LaCrosse/Mayo
Mauston | Praire du Chien | Black River Falls

What are Rural Training Tracks?
A Rural Training Track (RTT) is an accredited, three-year residency training program located in a rural area that prepares family physicians for rural practice. Each RTT has 2-6 residents and is affiliated with a traditional family practice residency program.

How is the curriculum formatted?
The Wisconsin RTT's are "one-two" programs. RTT residents spend the first year in traditional "block" format rotations like internal medicine, obstetrics, pediatrics and surgery at the home program in an urban area with the other core program residents. The residents travel to the RTT site once or twice a week to begin building their outpatient practice. In the second and third years, 90% of the inpatient and outpatient training is completed in the rural community. Most second and third year rotations are in a "longitudinal" format where residents spend short periods of time with visiting specialists over a much longer duration. Teleconferencing is used to connect rural sites with each other and with the traditional program to enhance didactic curricular requirements. Some residents live in the core program community for the first year and then relocate to the rural site for years two and three. Others locate in the rural site for all three years, commuting to the core program for the first year.

Where are the Rural Training Tracks in Wisconsin?

Location	Core Program	# of Residents accepted per year
Baraboo	University of Wisconsin - Madison Program	2 (Max. 6 total)
Menomonie	University of Wisconsin - Eau Claire Program	1 (Max. 3 total)
Antigo	University of Wisconsin - Wausau Program	1 (Max. 3 total)
* Augusta	University of Wisconsin - Eau Claire Program	1 (Max. 2 total)
Prairie du Chien	LaCrosse-Mayo Family Practice Residency	1 (Max. 3 total)
Black River Falls	LaCrosse-Mayo Family Practice Residency	1 (Max. 3 total)
Mauston	LaCrosse-Mayo Family Practice Residency	1 (Max. 3 total)

* Augusta is not a Rural Track, but an alternate rural outpatient site for the Eau Claire program

Why were RTT's developed?
Rural Training Tracks in family practice residency programs began in the late 1980's in an effort to increase the number of physicians selecting rural careers. Twenty-nine percent (29%) of rural residents of the United States live in areas with a shortage of health professionals, compared to 9 percent of urban residents (Dalen, 1996). Research indicates that the location of residency has an effect on the location of practice. Research has also shown that the more months a resident trains in a rural area and the more months of maternity care, the greater the likelihood that the graduate will select rural practice (Bowman, 1998).

Though a 1997 national survey ranked Wisconsin as the fifth healthiest state, more than 50 of the state's counties and regions are still federally designated as Health Professional Shortage Areas. The need for family physicians is strong all over Wisconsin. In rural areas, family physicians are needed in growing communities and to replace retiring physicians. In 1997, 68% of Wisconsin's family physicians provided maternity care.

There is an immense need for rural family physicians both now and in the future. Rural areas need physicians who can provide maternity care, emergency care, pre-and post-operative care and geriatrics in addition to general medical care.

How many RTT's are there?
In 2000, there were 30 RTT's in the nation. The first Wisconsin RTT was developed at Baraboo in 1996. The other Wisconsin programs were developed since then in healthy medical communities with a solid core of family physician and specialist teachers. Other RTT's are located in Nebraska, Colorado, Illinois, Kansas, Montana, New Mexico, Michigan, Idaho, Louisiana, North Carolina, New York, Ohio, Oklahoma and Washington.

What are the advantages of training in a rural community?

• Training in an environment that most closely mirrors future practice
• Smaller class size and more personalized, individual training opportunities
• Virtually no competition with other residents for learning opportunities
• You are "front-line physicians" in a rural ER, hospital and clinic who see interesting cases first
• Exposure to a large patient population with a wide range of procedural training, including obstetrics.
• The opportunity to maintain all the advantages of the rural lifestyle and still fulfill the requirements of residency training
• You operate more as a partner with one on one nursing and a continuity practice
• The lifestyle mimics the lifestyle of the rural physician
• You have the best of both worlds - a quality rural training experience with full access to all the resources of the core program and Medical School
• Enhanced opportunity for community involvement

How is rural health care changing?
Telecommunications, informatics, practice networks and many other innovations are rapidly evolving and improving the structure of rural practice. Part-time practice is a growing option for both rural and urban physicians. A number of rural hospitals have closed, but many others are remain strong due to networking, successful physician recruitment and careful use of resources. The nature of rural life is being subjected to major change as described by Cordes in a 1990 report exploring myths about rural America. He stated that (1) rural populations in the US are no longer declining but increasing, (2) farming has given way to manufacturing as the major source of employment, (3) there are more similarities than differences in the economic structure of rural and urban America, (4) rural areas are no longer isolated from mainstream urban life, (5) rural people share much of the knowledge and many of the attitudes and beliefs of urban people, (6) rural and urban people are similarly happy with their environment, (7) rural America is much more diverse than previously thought.

