Rural Track Pediatric Residencies, and Others
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1 Rural Track Pediatric Residencies, and Others Robert W Hostoffer, DO, FACOP, FAAP Professor, Ohio University College of Osteopathic Medicine Randy Longenecker, MD Professor, Family Medicine, Ohio University College of Osteopathic Medicine
2 Definition of Rural Area HRSA uses two definitions of a rural area U. S. Census Bureau définition Office of Management and Budget definition
3 U. S. Census Bureau definition Urbanized Areas (UAs) of 50,000 or more people; Urban Clusters (UCs) of at least 2,500 and less than 50,000 people. The Census does not actually define rural. Rural encompasses all population, housing, and territory not included within an urban area. Whatever is not urban is considered rural.
4 Office of Management and Budget definition The White House Office of Management and Budget (OMB) designates counties as Metropolitan, Micropolitan, or Neither. A Metro area contains a core urban area of 50,000 or more population, and a Micro area contains an urban core of at least 10,000 (but less than 50,000) population. All counties that are not part of a Metropolitan Statistical Area (MSA) are considered rural.
5 Other definitions Whether a hospital is classified as urban or rural for the purpose of funding GME, in places that are located on the margins of any of these definitions, may change from one cost reporting year to another; and of course, although the census occurs every 10 years, the operational application of this census information may be delayed for several years. The accrediting agencies (e.g. the ACGME) have shied away from using any single definition of rural RUCA Rural Urban Commuting Area codes Others: Economic Research Service, Department of Agriculture
6 The Need for Rural Pediatric Programs Large need for pediatricians to practice in rural venues Present training programs do not equip graduates with skills Present residencies do not select for rural interests of candidate
7 Difficulties in development One Half of residency must be spent in official rural area No Children s Hospitals in rural areas Curriculum must be designed to meet needs of pediatrician in rural setting Needs of pediatrician in rural setting are very different than urban venue Today we will review the AOA approved curriculum and determine if changes are necessary.
8 Discussion Difficulty in developing residency of different specialties in rural setting Specialty to discuss internal medicine, general surgery, OB/Gyn, ER. Rotations that can be done in rural training Rotations needed in more traditional setting Didactics needed in rural setting Basic standards thus need to be written Or can present standards allow for flexibility in rural needs
9 Differences Among Pediatric Basic Standards Procedures Ambulatory pediatric Hospitalist rotations Critical care Newborn nursery Electives Rural Requirements
10 Procedures Stabilization and transport of both newborn and pediatric patients of all ages, including victims of trauma.
11 Discussion Additional Procedures for Rural areas What would be added/changed or altered for different subspecialties?
12 Ambulatory Pediatrics Continuity Clinic Rural office based assignments Emergency and acute care of illness Transport experience Adolescent medicine Behavioral and developmental medicine
13 Discussion Additional ambulatory venues Amount of time sent in rotations What would be added/changed or altered for different subspecialties?
14 Continuity Clinic Continuing care of a group of patients in a rural community throughout the three (3) years of training is required. Differences: typically not in rural area
15 Discussion Types of Continuity Clinics Venues of Clinics What would be added/changed or altered for different subspecialties?
16 Rural-office based assignment Office electives or assignments may not exceed six (6) months Assignments may be solid blocks of time or may run concurrently with other assignments Curricular content must include small business principles, practice, finance and delivery models. In addition, the curriculum shall include one (1) month or 200 hours of OPP/OMM. Differences: Typically not in rural area
17 Discussion Additional time in rural assignments Variation to assignments Variation to venue What would be added/changed or altered for different subspecialties?
18 Emergency Medicine In addition to their experience in the continuity clinics, residents must have at least three (3) months of experience managing pediatric patients with acute problems, including respiratory infections, dehydration, coma, seizures, poisoning, trauma, lacerations, burns, shock and status asthmaticus. At least one of these months must be a block rotation in an emergency department that serves as the receiving point for EMS transport and ambulance traffic and which is the access point for seriously ill and acutely ill pediatric patients.
19 Discussion Additional time spent in assignment Types of ER experience Types of ER venues What would be added/changed or altered for different subspecialties?
20 Transport Residents must have at least one (1) month or 200 hours of experience in the transport of newborns and other pediatric patients via both ground and air.
21 Discussion Need of transport knowledge Venue of transport service Addition of time spent in venue What would be added/changed or altered for different subspecialties?
