Pilot Programs Pitch Neurology Training and Practice in Rura… : Neurology Today

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In rural areas, particularly in the West and Southwest, Mayo Clinic, University of Utah, and other medical schools have created pilot programs to expose neurology trainees to practice in rural or limited-resource settings. Neurologists at the helm of these programs discuss the benefits of that exposure and the upside of practicing neurology in rural areas.

When she was in residency at Dartmouth-Hitchcock Medical Center, Tracie A. Caller, MD, wasn’t sure that she would return to her home state of Wyoming to practice. But she gave it a try and, eight years later, she is the sole full-time neurologist in Cheyenne Regional Medical Group, serving patients across eastern Wyoming, western Nebraska, and northern Colorado.

The clinic has lost two full-time neurologists since she arrived. But the challenges of working in isolation are outweighed by the feedback she hears from her patients, Dr. Caller told NeurologyToday.

“In a rural area, people are so grateful to have access to a specialist,” she said. “I hear it day-in and day-out: ‘I’m so grateful I could get to see a neurologist here.’ It’s very rewarding that way.”

Neurologists who work in rural settings believe more physicians would choose rural practice if they were aware of the benefits. And academic medical centers that seek to alleviate the rural neurology shortage are creating opportunities for medical students and residents to see what rural practice looks like.

In June, Mayo Clinic sent its first neurology resident to the Winslow Indian Health Care Center in Arizona in a pilot program to test the rural rotation option.

“There is definitely a known need that is starting to be addressed from the academic side,” said Michael Stitzer, MD, the only neurologist in Winslow and preceptor for the Mayo Clinic resident. “I hope that what Mayo Clinic is doing becomes something that all of the major academic centers add to their curriculum.”

The University of Utah is already on board. In the past year, Thomas Buchanan, MD, a solo practitioner in Vernal, UT, has served as preceptor for three neurology residents who completed month-long rotations at his practice.

“Neurologists need to have exposure to rural rotations so that they are not afraid of accepting a job out in a rural community,” said Dr. Buchanan, a hub leader with the University of Utah’s Rural & Underserved Utah Training Experience (RUUTE).

Stroke neurologist Stephanie Lyden, MD, assistant director of RUUTE, debriefed two of the residents after their rural rotations and found them newly aware of the vast differences between neurology practice at a big academic center and a rural setting.

“The experience showed them a completely different perspective on resources for diagnosis,” said Dr. Lyden, assistant professor of neurology at the University of Utah Health School of Medicine.

One of those residents, Amanda Ellgen, MD, recognized an opportunity to conduct research, a requirement of her training program, based on her rural rotation. She launched a quality improvement project to reduce door-to-needle time for stroke patients at the hospital where Dr. Buchanan practices. With support from the hospital’s stroke coordinator, Dr. Buchanan, members of the university’s telestroke service, and Dr. Lyden, a stroke specialist, Dr. Ellgen developed a new stroke-care protocol and conducted a site visit to train emergency medical services staff, floor nurses, and emergency department staff via didactic lectures and mock stroke codes.

“This could have huge implications for clinical care and is a cool collaboration between the hospital and our department,” Dr. Lyden said.

The Reality of Rural Practice

dr Stitzer has been trying to expand access to neurology care by encouraging students in training to consider rural neurology ever since he started working for the Indian Health Service in 2012.

In addition to the lack of exposure to rural practice, he thinks the trend toward subspecialization in neurology contributes to the dearth of rural practitioners, who diagnose and treat patients with a wide spectrum of neurologic conditions. Another challenge is the responsibility that comes with working alone. In some cases, that means setting up an entire practice from scratch; in most cases, it means no hallway conversations with another neurologist to discuss a difficult case.

None of those challenges drove Dr. Caller’s former colleagues in Cheyenne away from rural practice. They all retired or left because of family reasons, she said.

dr Buchanan was undaunted by those challenges when, after practicing three years in the Salt Lake City area, he convinced a hospital in tiny Vernal to hire him in 2014. The hospital administrator was skeptical that the community could support a neurologist. Today, Dr. Buchanan’s schedule has a three-month wait for a new patient appointment. While some patients drive hours to see him, most of his patients live within 50 miles of Vernal.

He finds that rural practice offers autonomy and an escape from some of the pressures that lead to physician burnout.

“I’m a general neurologist, but I’m subspecialty trained in clinical neurophysiology, so I’ve set up a nice EEG program, and I’ve done what I wanted to do,” he said. “I see great patients. Everyone is very grateful for me to be here.”

Originally, Dr. Buchanan took call duty about 20 days each month, only on weekdays. “Right now, the call is pretty light so I’m on call all the time but I could take as few as 10 days of call,” he said.

