As rural areas grapple with physician shortages, the Sanford School of Medicine (SSOM) at the University of South Dakota is demonstrating that solutions depend on partnering with communities and retaining physicians who have had intensive, hands-on training in rural settings.
The AAMC recognized SSOM’s achievements in November with the 2017 Spencer Foreman Award for Outstanding Community Service. The award is presented annually to an AAMC member medical school or teaching hospital with a long-standing, major institutional commitment to partnering with its community to address health needs.
Community service programs are often associated with urban centers that have high poverty rates, explains Philip Alberti, PhD, AAMC senior director, health equity research and policy. But SSOM illustrates that “the definition of community is broader and includes rural and frontier communities,” he says.
Cultural immersion is key
SSOM is the only medical school in South Dakota, a large, sparsely populated state. (Based on the 2010 U.S. Census, an average of 10.7 South Dakotans live on each of the state’s 77,000 square miles.) According to SSOM Dean Mary Nettleman, MD, South Dakota’s primary health challenge is access to patients who need care in rural areas.
All but four of South Dakota’s counties are listed as underserved on the basis of having a remote, rural population. Of 53 hospitals in the state, 38 are critical access hospitals. Only two cities have a population over 30,000, and they are on opposite sides of the state, so a trip to one of these centers can take hours. Helicopters from these cities do not have the range to cover all of South Dakota, which makes locally available health care even more important, Nettleman notes.
To meet these challenges, SSOM tries to recruit students from across the state because students from rural backgrounds are more likely to practice in rural areas. As a result, SSOM is among the top schools in the nation for the proportion of graduates practicing in rural areas. Currently, 92% of its medical students are South Dakotans, and 44% grew up in communities of fewer than 10,000 people.
“This is a true partnership with the people of South Dakota. The entire state is our community.”
Mary Nettleman, MD
Sanford School of Medicine, University of South Dakota
Students are first introduced to South Dakota’s diverse communities and cultures through a mandatory cultural immersion program because, as Nettleman says, “You can’t just walk in and change health care.”
All SSOM students receive extensive experience in rural medicine. Some spend nine months in the Frontier and Rural Medicine (FARM) program, which pairs medical students with family physicians in rural communities. Other students work with Native Americans who have limited access to health care and face significant health disparities.
When tribal leaders identified the need for more dedicated physicians, particularly those who are Native American, SSOM partnered with tribes to address the issue. Of the last 125 SSOM participants in pipeline programs who became physicians from 1987 to 2016, 37% were Native American, Nettleman says. SSOM also operates a satellite of the University of North Dakota’s Indians into Medicine (INMED) program, an effort to attract members of federally recognized tribes to apply to medical school. A total of 46 Native Americans graduated from SSOM from 1987 through 2017, of whom 33 went through the INMED program.
All hands on deck
SSOM’s community programs not only target rural South Dakotans’ health needs, they also provide faculty-supervised hands-on experience for students. In the FARM program, South Dakota native Anna Bahnson assisted with 11 cesarean and 21 vaginal deliveries and 100 colonoscopies and endoscopies. With physicians “looking over my shoulder to guide me,” she explains, “I first observed colonoscopies, then helped get patients into position. As I got more experience, the physician let me drive the camera out with his guidance.”
During the second half of her second year and the first half of her third year at SSOM, Bahnson worked at a 25-bed critical access hospital in Parkston, S.D. (population 1,508 in 2010 Census data. She assessed emergency room patients, stitched up a laceration near the eye of a patient who had been hit by a baseball, and was involved in numerous patient care plans.
“There’s no standing in the corner around here,” Bahnson says. “You jump right in. From the first day, it’s been an incredible hands-on immersive experience. And I’m very grateful for it.”
At a small critical access hospital in Winner, S.D., near the Rosebud Reservation, third-year student Erik Manke likewise gained experience, from making daily rounds and suturing to learning how to triage and being first assistant in surgery.
Manke also provided obstetric care to Sioux women. “A lot of time was spent on communication and education,” he explains. “Some women weren’t aware that they need periodic care. If they had one visit and everything was fine, they thought they didn’t need to come back. So we explained how many visits they need, listened to heart sounds, and monitored their care.”
In addition, Manke took part in a community service project, to teach people in rural areas how to apply tourniquets in an emergency, such as a farm or hunting accident, since hospitals can be miles away.
Manke, who has lived in South Dakota most of his life, says he “feels very blessed” by the opportunities to learn rural medicine firsthand and “get in touch with the culture.” In the future, he says, “I want to serve in a rural or semirural area.”
Thanking the community
The success of SSOM’s pipeline, rural health, and research programs show that the size of an institution’s endowment or faculty is secondary, Alberti sums up. “The most important resource for community engagement is an institution’s passion, commitment, and willingness to listen to and partner with the people they serve.”
Nettleman credits South Dakotans for the Spencer Foreman award. “This is a true partnership with the people of South Dakota,” she maintains. “The entire state is our community. We’re one of the smallest medical schools in the country. We have only about 40 faculty members and not a lot of resources, but we’ve partnered with the community.”
The FARM program, for example, grew out of many conversations with the governor’s office, health departments, medical school faculty, and community members. In holding these conversations, she says, “We have to be sensitive to the community and stay true to our mission.”
After the Foreman award was announced, SSOM erected 16 billboards across the state to recognize South Dakotans’ partnership in achieving it. The school also filmed four two- to three-minute videos to illustrate its community service. View these videos on the AAMC's Health Equity Virtual Site Visit website.