Rural vs urban rotations?

[Brahventus]

For 3rd year, our school lets us choose between doing our core rotations in the area which is pretty urban or at several satellite rural areas. I heard that rotating at rural hospitals allow you to do more and have a better chance at forming relationships with attendings vs more populated urban rotation sites. Any advice?

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[adamanteus]

I did 3rd year rotations at a rural location, and even though it's going to be preceptor-dependent, most of mine allowed me to do as much as I asked for. My surgery preceptor let me do a lot of stuff that the patient may or may not have been aware a student was doing, both in surgery and in the clinic. I was one-on-one with all attendings, and first assist in all surgeries. Downsides would be not having any experience with doing rounds with residents and the formal teaching/didactics that you get an academic centers.

 

[Brahventus]

Which do you think would be more beneficial in terms of getting into a residency?

 

[adamanteus]

There are a couple of factors to consider. Yes, at rural places you might get more hands-on, but when you start in residency, everybody is expected to be a Level 0. If you are above that at the start, then good for you. So you might feel better about some things at the beginning, but that probably doesn't play much of a factor when it comes to programs selecting you in the match.

On the other hand, programs might want to see that you are familiar with rounds/presenting well/seeing patients in an academic setting so that they don't have to worry about you struggling from the get-go on something like that. I'm applying family med, and so far only one person (out of 8 interviews to date) has asked me about my third year experiences in a rural place.

 

[22031 Alum]

There are a couple of factors to consider. Yes, at rural places you might get more hands-on, but when you start in residency, everybody is expected to be a Level 0. If you are above that at the start, then good for you. So you might feel better about some things at the beginning, but that probably doesn't play much of a factor when it comes to programs selecting you in the match.

On the other hand, programs might want to see that you are familiar with rounds/presenting well/seeing patients in an academic setting so that they don't have to worry about you struggling from the get-go on something like that. I'm applying family med, and so far only one person (out of 8 interviews to date) has asked me about my third year experiences in a rural place.

Agreed. I remember very little when new interns come in having done a bunch of procedures as students. I do remember when new interns struggle with "resident" tasks like managing the lists, rounding efficiently and writing good notes. If you have access to clinical experiences that shine in both aspects, that's the clear choice. But if you have to pick one or the other, I'd recommend the one that prepares you to be a resident-- especially for rotations in the field you plan on entering.

 

[Mirp]

Core rotations should only be 3rd year so IMO it doesn't matter so much whether you pick the rural or urban track as long as you mix it up a bit 4th year to get that exposure 22031 Alum mentioned. That said, many of my colleagues trained at rural tracks at their med school and have done just fine on those difficult time crunch rotations as interns. Your residency program will make sure to encourage the behavior they're seeking.

All that aside, don't forget that 3rd year is basically the only time you'll have a chance to get some hands on experience in the field you think you want to work in for the rest of your life. 4th year is basically dotting your i's, crossing your t's and doing a couple of extended interviews. 3rd year may change your mind about what you want to do or reinforce what you already believe. Either way, rural vs urban is likely to play a role in that. Just some more food for thought.

 

[Psai]

Go rural and learn how to do stuff.

 

[cabinbuilder]

On the other hand, programs might want to see that you are familiar with rounds/presenting well/seeing patients in an academic setting so that they don't have to worry about you struggling from the get-go on something like that. I'm applying family med, and so far only one person (out of 8 interviews to date) has asked me about my third year experiences in a rural place.

In whose dilusional world? OMG, this whole rounding this is so super over rated. My worst rotations as a student were in bigger centers getting dragged around doing rounds at all ungodly hours. Sitting the the library all day waiting for the attending to get out of clinic only to be berated about being stupid. Hated morning report every single day. Go rural during third year. Have fun. Learn stuff.

 

[LUCPM]

Second the above. I've done my 3rd year at a rural hospital and 4th year at a bigger, urban hospital. I waited for almost 7 hours until my attending showed up on Thanksgiving day to round on two patients. They don't care if you are doing nothing but waiting for a 10 minute round on Thanksgiving day because you are a freakin' med student. On the contrary, all my rural attendings gave me an extra day or two around holidays because I was a med student. And most of them made sure I was learning something when I was actually in the clinic.