22 Adolescent Medicine Residents must have one (1) month of patient care experiences in the following: health maintenance examinations, family planning, sexually transmitted diseases and gynecology. Experiences in chemical dependency, sports medicine, health needs of incarcerated youth, and college health issues are strongly recommended. A separate clinic for adolescent patients is desirable. Also recommended is experience with healthcare for adolescents provided in schools, group homes, family planning clinics, and inpatient psychiatric facilities.
23 Discussion Additional time spent in area Interest clinics within assignment What would be added/changed or altered for different subspecialties?
24 Behavioral and developmental Residents must participate in a structured experience in normal and abnormal behavior and development involving didactic and clinical components. Experience must include the care of patients from newborn through young adulthood. Residents must learn how to serve as care managers for patients with chronic diseases and multiple problems. Subspecialty consultants and ancillary personnel must be available to the residents as they care for these patients.
25 Discussion Additional time spent in assignment What would be added/changed or altered for different subspecialties?
26 Hospitalist Rotations General hospitalist inpatient pediatric rotations must be a minimum of five (5) months. Differences: Typically on a general or subspecialist inpatient service
27 Discussion Additional time spent in assignment Is a rural hospitalist the same as a children s hospital hospitalist What would be added/changed or altered for different subspecialties?
28 Critical Care There must be a rotation in neonatal critical care (Levels II and III) for a minimum of three (3) months, exclusive of experience with the normal newborn. At least two (2) of the three (3) months must occur in a setting where residents have the opportunity to regularly participate in the resuscitation of newborns in the delivery room. There must be a rotation in the pediatric intensive care unit for a minimum of one (1) months. The maximum number of required rotations in both critical care areas combined must not exceed six months. Hospital Procedures There must be one (1) month rotation dedicated to intravenous access, intubation and other hospital procedures.
29 Discussion Additional time in critical care What would be added/changed or altered for different subspecialties?
30 Newborn Nursery There must be the equivalent of at least two (2) months that include care of newborns in the routine nursery setting. This experience must include routine physical examination of the newborns (at least 50 normal newborn examines), attendance at routine, high risk deliveries and C-sections, and counseling of the parents on the care, and comprehensive issues of the neonatal period. Differences: typically one month
31 Discussion Additional time spent in assignment What would be added/changed or altered for different subspecialties?
32 Electives The total amount of time committed to all subspecialty elective rotations must be no more than eight (8) months. No more than six (6) months may be spent on any one subspecialty during the three (3)-year residency. The subspecialty rotations must occur primarily in the second and third years of training
33 Discussion Additional time spent in assignment What type of electives What would be added/changed or altered for different subspecialties?
34 Rural Requirements In addition to meeting all of the above requirements the program must include four (4) months in a rural setting including a rural public and community health experience. Differences: typically not a requirement
35 OGME 1 OGME 2 OGME 3 OGME 1 OGME 2 OGME 3 SURGERY 1 SURGERY 1 INTERNAL MEDICINE 1 INTERNAL MEDICINE 1 WOMEN S HEALTH 1 WOMEN S HEALTH 1 EMERGENCY MEDICINE EMERGENCY MEDICINE 1 1 AMBULATORY PEDIATRICS AMBULATORY PEDIATRICS NEWBORN NURSERY 1 1 GENERAL IN-PATIENT PEDIATRICS HOSPITAL PROCEDURES NEWBORN NURSERY GENERAL IN-PATIENT PEDIATRICS PICU NICU PICU NICU PEDIATRIC SPECIALTY ELECTIVES PEDIATRIC SPECIALTY ELECTIVES TOTAL TOTAL
36 Expected Sites for Rural Programs Athens, Ohio South Carolina Montana Alaska New Mexico Oregon Alabama
37 Financing Currently an urban hospital sponsor of an RTT in Family Medicine can build a rural cap ( over regular cap funding) from CMS for a 1-2 RTT or an integrated RTT where >50% of the residents training occurs in the rural location Children s Hospital GME (CHGME) is set each year by Congress as an annual appropriation and the rules generally follow CMS Rural hospitals can build a new cap in any specialty at any time; they simply can t expand an existing specialty program that has already reached it s initial 5 year cap
38 What about other specialties? Can it be done? Internal Medicine General Surgery Obstetrics and Gynecology Emergency Medicine
39 Discussion
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