What do you see as the future of RTT's?
Expanding in popularity where the educational program is sound. Rosenthal, et al. Identified five major elements of successful RTT's: (1) academically sound urban component of program, (2) supportive urban medical center, (3) financially viable rural hospital, (4) modern rural practice unit, and (5) robust rural community. The six Wisconsin RTT's meet these criteria. We think they will become increasingly popular with students interested in rural practice because they now have a track record and they are very relevant to one's future practice.

QUESTIONS FREQUENTLY ASKED BY MEDICAL STUDENTS:

Are you required to enter a rural practice after graduation from an RTT?
No, there is no obligation to do so. However, most graduates do choose rural practice. All the Wisconsin RTT graduates have entered rural practice.

What if I join an urban practice after graduating from an RTT? Am I at a disadvantage?
No, you are not at a disadvantage. Residents receive more than adequate training in an RTT to practice anywhere.

What kinds of students choose an RTT? Did they all grow up in rural areas?
Many students come from rural areas, but there are also others who grew up in large metropolitan areas who realize the benefits of living in a rural setting. They are all committed to providing quality healthcare to the rural population. Our observation is that students attracted to RTT's tend to be very independent, highly motivated people. They are not afraid to expose their weaknesses to grow as a physician and become the best possible doctor.

Do rural physicians and rural residents work harder than their urban counterparts?
Yes and No. The number of patients, procedures and general involvement with patients is probably more in most rural settings than in urban settings. However, the rural physician's time may be more flexible with less stress. Close teamwork makes the work survivable. Rural systems erect fewer barriers to mixing professionals and non-professions to address specific needs across vocational boundaries. Family physicians, specialists, home nurses, office staff, family and community can work together in patient-specific, non-traditional ways.

Can spouses of residents and rural physicians find work in a rural area?
The usual experience is that if the MD is interested in rural practice, the spouse is also interested in living in a rural area. If the spouse has a professional or highly specialized career, they may want to choose a rural track that is in a college town or is closer to urban areas. Some spouses have willingly changed careers to enjoy the rural lifestyle with their family.

Do you interact with special populations in the urban area? Examples? (American Indians, Amish, etc.)
Yes. Each RTT has established relationships with reservations or agencies that care for special populations. Most often, the patients come to the RTT clinic. For example, in Black River Falls and Baraboo residents provide maternity care and deliver babies of women from the Ho-Chunk Nation.

What if the rural residency program does not match?
It is not a disaster or an indication that this is a weak program. Rural Training Tracks can operate well without a full complement of residents because they are functioning rural practices that are not totally dependent on residents to cover services. Because the instruction is individualized, RTT's seek well qualified applicants who will fit well with the practice. They are willing to leave positions unfilled until there are quality candidates.

Do you feel uncomfortable meeting your patients in the grocery store or on the street?
Not at all. In rural areas, your patients are often your neighbors and friends. They tend to respect your role as a physician, but are able to separate the private and professional life. There seems to be more of a recognized interdependence on one another in a small community. I haven't had any problem with people infringing on my private life to ask medical questions.

How do you find out about the RTT's all over the country?
The internet is the most convenient source of information. All the nationwide RTT's are listed at http://www.unmc.edu/Community/ruralmeded/student.htm. You can also check the AAFP Directory of Family Practice Residency Programs at http://www.aafp.org/residencies/. Talking with RTT residents is also a good source of information.

How do you know that an RTT is good?
Difficult question. Are there enough family practice faculty? Are other specialists available for teaching? Are the current residents happy and are the graduates satisfied with their training? One graduating resident reports that he has had no trouble successfully moonlighting over 1500 hours in ER's during his last two years of the program. He feels that his training program is respected because he is always asked back and been able to develop an excellent rapport with many regional hospitals.

Do you ever get caught without a safety net when providing patient care in an RTT?
Never. Accreditation agencies and programs have strict rules about supervision. There are systems to guarantee that you will have backup. You definitely have to learn your limitations to be an effective rural physician. You have to be prepared to make early decisions regarding transfers of patients, considering weather, season, time and available resources.

How good is the telecconferencing? Quality? Convenience? Feeling of Involvement?
The systems in place now are good and continually improving. Gunderson Lutheran has many conferences to choose from and you can be as involved with them as you like. All the locations have some type of system that allows them the RTT residents to see and/or hear conferences from their home program. All the Wisconsin RTT's have begun participating in "Virtual Rounds" where an RTT resident presents a case via telephone conference and website. Archiving conferences on websites for future viewing is just getting started.

How do RTT's in Wisconsin differ from RTT's in other states?
You would have to judge that for yourself. Students applying have observed that the Wisconsin RTT's are all in thriving small communities where people use the local clinic and local hospital as their primary healthcare site. They are not bedroom communities for larger metropolitan areas where people routinely go to the urban area for their care. Also, rural Wisconsin is mostly comprised of group practices where family physicians provide the majority of the care in collaboration with smaller numbers of specialists. Over two-thirds of the rural family physicians provide maternity care. Rural areas are part of larger practice networks that give them access to a wide variety of specialists and specialist services.