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[adamanteus]

In whose dilusional world? OMG, this whole rounding this is so super over rated. My worst rotations as a student were in bigger centers getting dragged around doing rounds at all ungodly hours. Sitting the the library all day waiting for the attending to get out of clinic only to be berated about being stupid. Hated morning report every single day. Go rural during third year. Have fun. Learn stuff.

Some programs do care about it. I'm not saying it's justified. I've spoken to program directors outside of family med (prior to my interest in FM) who specifically asked in depth questions about my experience with rounding and reporting to residents and this seemed to be a big deal to them. Whether it actually matters or not is another thing, but the OP asked which setting would be better, and I was offering the two sides of the coin based on what I've experienced and have been told by PDs.

 

[cabinbuilder]

Some programs do care about it. I'm not saying it's justified. I've spoken to program directors outside of family med (prior to my interest in FM) who specifically asked in depth questions about my experience with rounding and reporting to residents and this seemed to be a big deal to them. Whether it actually matters or not is another thing, but the OP asked which setting would be better, and I was offering the two sides of the coin based on what I've experienced and have been told by PDs.

OH, I wasn't getting down on you per se. I'm just speaking from experience going through residency and being in the real world. Rotations really are meaningless in the long run and they teach you everything in residency anyway so I would not pick a rotation based on perceived future PD's response but on the availability to experience and do as much as possible.

 

[22031 Alum]

I agree that you can't make all decisions based on what a PD may like, but guess who stands between you and eventually getting out to actually practice?? PDs. You have to at least consider what they think is important, and my experience in the world of resident selection tells me that procedural experience < resident skills. We expect to have to teach you the former. We expect everyone to come in with a certain baseline comfort with the latter.

 

[RuralMedicine]

I did rural track for my third year and in my case I think it was the right decision. The majority of my attending preceptors wanted to teach and did so well. I do think we had less canned didactic lectures than my peers at our non rural sites but I was directed in reading about patients (and I really saw a lot--although I was at a rural site it was a rural tertiary center with 300+ beds so there wasn't a dearth of pathology) and then used the recommended rotation curriculum to fill in the gaps when I had down time. I also think I learned early on to take ownership for my diagnoses and management plans (obviously there was a safety net and there absolutely needs to be) but I think this is an important part of clinical rotations and I think it is easier to miss out on this in a larger setting. I did all of my fourth year rotations at larger academic centers so I certainly was also exposed to team rounds with physician N=20 and I apparently functioned well enough to achieve honors in the majority of those rotations.

Having said this, I realize that not all rural tracks are created equally so perhaps the first question is to look at the quality of your rural track (both in terms of teaching, and patient pathology) and then consider whether the program is a good fit for you.

 

[RuralMedicine]

I agree that you can't make all decisions based on what a PD may like, but guess who stands between you and eventually getting out to actually practice?? PDs. You have to at least consider what they think is important, and my experience in the world of resident selection tells me that procedural experience < resident skills. We expect to have to teach you the former. We expect everyone to come in with a certain baseline comfort with the latter.

I do agree that patient management skills should trump procedural skills in focus as a medical student. Perhaps a bit ironically, or perhaps not, one of my surgery attendings from third year was the biggest champion of that opinion. So I came out of that rotation with a good understanding of the whys/whens/ when nots of surgery along with the ability to do one hand ties, and a subcuticular closure.

 

[IslandStyle808]

I did rural track for my third year and in my case I think it was the right decision. The majority of my attending preceptors wanted to teach and did so well. I do think we had less canned didactic lectures than my peers at our non rural sites but I was directed in reading about patients (and I really saw a lot--although I was at a rural site it was a rural tertiary center with 300+ beds so there wasn't a dearth of pathology) and then used the recommended rotation curriculum to fill in the gaps when I had down time. I also think I learned early on to take ownership for my diagnoses and management plans (obviously there was a safety net and there absolutely needs to be) but I think this is an important part of clinical rotations and I think it is easier to miss out on this in a larger setting. I did all of my fourth year rotations at larger academic centers so I certainly was also exposed to team rounds with physician N=20 and I apparently functioned well enough to achieve honors in the majority of those rotations.

