the Vice President for Academic Affairs, Upstate Medical University; Sarah Lewis, M.S., clerkship administrator for family medicine and pediatrics; and Emily M. Mader, M.P.H., M.P.P., clinical research associate, Department of Family Medicine.

Upstate’s RMED program, celebrating its 25th anniversary this year, is offered through the Department of Family Medicine. The program enables students from Upstate’s Syracuse and Binghamton campuses to complete up to 40 percent of their clinical training in community-based settings that include private offices and small rural hospitals over a 36-week period. RMED students quickly become immersed in the delivery of primary care and develop long-term relationships with clinical preceptors and their communities.

Caption: This student’s photograph depicts a road in the wilderness. The vignette reads: “Many rural patients live, work and/or play in remote wilderness. This has many implications on access to care, particularly emergency care. In the winter, this road is used as a snowmobile trail. It can take several hours for a rescue team to reach a snowmobile trauma in such a location.”

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