Can I do a fourth year elective in an RTT?
Yes. Contact any one of the sites to arrange an elective.

How can I familiarize myself with RTT's while I'm in medical school?
Research via the internet. Visit the sites during medical school and talk with faculty and residents. Some schools are starting Rural Family Medicine Interest Groups with support from family medicine faculty.

Do rural physicians make less money than their urban counterparts?
No. Many rural physicians make substantially more. Residents graduating from RTT's in 2001 report that starting salaries cited were $20K more for rural positions. Graduate surveys validate this finding.

Are their loan forgiveness programs that help students and residents that are committed to rural practice?
Yes. The Wisconsin Department of Health and Family Services and the Wisconsin Office of Rural Health have information on potential funding.

IN THEIR OWN WORDS…QUOTES BY FACULTY AND RESIDENTS IN RTT'S

" In response to those who think that rural physicians only see kids with snotty noses and refer everything to large urban centers…This week I had 2 people in the hospital with ruptured diverticula requiring surgery and triple antibiotics, 2 elderly people in with pneumonia, one in the hospital with urosepsis, took care of a pediatrician from my group with kidney stones, evaluated and sent someone to Madison with a complete placenta praevia at 28 weeks gestation who had bled (gave first dose of steroids here), ran a code blue on someone who collapsed in the next hospital room (patient was resuscitated from V-fib), and saw patients in the office all week. Tim Deering (3rd yr Baraboo family practice RTT resident) helped with the hospital patient load, Stuart Hannah (1st yr Baraboo resident) did the defibrillation on the successful code and Stuart did a thoracentesis on another patient of mine who had a large pleural effusion. I don't think we have seen one snotty nose to blot all week."
James Damos, MD, RTT Director in Baraboo who practiced in Madison from 1987 to 1999 before moving to Baraboo.

"I try to find out who my patients are. Getting to know what they do and the stories of their lives-that's the fun part."--- " In a bigger city, if a patient comes in with a stroke, she sees a neurologist…in a rural town you are the doc. You learn when to hit the panic button. You need to know when enough is enough and when you need somebody else to help you. You learn really quickly what you can and can't handle. That in itself is quite an art."
Bruce Schultz, MD, Menomonie RTT graduate

" I always knew I would be more comfortable in a small city." "The residency only confirmed my belief that rural America is where I want to work and live."
Bruce Schultz, MD, Menomonie graduate who grew up in the suburbs of Colorado and Milwaukee

"The day to day work is much more similar to what a rural doctor would experience. I like the idea of working where there is a true need. I like the feeling that if these doctors weren't here, these services might not be here."
Hans Elzinga, MD, Baraboo graduate

"I believe a large part of the rural physician shortage that exists today is secondary to how medical education has evolved. FP residents training in large medical centers appear to be brainwashed into thinking that they cannot manage cases common to rural practice without specialty consultation. A sense of "helplessness" evolves with delivery room emergencies (retained placenta, postpartum hemorrhage, instrument delivery), neonatal emergencies (resuscitation, sepsis evaluation, hypoglycemia), and other skills needed in rural practice. They are scared away from rural practice. "
Jim Damos, MD, Director, Baraboo RTT

"I felt fully prepared when I finished my residency and now that I'm in my practice, I have found that I actually was prepared. In the Menomonie residency program, I felt like a partner, so the transition to having my own practice was easy."
Eric Sorenson, MD, Menomonie RTT, 2000 Graduate

Rural Training Tracks (RTT's) in Wisconsin

University of Wisconsin Programs: Website: www.fammed.wisc.edu/education/residency/

Antigo Rural Track - Wausau Family Practice Residency Program
Hilary Scully, MD, Program Director
Mary Zaglifa, Recruitment Coordinator
(715) 675-3391
mzaglifa@wausau.fammed.wisc.edu

Baraboo Rural Track - Madison Family Practice Residency Program
James Damos, MD, Program Director
Linda Scheid, Recruitment Coordinator
Phone (608) 263-4668
lscheid@fammed.wisc.edu

Menomonie Rural Track - Eau Claire Family Practice Residency Program
David Eitrheim, MD, Site Director
Sue Jackson, Recruitment Coordinator
(715) 839-5177
applicant@eauclair.fammed.wisc.edu

La Crosse-Mayo Programs

Black River Falls, Wisconsin - Krohn Clinic
Richard Rogge, M.D., Site Coordinator
Phone: (715) 284-4311
E-mail: rwrogge@hotmail.com

Mauston, Wisconsin - Mile Bluff Clinic
Nancy Ness, M.D., Site Coordinator
Phone: (608) 847-9707
Email: dkness@mwt.net

Prairie du Chien, Wisconsin - Gundersen-Farrell Clinic
Mark Grunwald, M.D., Site Coordinator
Phone: (608) 326-6466
E-mail: mgrunwal@gundluth.org

Further information on rural medical education for students:
http://www.unmc.edu/Community/ruralmeded/student.htm