Having said this, I realize that not all rural tracks are created equally so perhaps the first question is to look at the quality of your rural track (both in terms of teaching, and patient pathology) and then consider whether the program is a good fit for you.

What similarities and differences did you find in rotating in a rural tertiary center versus an urban one (including academic)?

 

[RuralMedicine]

What similarities and differences did you find in rotating in a rural tertiary center versus an urban one (including academic)?

Rural Tertiary Care
-Not all services (i.e. my hospital did not have a 24 hour cath lab, they had a level 2 NICU, they were a level 2 trauma center (mainly because with 2 neurosurgeons they weren't going to require one of them to be in house all the time), we did not have a burn unit) are available so there is still some transfer to other tertiary care facilities after initial stabilization.
-Rural/Urban trauma are different
-Smaller medical staff and perhaps this lead to more/closer cross specialty collaboration.
-No GME at the time I was a student [This facility does now small IM/FM (I believe 3 residents a year each) residencies]

Urban Tertiary Care [More based on my residency experiences at an Academic Urban Medical Center because I ended up going to a lot of different hospitals my 4th year by choice-it was a good way to check out residency programs and there were so many differences]
-If it exists it can be provided somewhere within our system [Our system consisted of the traditional University Medical Center, a stand alone Children's Hospital, a private Tertiary Care Hospital (which merged with the UMC) and was actually the cardiac hub for the system].
-Urban trauma is different (although where I trained we did get some of the rural trauma flown in so there was a bit of a mix).
-Our children's hospital was the only stand alone in the state so we kind of saw it all but this is not always the case if there are a few hospitals close together they will often each get their niches or strengths (or perhaps weaknesses) and they may not all have all subspecialties [or in the state my husband and I currently practice in none of them have all specialties so it's kind of like hmm do I send my patient with likely lupus to the hospital with pediatric rheumatology or do I send her to the hospital without that but with pediatric nephrology because she will likely need a kidney biopsy--I quickly realized how much I had taken for granted as a resident].
-Larger medical staff so you can be at the same hospital and have no interactions with many of your colleagues in name. I would still say that cross specialty collaboration was pretty strong and I have residency friends who were not in my field (and not people I had known prior to residency either).
-From a medical student standpoint (again based on my experiences as a teaching resident with students from our university medical school) I think it was very possible to blend into the background and just kind of tag along for the experience but have it be a quite passive learning experience and environment. This isn't what I would advise students to do and I certainly have had students who really attacked their rotations in a positive way so I acknowledge that some of this is student dependent. Having said that, I don't think that the program I rural tracked through would have allowed a student to take the tag along approach (exactly how that would be handled I'm not sure but I just don't see it flying).

This has gotten quite rambling so if you have any more specific questions feel free to ask. My husband is currently a rural attending preceptor. I currently work part time as a hospitalist at a university regional campus and have students periodically (who I share with my colleagues just like we share patients since none of us are there all the time).

 

[IslandStyle808]

Rural Tertiary Care
-Not all services (i.e. my hospital did not have a 24 hour cath lab, they had a level 2 NICU, they were a level 2 trauma center (mainly because with 2 neurosurgeons they weren't going to require one of them to be in house all the time), we did not have a burn unit) are available so there is still some transfer to other tertiary care facilities after initial stabilization.
-Rural/Urban trauma are different
-Smaller medical staff and perhaps this lead to more/closer cross specialty collaboration.
-No GME at the time I was a student [This facility does now small IM/FM (I believe 3 residents a year each) residencies]

