Spring 2016
Rural Education

synapse: University of Nevada, Reno School of Medicine

David Hogle and Spencer VanDyck

Rural Learning: Internist David Hogle, M.D., left, has guided students like Spencer VanDyck, right, through their rural rotations since the early 2000s. Photo by Keith Clark.

Preceptors Offer Hands-On Learning Experiences

Story by Anne McMillin, APR

The rural training experience, a requirement for all University of Nevada School of Medicine students, has its roots in the school's original charter to provide primary care physicians for rural Nevada.

For most of its nearly 50 years, Nevada's only statewide public medical school has placed students, and more recently residents, in rural rotations, with the goal of providing health care for Nevada's underserved rural communities and exceptional growth opportunities for learners.

Jamie Anderson, director of rural medical education at the medical school, is quick to give credit for the success of rural rotations where it is due.

"It is our dedicated preceptors, some who have taken in students for 20 or 30 years, that are the backbone of the success of this program. We are very lucky to have our rural preceptors."

She said the medical school's rural preceptors are very open to accepting direction on skills that students need to learn during their rotations. She added that based on what she's heard at national meetings on this topic, other medical schools often struggle with this aspect of their relationship with preceptors.

"Our preceptors work with their students until they ‘get it'," she said.

Anderson added that the immersion experience students and residents undergo in rural Nevada, often without the luxury of state-of-the-art equipment or medical specialists, challenges their decision-making skills and allows them to see pathologies and patient conditions they may not otherwise see.

Corrine Martin, education coordinator based on the medical school's Elko campus, added that under the watchful eyes of preceptors, learners get to "see it all" and have to make the decision about whether to treat a particular patient in the rural setting or transfer them to an urban hospital, often hours away by ambulance or air transport.

While the School of Medicine has historically placed students in rural communities, it has really been in the last five to seven years that the opportunities for rural learning have jumped. Students in all four years of medical school now can opt for a rural experience as can residents in family medicine and internal medicine.

Aaron Dieringer, M.D.'15 and current family medicine resident in Reno, spent the summer between his first and second year of medical school in a rural community, completed his pediatrics and internal medicine clerkships of third year in Elko and did his fourth-year rural rotation in Ely.

Dieringer said the Ely hospital staff, from physicians to housekeepers, were glad to have students in their midst. He said the doctors took care of him, and, as a student, he moved quickly between the physicians to learn as much as he could; a feat that was easily accomplished in the small hospital.

"I learned more in four weeks in Ely than I did in my first two years of medical school," he said. Working with Norman Christensen, M.D., he saw urology cases in the operating room, cast broken limbs in the emergency room and delivered babies.

"Without specialists available, the primary care physician does it all. Anything that comes through the door."

Over in Elko, preceptor Maureen Durkin, M.D., often called Dieringer in to see a variety of cases and was very dedicated to teaching through that process. As a third-year student, he was addressed as "doctor" by both physicians and patients.

Dieringer said without specialists at hand, he was forced to do his own research and learn on his own.

"I learned to talk to patients and hone my skills at researching and planning a course of treatment. My medical skills advanced quicker."

Chris Kurnik, Class of 2017, who recently completed his pediatrics and internal medicine clerkships in Elko, said one of the most surprising aspects of his rural rotation was that he rarely had angry patients due to office delays.

"They were grateful to get in to see a doctor, even if it was late."

Being in a smaller hospital had its advantages for Kurnik in that it was easier to track processes and people.

"I was more aware of what was happening and was able to handle patients from beginning to end. Care was not split up between hospital functions."

Kurnik found his preceptors eager to teach and wanting to help him learn as much as he could during his time with them.

"I was very involved with the patients and had to take responsibility for them with only one attending with me."

Annie Hong, Class of 2017, also spent time in Elko for her internal medicine and pediatric clerkships.

"I liked my rural experience because I'm thinking of primary care and I got more chances for continuity of care. I got to know my patients, their history and backgrounds. It made medicine more personal because it is someone's story."

Hong found the rural hospital setting less about the procedure and technology and more about the fundamentals of medicine. Because there are fewer people in the rural hospital, Hong found herself more involved with the process and health care team, even as a student.

Overall, Hong said her rural learning experiences was terrific, because she got to learn more, work with doctors and simulate putting in orders.

"Our preceptors are very supportive of our learning. They want to teach us and have us learn. They gave us the best learning experience."

Caroline Perez, Class of 2016, was impressed by the genuine bond she witnessed between doctor and patient during her rural rotation in Minden with Sue Sanchez, M.D.

"Most of the patients I saw had been seeing the same physician for years and coming to the doctor was like seeing an old friend. In many cases, a hug was part of the physical exam! This type of relationship is really important to witness, whether going into a field that provides longitudinal care or not. It's a great perspective to see patients in a more personal context," she explained.

Working in a small community in a geriatric-based practice, Perez was surprised to learn that not all patients want to change, even when it is for the better.

"Some may choose to decline treatment or continue a treatment that is no longer advisable simply because they believe it is best. In these cases, I really learned the importance of laying out the information of risks and benefits to the patient and then recognizing that at some point you have to let go, let the patient decide and understand that decision."

For their part, rural preceptors who take in students and residents also have great things to say about the experience.

David Hogle, M.D., an internist in Elko, has taken School of Medicine students for more than 15 years and finds their "a-ha" moments some of the most rewarding, because they learn through experiencing real medical problems.

There are personal benefits to him, as well.

"It is stimulating to have students around because I'm forced to think about answering questions I haven't thought about in a while and I have to justify my responses," he said.

"I've known my patients for years and have a feel for how they present. I know their personalities and I try to prepare my students as needed based on that."

Hogle has students see the patient first, without him, and them come out and consult with him for a treatment plan.

"Then together, we present the treatment plan to the patient," he said.

Using this process, Hogle sees students grow and mature over just a few weeks.

"They become remarkably better at recognizing symptoms and get acclimated to the toolbox of skills they have."

Leonard Parkinson, M.D., a family medicine physician in Winnemucca, said practicing in a rural setting is "like going back to the horse, buggy and black doctor's bag."

He sees teaching students in a rural community as an opportunity to have them learn by experience.

"You can't tell it to them; they have to feel and see it to get their head around it and learn by doing," he said.

He added that practicing medicine is a calling, not a job, and he tries to impart that to his students.

"It's easy to get to know patients because they are your friends and neighbors. It's a different level of involvement than in urban areas."

As for his patients, Parkinson said most are excited to have a part in the education of up-and-coming physicians.

"Students are very well received by my patients… and they love the extra time and attention they get from students."

Richard Davis, M.D., an orthopaedic surgeon, has a busy practice based out of Banner Churchill Community Hospital in Fallon. As a hospital employee, he can offer students many clinical opportunities due to his patient volume.

"We recognize and do what we can here and I try to teach students what we can and can't do," Davis explained. What he does do includes giving injections, surgery and physical therapy. His practice offers numerous opportunities to see pathology and, he believes, offers a rich learning experience for students.

After taking in School of Medicine students for four years, Davis has high praise for his charges.

"University of Nevada, Reno students are of high quality; they are smart, engaged and interested. They have excellent minds and have been well trained," he said.

He said he is glad to have the chance to pass on what he knows to the next generation.

"That is the ethos of medicine."