Partnerships to Establish and Sustain Rural GME: Q and A with Randy Longenecker, MD
This interview is part of a series featuring Sponsoring Institutions and programs providing rural graduate medical education (GME) experiences. The series was initiated following the 2022 ACGME Annual Educational Conference presentation on Medically Underserved Areas/Populations: Partnerships to Establish and Sustain Rural GME, available in the ACGME’s digital learning portal, Learn at ACGME. Note: an account (free to create) is required to access most content in Learn at ACGME.
Randy Longenecker, MD is assistant dean emeritus and professor of Family Medicine at the Ohio University Heritage College of Osteopathic Medicine (OUHCOM). OUHCOM is an osteopathic medical school anchored in Appalachian Ohio. It has three campuses in Athens, Dublin, and Cleveland, Ohio. In 2013, after 30 years of comprehensive rural family medicine practice, 15 of those as program director for a rural track residency, Dr. Longenecker established the Office of Rural and Underserved Programs at OUHCOM and developed the Rural and Urban Scholars Pathways program that currently engages more than 12 percent of students across all three campuses. With philanthropic funding, OUHCOM became the incubator of the RTT Collaborative (now the Rural Medial Training Collaborative), which originated in 2012. Although Dr. Longenecker no longer teaches, he continues to write, advocate for rural communities, and advise rural programs in medical school and residency.
ACGME: What drew you to academic medicine and to rural GME specifically?
Dr. Longenecker: I developed a taste for teaching in residency but wanted to clinically practice first. In clinical practice, I developed a taste for administration as a medical staff leader, and during a sabbatical from clinical practice, I developed a taste for research and scholarly activity! I initially became a member of the Society of Teachers of Family Medicine to join the group on family-centered maternity care as a clinician and volunteer community preceptor who occasionally took a medical student on rotation. Then, during a sabbatical from clinical practice, I learned about rural training tracks [RTTs] and decided I wanted to start one in my own community. In 2000, I joined a group of rural medical educators in San Antonio that eventually became the National Rural Health Association Rural Medical Educators. In 2010, I had the opportunity to direct the HRSA [Health Resources and Services Administration]-funded RTT Technical Assistance program from which emerged the non-profit, the RTT Collaborative. Thirty years of comprehensive rural family medicine, including maternity care, followed by 10 years in medical school and national non-profit administration of efforts in rural GME, have fueled my ongoing passion and commitment to community-engaged health professions education and training in rural places.
ACGME: Describe the rural GME experiences within your organization (e.g., types of sites, structure, curriculum, etc.).
Dr. Longenecker: OUHCOM is closely affiliated with (but does not sponsor) 10 of the 13 rurally located residency programs in Ohio. Students rotate in each of these programs, including the specialties of family medicine, internal medicine, psychiatry, and emergency medicine. None of the OUHCOM-affiliated programs are designed as a rural track program, although the one rural psychiatry program functions as such with 13 weeks of urban training. In most cases, the rural context is the curriculum, with a minority of the programs explicitly emphasizing rural content or a rural mission.
ACGME: How did your organization become involved in establishing rural GME experiences?
Dr. Longenecker: OUHCOM was established in statute by the Ohio legislature in 1975 to meet the need for doctors in rural Appalachia. As one of the first Osteopathic Postgraduate Training Institutions [OPTIs], OUHCOM provided supportive academic services to rural hospitals in the state until the transition to a single accreditation system for all US GME in 2015-2020. Each of these hospitals in turn hosted osteopathic medical students. Philanthropic funding through the Osteopathic Heritage Foundations Vision 2020 grant called for establishing rural tracks in medical school and residency, and I was hired in 2012 in part to direct those efforts.
ACGME: Describe the internal and external partnerships that have been important in establishing and sustaining these experiences.