Urban Tertiary Care [More based on my residency experiences at an Academic Urban Medical Center because I ended up going to a lot of different hospitals my 4th year by choice-it was a good way to check out residency programs and there were so many differences]
-If it exists it can be provided somewhere within our system [Our system consisted of the traditional University Medical Center, a stand alone Children's Hospital, a private Tertiary Care Hospital (which merged with the UMC) and was actually the cardiac hub for the system].
-Urban trauma is different (although where I trained we did get some of the rural trauma flown in so there was a bit of a mix).
-Our children's hospital was the only stand alone in the state so we kind of saw it all but this is not always the case if there are a few hospitals close together they will often each get their niches or strengths (or perhaps weaknesses) and they may not all have all subspecialties [or in the state my husband and I currently practice in none of them have all specialties so it's kind of like hmm do I send my patient with likely lupus to the hospital with pediatric rheumatology or do I send her to the hospital without that but with pediatric nephrology because she will likely need a kidney biopsy--I quickly realized how much I had taken for granted as a resident].
-Larger medical staff so you can be at the same hospital and have no interactions with many of your colleagues in name. I would still say that cross specialty collaboration was pretty strong and I have residency friends who were not in my field (and not people I had known prior to residency either).
-From a medical student standpoint (again based on my experiences as a teaching resident with students from our university medical school) I think it was very possible to blend into the background and just kind of tag along for the experience but have it be a quite passive learning experience and environment. This isn't what I would advise students to do and I certainly have had students who really attacked their rotations in a positive way so I acknowledge that some of this is student dependent. Having said that, I don't think that the program I rural tracked through would have allowed a student to take the tag along approach (exactly how that would be handled I'm not sure but I just don't see it flying).

This has gotten quite rambling so if you have any more specific questions feel free to ask. My husband is currently a rural attending preceptor. I currently work part time as a hospitalist at a university regional campus and have students periodically (who I share with my colleagues just like we share patients since none of us are there all the time).

Thank you for the exemplary response.

Were your attendings in the rural tertiary center very proactive in helping you learn about making patient notes and with presentations? I ask this question since students have had variable experiences in this.

What should students be aware off in rural rotations that would help in the transition to residency?

Were there things you gained from your rural rotations, that you weren't initially aware off, which helped tremendously in residency and current practice?

Sorry for all the questions. I have been very curious about the different types of rotation structures.

 

[RuralMedicine]

I've responded to your questions below.

Thank you for the exemplary response.

Were your attendings in the rural tertiary center very proactive in helping you learn about making patient notes and with presentations? I ask this question since students have had variable experiences in this.

I wrote H&Ps and daily progress notes on every patient I followed. I generally received decent feedback (one nephrologist in particular really spent a lot of timing providing feedback/critique of my H&Ps and I guess they must have gotten better over time because he wrote great things on my evaluation and later wrote me a really strong letter) on these. I also wrote all the orders on my patients so that kind of forced me to own the plan (because I had to put it down in writing) and also I guess reinforced the plan if it was revised. I was comfortable writing admitting orders, post-op orders, discharge orders by the end of the year. As far as presentations I generally presented patients to the attending during rounds and again I think I received decent feedback both on exam findings, management etc but also on just how to organize a presentation. One of the requirements of our program was that we did an end of rotation capstone presentation which involved a case presentation with a sort of review article style discussion of the management (i.e. I did a HTN case and discussed the practice guidelines in FP, I did a patient with Gestational Diabetes and discussed those guidelines, my surgery one was a little interesting because we had a patient with diverticular disease and perforation who presented atypically and was septic at our involvement). These were done as noon conferences and were actually attended by 15-20 attendings (it probably helped that they got some CME and lunch for their time/trouble). This hospital had a multi disciplinary journal club (i.e. surgery, EM, OB, IM etc all sat down together---articles were selected that had broader implications) so I did a few of those (in one case my attending assigned me an article that went along with his and we both presented, in another case my attending thought it would be great to let me have their turn for journal club).

What should students be aware off in rural rotations that would help in the transition to residency?

I'm not sure if this is really specific to rural but I think students should be comfortable with physical exam skills, able to obtain a solid history and then work through a differential and workup and initial management plan. This is basically what medicine is (obviously different specialties have different nuances on this theme). It is also helpful to be able to communicate and interact within the health care arena and I think sometimes this is a stumbling block for some but I also think it is almost innate for others. I kind of took it for granted but I had some students who struggled here so it was something I tried to actually teach later.