The trade-off is that he has freedom over his schedule. “I take off whenever I want–I have all the holidays off,” he said. “I do have someone check phone messages, and I can be called, if something can’t be handled in the ED.”

The challenge of diagnosing and treating many conditions is one reason Dr. Caller chose general practice, but it requires her to keep current on a wide range of topics. She attends many conferences, including occasional subspecialty conferences, to do so.

“That’s a way to get up to speed on what’s happening in epilepsy or what’s happening in movement disorders, so that I can decide what I can treat here versus [what I can] refer, and where to draw that line,” she said.

She also networks with other neurologists in Wyoming and Colorado to make up for the lack of neurology colleagues in the office. “Networking for me is really important, so that if I have a Parkinson’s patient that I’m struggling with what to do, for example, I have some place to reach out,” she said.

dr Stitzer routinely draws patients from across Arizona, as well as Utah, Colorado, and Nevada. To mitigate the shortage of neurologists in the area, he works to improve training for others who care for patients with neurologic conditions. “I try to improve access to headache care by training non-neurological providers and increase patient access to resources that can improve headache care,” he said.

A Pipeline for Rural Neurology

Increasing the number of rural physicians requires cultivating greater awareness of rural practice as an option. That’s a primary mission of the University of Washington School of Medicine’s WWAMI medical education program. WWAMI stands for the five states—Washington, Wyoming, Alaska, Montana, and Idaho—the medical school serves through agreements and financial support from the state legislatures in each state.

“We are committed to trying to help people be exposed to rural practice [based] on the idea they might come back and work there when they are done with their training,” said John McCarthy, MD, assistant dean of rural programs for the medical school.

That effort includes a robust roster of rural clerkship opportunities, including about 20 neurology clerkships, for students in their third and fourth years of medical school. dr Lyden, a University of Washington alumnus, completed rotations in Whitefish, MO, and Bozeman in Montana as well as in Casper, Cheyenne, and Lander in Wyoming, and in Yakima, WA.

“I think that greatly influenced the rest of my career because I was able to see how health care is widely different in these different health systems,” she said.

Although her main practice is in Salt Lake City, she runs to an outreach neurology clinic in Jackson Hole, WY, which has a population of 10,500, through an affiliation agreement with University of Utah. She also serves as the interim director of the university’s telestroke program, which provides telestroke consultation to 25 hospitals throughout Wyoming, Montana, Nevada, Utah, Idaho, and Colorado.

“Almost all these sites are rural and are usually very thankful for having access to specialty care via telehealth,” she said.

dr Caller, who also attended the University of Washington School of Medicine, did several rural clerkships that helped her see how specialists can support primary care physicians who need to provide neurologic care in small communities.

“The specialist would see the patient, generate some ideas for what might be done, and identify the next steps,” she said. “I’ve incorporated that into my practice by working closely with primary care and giving them suggestions—’If this doesn’t work, try this,’ and, ‘Here’s when I really need to see the patient back’—so we have a coordinated plan of care.”

In 2020, dr. Caller started a clerkship site for neurology in Cheyenne, exposing some students to both rural practice and neurology for the first time. She works with about five students each year; they rotate with her on inpatient and outpatient service and work with a neurosurgeon.

“In many cases, they didn’t really think about neurology being available in Wyoming and didn’t understand what neurologists do,” she said. “The students have really enjoyed being out here because they get to see a lot of different patients, and they aren’t competing with other students for clinic patients. When you’re the only student, you get a lot of hands-on learning.”

At the University of Utah, Dr. Lyden and her colleagues are building a pipeline of rural physicians that starts in elementary school, introducing young children to health sciences, and continues with a program that targets students in middle school, high school, and undergraduate education.

At the medical school level, RUTTE supports the clerkship directors from neurology and other specialties to help place students in rural clerkships. “And we also help provide lodging and mileage reimbursement for the students so that they aren’t incurring any financial hardship by going on these rural rotations,” Dr. Lyden said.

Mayo Clinic’s pilot of a residency rotation at Dr. Stitzer’s practice stems from years of work by Cumara B. O’Carroll, MD, a stroke neurologist at Mayo Clinic, to broaden residents’ exposure to under-resourced practice settings.

“Because of our patient population, traditionally trainees across the enterprise at Mayo Clinic have less exposure to resource-limited clinical settings and few opportunities to manage those complications that are influenced by the social determinants of health,” she said.

dr O’Carroll, director of a service-learning committee for Mayo Clinic nationwide, championed the pilot program to help change that. “This is a pilot to show what’s possible, but there are going to be many more of these, whether in rural settings or limited-resource settings,” she said. “We hope to start incorporating this type of experiential service learning into our core residency programs across the enterprise.”

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