40 Years of Rural Medical Education

To tell you that we are experts in Rural Medical Education is a bit of an understatement! We have been training and retaining rural doctors in our state for more than 40 years! So, let's take it back to where it all began, the U.P., and learn how it all happened from the man that was there! 

This Rural Mission is a podcast brought to you by Michigan State University College of Human Medicine. The podcast is produced with funds from the The Herbert H. and Grace A. Dow Foundation and The Michigan State University College of Human Medicine Family Medicine Department. Welcome to season two. I'm your host, Julia Terhune, and I hope you enjoy this episode.

I don't think there's been a week that has gone by since I started working for the college of human medicine that I haven't talked about how we have been recruiting, training and retaining rural doctors for over 40 years. For those that I work with, I'm pretty sure they were able to dub those words with almost my exact inflection. I talk about it all the time and not just because it's my job, but because I'm really proud of the outcomes of our program. I'm really proud of the work that everyone for decades has put into the success of our medical students and the success of the rural medical systems that take our medical students. Now in 2019, I get to change my script just a little bit because this year we are celebrating 45 years of rural medical education.

In these 45 years, we have been able to show the outstanding and significant outcomes related to developing the rural medical workforce, and we have expanded our rural medical education certificate programs to include two additional rural campuses where students can receive that certificate. Those campuses are now Traverse City and Midland. With that expansion in 2012, we have been able to cover the map of Michigan with rural medical education opportunities. Those opportunities provide students with an understanding of the unique needs found in many of our rural regions across the state.

For those medical students who want to get rural medical training, they can pick from two different programs, the rural physician program based out of Marquette or the rural community health program that's based in either Midland or Traverse City. Both programs are under one big umbrella called the Leadership in Rural Medicine program. But this umbrella wouldn't exist at all if it wasn't for the men and women who worked so hard to establish rural medical education opportunities in the upper peninsula starting back in 1974. To honor this legacy, we wanted to showcase the man who was there when it started and let him tell you the story about how it all began. Dr. Daniel Mazzuchi was an internal medicine doctor who came to the upper peninsula of Michigan in the late 1960s.

He was an integral part of establishing the program first in Escanaba and then in Marquette in later years. His influence on the college was so tremendous that much of what he's established during his medical education career is still in place today. Dr. Mazzuchi sat down with Dr. Andrea Wendling, the current director of our program, and told us the story of how it all began.

To talk about medicine in Marquette, you have to kind of... Medical education in Marquette, you have to kind of break it up because nothing happens in a vacuum. The political factors that went into allowing the UP experiment, which is what it was called, to be started, the people or cast of characters involved in it, and then how it eventually evolved as medicine evolved in the UP.

We owe a great deal of credit to the development of our Marquette campus and our rural medical education heritage to the late Donald Weston who served as Dean of the college of human medicine from 1970 to 1989.

He's the reason why we're here. I mean, that's a simple declarative sentence. He was a fly fisherman and he and his buddies were up fly fishing somewhere in the mountains. They were dreaming. They were iconoclasts. People really have no idea how iconoclastic they were. They thought that they could develop more of an apprenticeship model of medical education. They thought about it for places like they were fishing in, Montana and Idaho and all. Eventually that became the whammy program. They were also very politically aware and connected and hung out with politicians from the state government. They were drinking and talking and talking about this stuff. One of the guys said, "The hell you thinking about Montana for? I mean, we have a problem in the UP. Why don't we do something in UP?"

People up here in 1973 had an idea and that was to have this apprenticeship model on an experimental basis built around a practice. He got a lot of communities interested in it. Eventually Escanaba was the site they chose, not Marquette. They hired a guy named Paul Warner and another guy named John Hickner and they developed a family practice down there and he put students in there for all four years. Unheard of. This was an experiment. 10 students every other year. After about three or four years, the LCME called Weston and said, "If you don't stop this, we're going to discredit the school."

Why did they say that?

There was no way... Unless the students decided to take national boards on their own, the LCME could judge the progress of people. The curriculum was let's call it innovative to sprain the meaning of the word. In terms of available data, the students were doing fine, but the available data wasn't sufficient in the minds of the people who were in charge of the LCME at that time. The long and short of it is a compromise was reached to relocate the first two years back to campus and to make this a clinical campus, but with a different mission. That's lasted to this day.

Yeah. What was that mission at the beginning?

The beginning was to try to resolve the problem of rural areas in getting people to come here to practice or even more importantly, to encourage people who lived here, who would ordinarily want to stay here, to get into medical school, to open the doors a little wider for them. We, by the way, had a separate admissions committee. The thing was it was a day when the decision was placed in the hands of a small group of people who had their own ideas about who should be going to medical school and who shouldn't. Although I would say they were very, very well intended people, I was a part of them. It was a very serious matter for them. But they took to what would be viewed today as an extreme, their desire to be sure that people came back here as much as possible.