Dr. Longenecker: The OPTI was a key strategy adopted by osteopathic medical schools in the 1990s for assuring GME for their graduates, and affiliation with a number of programs and positions adequate to meet the post-graduate needs of graduating students is still a requirement for osteopathic medical school accreditation. Almost all of the hospitals affiliated with the OUHCOM OPTI elected to become their own Sponsoring Institution during the transition to a single accreditation system. Another important development in the past decade was the rebasing of Medicaid GME financing by Ohio’s Governor, when large disparities in funding between urban and rural hospitals became public in 2014. Up to that point many of these rural hospitals had gotten no or very little Medicaid GME funding. In 2020, five Ohio medical schools with rural pathway programs, led by OUHCOM’s Office of Rural and Underserved Programs, formed an informal Ohio Rural Physician Training Pathways network to collaborate on strategies for encouraging students toward rural residency and rural practice.
ACGME: Describe the challenges you have experienced in developing and sustaining rural GME partnerships and experiences; and explain how you have overcome them.
Dr. Longenecker: Although 18 percent of Ohio’s 20-plus million population live in rural places by census definitions, Ohio is a patchwork of rural places, and few congressional districts are predominately rural. Rural communities therefore represent a minority interest in state government. In addition, eight of Ohio’s nine medical schools are located in cities, and most of Ohio’s many residency programs are in cities as well. An effort to create a formal consortium of rural programs as institutional sponsor failed for lack of support by the affiliated medical schools and was complicated by the disruption in the osteopathic medical community afforded by the transition to ACGME accreditation. The bright spot in all of this was the formation of the RTT Collaborative in 2012, which is now the Rural Medical Training Collaborative, to include rurally located and rurally focused programs all over the US, and which has contributed to the increased visibility and attractiveness of rural residencies generally. The rural programs in Ohio have done well in part from a long history of student rotations in these hospitals and established relationships across undergraduate and graduate medical education. The OUHCOM Rural and Urban Scholars Pathways program, with multiple open enrollment periods across the four years of medical school, has led to greater numbers graduating to rural residencies and to eventual rural practice than could have been achieved by the medical school rural scholarship restricted track program originally proposed.
ACGME: Describe some of your organization’s outcomes since establishing rural GME experiences, including the impact to the surrounding community.
Dr. Longenecker: As the founding executive director of the RTT Collaborative, based at OUHCOM for the 10 years before and immediately following my retirement, I have seen the number of rural programs in Ohio increase from seven to 13. The RTT Collaborative held its first Annual Meeting in Athens, Ohio in 2014, as an outgrowth of the preceding HRSA-funded RTT Technical Assistance program. One of the newest programs was a recipient of a Rural Residency Planning and Development Grant. It is too early to assess community impact of changes in the past decade; it will be another decade before the evidence is in, since it will require multiple linear regression analyses of national data sets to control for many confounding variables important to practice placement in rural communities.
ACGME: What advice do you have for those interested in establishing rural GME experiences?
Dr. Longenecker: Don’t do it alone. Seek counsel from rural GME peers and individuals and organizations with deep knowledge of the complexity of rural GME development, finance, and governance.
ACGME: Describe the resources that have helped your organization to establish rural GME experiences.
Dr. Longenecker: OUHCOM and programs that participate in the RTT Collaborative benefit from the distributed expertise of the rural GME community. I have participated as director or associate director for the RTT Technical Assistance program (HRSA-funded 2010-2016), Rural PREP (HRSA-funded 2017-2022), and the RRPD Technical Assistance Center (HRSA-funded 2018 to present), all of which have contributed to the repository of resources available at http://ruralgme.org and a growing evidence base in the published literature.
ACGME: Is there anything else you would like to add we haven’t asked about?
Dr. Longenecker: The challenges and caps to rural GME are many and will require persistent effort and creativity if workforce maldistribution of the physician workforce is to be successfully addressed.
Email muap@acgme.org if you want to get in touch with Dr. Longenecker. Is your Sponsoring Institution/program already providing rural GME experiences and would you like to be featured in a future post in this ACGME Blog series? Email muap@acgme.org to share what you’re doing. Visit the MUA/P web page to learn more about the ACGME’s efforts.