Were there things you gained from your rural rotations, that you weren't initially aware off, which helped tremendously in residency and current practice?

This is hard to answer because I think a lot has shaped the physician I am now. I suppose that my third year laid my earliest foundation but I also think I grew a lot as a resident and then grew a lot more as an attending. In my case, because I wanted to practice rurally I think it was helpful to see how one rural hospital worked and I suppose it was during my third year that I realized that FM was one approach to rural practice but that there were also others and that perhaps FM was not the best choice for my goals. I had great FM attendings so it wasn't that I wasn't exposed to good physicians it was just realizing that the practice I envisioned was probably not really FM.

Sorry for all the questions. I have been very curious about the different types of rotation structures.

 

[HooliganSnail]

In whose dilusional world? OMG, this whole rounding this is so super over rated. My worst rotations as a student were in bigger centers getting dragged around doing rounds at all ungodly hours. Sitting the the library all day waiting for the attending to get out of clinic only to be berated about being stupid. Hated morning report every single day. Go rural during third year. Have fun. Learn stuff.

Is there anything worse that ROUNDS.....UGH

 

[HooliganSnail]

Second the above. I've done my 3rd year at a rural hospital and 4th year at a bigger, urban hospital. I waited for almost 7 hours until my attending showed up on Thanksgiving day to round on two patients. They don't care if you are doing nothing but waiting for a 10 minute round on Thanksgiving day because you are a freakin' med student. On the contrary, all my rural attendings gave me an extra day or two around holidays because I was a med student. And most of them made sure I was learning something when I was actually in the clinic.

Sent from my SCH-I545 using Tapatalk

I think this illustrates the big picture of med student rotations, they really are preceptor dependent.

Some attendings suck. Many rotations you learn mostly from the resident your with.

 

[HooliganSnail]

Thank you for the exemplary response.

Were your attendings in the rural tertiary center very proactive in helping you learn about making patient notes and with presentations? I ask this question since students have had variable experiences in this.

What should students be aware off in rural rotations that would help in the transition to residency?

Were there things you gained from your rural rotations, that you weren't initially aware off, which helped tremendously in residency and current practice?

Sorry for all the questions. I have been very curious about the different types of rotation structures.

I did my med student rotations in an urban large system. It was not a good experience.

It had nothing to do with rural or urban, it had to do with culture. The culture at my hospital was the student shadowed and did nothing, and mainly spent time in the library to pass multiple choice tests.

I remember presenting a case maybe once in med school on rounds, that is it.

When you transition to residency, you will have to adapt the new things and responsibilities you have never handled before. You will never be
"fully prepared" no matter what your experience in the past. But you will do just fine.

You will adapt, it is in your nature. You managed to get into medical school, you adapted to the large volume learning in pre-clerkship. You will adapt to your clerkship rotations every month. You will adapt to residency, I promise

When choosing a rotation site, find out what the culture is at that institution. That will have more of an impact than rural/urban.

Good Luck

 

[IslandStyle808]

I did my med student rotations in an urban large system. It was not a good experience.

It had nothing to do with rural or urban, it had to do with culture. The culture at my hospital was the student shadowed and did nothing, and mainly spent time in the library to pass multiple choice tests.

I remember presenting a case maybe once in med school on rounds, that is it.

When you transition to residency, you will have to adapt the new things and responsibilities you have never handled before. You will never be
"fully prepared" no matter what your experience in the past. But you will do just fine.

You will adapt, it is in your nature. You managed to get into medical school, you adapted to the large volume learning in pre-clerkship. You will adapt to your clerkship rotations every month. You will adapt to residency, I promise

When choosing a rotation site, find out what the culture is at that institution. That will have more of an impact than rural/urban.

Good Luck

Thank you for the response

What did you do to make the most of your experience? How did you learn about your rotations? What are ways one could learn more about each site?

 

[Psai]

Ask to do things
the best way to learn about rotations is to ask upper classmen