The bias, if you will, was very heavily towards people from the upper peninsula as was the intention of the founder of this program. That's what he wanted, but also towards women, also towards older people in general. I would say those things have by and large continued as far as I can see in a much different way and under it. But I think this campus has almost always had at least 50 and more percent women students and has always had a handful... Always had people in their late twenties, early thirties coming in, which I think is outstanding. I think it's the way it should be, but no, it was just that they kind of went a little overboard.

Can you talk about how you figured their curriculum out and how you could coordinate that with the main college?

I did not figure out the curriculum. Okay?

Okay.

I worked with department chairs. Department chairs were responsible for the curriculum here from day one just like they were everywhere else. It wasn't a detached program. It was an integrated program. It had people in the department who believed strongly. It was not in a vacuum. It was all integrated and carried out under their distant supervision. Every department had their persons here. They were likely to be local and they made regular trips up here. The students took always the same exams that happened on campus. All that other stuff [inaudible 00:10:25] But anyway, yeah, that part I would describe it as real but imperfect. It wasn't perfect because it wasn't next door. It was far away. I went down there as associate dean in '84, five, six, and I was responsible for all the campuses.

I came back here in '87. I think it was when I came back and took stock of things and I thought to myself, you know what, this place looks like every other campus there is. That's not good. It might've been while still I was... I don't remember exactly, but somewhere in there in the '80s started thinking out loud, we need to do something to make this a special program again. Yes, we were no longer called the UP experiment. They were called the UP campus. Yeah, we had had some graduates and they were practicing all over, but a lot of them are in the UP. I thought, hmm, why not a two month long family practice experience in the little towns of the UP with the people who graduated from this program as their kind of overseers and so forth? Ultimately they gave permission for us to do a two month long...

In addition to the one month, a two month long family practice experience in these little tiny towns.

That extended time in rural family medicine lives on for our rural physician program students in Marquette. I know students are thankful that Dr. Mazzuchi started that model, and I know this because I was able to talk to one of the graduates of the program. Dr. Nicole Zimmer is now a family medicine resident at the MidMichigan Family Medicine Residency in Midland, Michigan. Her longitudinal family medicine experience set her on that path that Dr. Mazzuchi had envisioned. What was a highlight of your time up at the Marquette campus? If you could pick a day that you could relive right now, what would it be?

I really enjoyed... We do 12 weeks of family medicine up there. Four weeks was in Marquette and eight weeks we spend kind of in a rural area. Mine happened to be Ironwood. I loved everything about being up there. It was in the spring, so it was absolutely beautiful. I mean, you could go on the trails. Everything was opening up. I worked with this physician, Dr. Hubbard. He was absolutely an amazing teacher and wonderful and hilarious. I mean, sometimes you get nervous about eight weeks one-on-one with a physician, but it flew by. He was a great teacher. He was amazing. While working with him, I had my very first delivery. It's still just like rocks me to this day. I remember going through the motions with him.

We're kind of talking about, okay, during this stage of labor, this is what you need to do, and this is where your hands need to be, and this is what you're checking for. It was really funny because they didn't find out what they were having, a boy or a girl. I was so excited to deliver this baby because I wanted to tell them this couple if they were having a boy or a girl. When the baby was born, you're supposed to suction and dry off the baby a little bit and then pass it up to mom. Well, I was so excited I kind of forgot about that. I held the baby up like Simba and I was like, "It's a boy." Everyone starts crying and they're all excited. Dr. Hubbard just gently nudge me. He was like, "All right, Nicole, bring him back down."

Then of course, we do the suction and the stimulating and the baby was perfectly fine and crying and everyone was happy, but he always joked with me after that in all of our deliveries. He goes, "Don't do the Simba move this time." It's just kind of stuck, but it was my first delivery. My love of OB as a primary care provider just blossomed on to that and I hope to do that in my future practice. It's one of the reasons I chose this campus too based on the rural medicine and the OB experience you get here. I knew at that moment it had to be part of my life. I had to be delivering babies. It was just such a thrill.

The first team we sent to Haute, two girls, two women. I remember on the front pages of the newspaper, there are pictures there. I remember the little teeny hairs on my head standing up. I go, "Wow. This is exactly what I'm looking for." I mean, they treated them... They had never seen students before. None of these people had ever seen students before. They treated them in a truly heroic fashion, and they had the greatest hands on experience since we went to medical school. You don't want to know about our hands on it. I grew up in the city hospital. I mean, honestly God. But anyway, it was an overnight success and what better people to have as teachers than people who are your own graduate.

I think part of the benefit of a program that's been so well-established is the connections that are made. When we had to set up rotations there, it was office staff who had worked with that physician for the past 20 years. They'd been taking students that whole time. The atmosphere of education and learning and opportunities was already set up. We didn't have to forge the way for that. The previous students and administration, they have been done. We're working with physicians in the community who loved what they were doing, love the UP. They were great teachers. Having that 40 years experience allowed them to realize, "Oh, hey, I know that you guys have this during this rotation. Let me help you out, or I know in the past students have really struggled with this part of the exam.

I think you should read these materials." They were really helpful with resources or kind of identifying weaknesses before you even got there because they had seen students before you who are weak in that area or realizing there was a very human aspect of it too as far as realizing, okay, I know that you have an exam this week. I know that there are surgeries planned for late, but you had seen dozens of appendectomies, why don't you study and we can catch up after this case when the next one comes in? There was definitely opportunities to foster both the educational experience in the classroom still with bookwork and hands on experience. They were really great about realizing kind of what we needed as students before we really knew ourselves what we needed most of the time.

Last year we did a study where we looked at the impact of the undergraduate medical education program and the workforce in the UP and really its impact in rural areas throughout Michigan. We took all of the graduates from the UP campus over a 30 year period, from 1978 up until 2008, and looked at where they were practicing in 2011. What we found was that 27% of all of the graduates of that program were actively practicing in a UP County in 2011.

It's amazing.

Yeah. The impact that that has on the workforce for the UP sustained over time is amazing.

We used to wonder out loud with each other, you know, how much longer we'd be working here.

Yeah, yeah. Now it's 40 years and it's made such a difference over time. The other thing we found in that study is that the mission of the program based on outcomes has actually strengthened over time. We looked at the first decade of graduates, the second decade, the third decade. In the more recent graduates, it's actually a higher percentage of them are from the UP and a higher percentage of them stay in the UP than even early on.

That's wonderful.

It is. Because we worried a little bit would we we saturate what the U P could need even over time, but it doesn't appear to be. It just strengthens over time, which Bill Short at the time we published the article, his theory was that having the graduates of the program become faculty has actually strengthened the program over time both from a mission fit and from a stability fit for the community.

It makes perfect sense to me. It's easy to look at it once it's already happened.

Right.

It was one of our goals for sure.

Yeah.

One of our hopes. I do think that this campus, and perhaps a couple of others, provide students with more clinical hands on experience than most campuses in most medical schools across the country. We used to assess that or try to assess it by asking them after they finished their first year of residency, how they compare to people in their class, and they are always... Many of them had way more physical experience delivering babies hands on in the OR, that kind of thing. They really had a lot of real doctor type experience.

We just did another survey of the last 10 years and that message came through very clearly that they felt like compared to their peers, they had more one-on-one experiences. They had more OR time, more face-to-face patient time, early triage, and then procedures, delivering babies and first assisting in surgery, which many of their peers didn't get.

Our rural medical education programs are a place for rural students to have a home or to return to home. We are also a place for students who want hands on experience in surgery or emergency medicine or even general practice. They can come and learn in a small one-on-one environment. Finally, we're a place for students who want to learn more about health disparity and the needs of those who are most vulnerable and find a way to fix and solve those problems. Some of our students want all three of these things and we provide that too. We leave you today with a short testimony of what this legacy has provided one student, who at the time of this interview was only a medical school hopeful and is now part of our incoming class of 2023. John Berglund is from Bergland, Michigan.

This is what John says about the rural physician program in Marquette and what it means to him to have this opportunity.

Well, to be able to start my training in medicine in the region that I hope to end up one day would be huge for me. I can imagine it being a little tough training in a large city for four years or onwards and then making that huge jump to the rural area like the UP, I think it'll be pretty tough. But it's great to be able to learn and train with the people and the patients that I hope to one day care for before I even progressed. Plus, I would not have to leave my favorite place in the world, the UP. I don't think it could get much better than that. If I can give anything back to my hometown, I hope it's that that I can come and serve the people in my hometown and pretty much my whole county. I guess training there would be would be huge because I would get...

I know the people from Bergland and to be able to train in that area and to train there and to get people to know even more and to build that trust and connection before I even start to be a doctor there I think is huge.

Thank you as always to Dr. Andrea Wendling. Her devotion to rural medicine has paved the way for so many students to make an impact in their communities and has been a mentor and example to so many students. It's an honor and a privilege that I get to work with her. Thanks also to Dr. Mazzuchi, Dr. Nicole Zimmer, and the future Dr. John Berglund. I speak for all of us at the Leadership in Rural Medicine Programs when I say we are happy that our relationship has continued for all of these years. I would like to also thank the community assistant deans who help make our rural certificate programs run in Marquette, Midland, and Traverse City. Those individuals are Dr. Stuart Johnson in Marquette, Dr. Paula Close in Midland, and Dr. Daniel Webster in Traverse City.

Thank you for all of the hard work that you do and all that you pour into the staff and students at your campuses. I hope you've enjoyed this podcast, but more importantly, I hope it has encouraged you to make rural your mission.