Perceptions and Attitudes toward Community Health and Interprofessional Education in Students with and without an Additional Community Medicine-Focused Program

Abstract

The Rural Medical Education (RMED) Program at the University of Illinois College of Medicine Rockford campus, and part of the National Center for Rural Health Professions, strives to recruit students from rural areas, who, after completing residency, return to rural Illinois as primary care physicians. RMED students meet monthly to learn about the community and public health in rural communities. Furthermore, they complete a 16-week rural preceptorship during their fourth year. During the fourth year of medical school, all RMED students, as well as the students following the regular curriculum, are asked to complete a survey, related to the understanding of medical students’ views of community and interprofessional education. We aimed to identify how the community-based curriculum affects the students’ understanding and appreciation of community as they go into rural health practice. The results showed that students in the RMED Program are more aware of the community they are part of, as well as being more interested in becoming part of their community. RMED students reported a statistically significantly higher rating of feeling appreciated and accepted by their community and rated their confidence in their abilities in the community statistically significantly higher. Interestingly, RMED students were not more likely to be more familiar with several health professions and programs within their community, compared to non-RMED students. Results comparing self-rated capabilities for RMED students within the community both before and after adding components of an interprofessional education curriculum showed no statistically significant changes. These results support previous research, while also providing more support for the development of successful interprofessional education courses.

Background

For nearly a century, medical education has been focused on the clinical sciences. In the past decades, it has been noted that advanced technical understanding and resources alone cannot fulfill the promise of excellent and appropriate health care [1]. Medical education based on instruction at medical centers has brought advancements that have profoundly changed the understanding and treatment of disease. However, while the treatment of disease has advanced through scientific knowledge, it is increasingly recognized that there are other important factors that influence health outcomes and personal well-being. These factors are not always well-addressed through traditional medical education methods. Students’ attitudes and perceptions should be taken into consideration when assessing their understanding and awareness of community health. It is important to not only educate students on community-based care and the social determinants of health but also teach them how to address health inequalities, in an attempt to alleviate the inequity for the patients and communities most affected [2].

A proposed solution to enhance students’ understanding and awareness of community health is to increase the clinical exposure that students receive earlier in the medical school years. Previous research focusing on the effect of clinical exposure in the first year of medical school showed a significant increase in the number of students who considered psychosocial factors as primary causes of disease, as well as major shifts in interest in “patients as persons” and “the importance of the interpersonal aspects of the doctor-patient relationship.” Almost all students reported that the most effective teaching and learning experiences were the bedside tutorials and accompanying small group sessions, focused on patient-physician contact and interactions [3]. However, increasing student numbers in a teaching hospital is not always matched by an increase in the number of patients suitable for student teaching. This overcrowded environment does little to foster teaching of students related to patient care, while it could contribute to risks of increasing student stress and teacher burn-out [4].

Another well-researched method to enhance clinical exposure is “community-based medical education,” which refers to medical education that is based outside a tertiary or large secondary level hospital. It describes a curriculum that is based on addressing the health needs of the local community and preparing graduates to work in that community. Community-based medical education focuses on the care provided to patients both before the decision to refer to a tertiary hospital and after the decision to discharge the patient from such care [5], therefore providing students with more exposure to patients who are managing their illnesses within their own family, social and community contexts [6]. These community-oriented programs have multiple benefits. They allow students to experience more personal relationships with patients, while also offering a broader range of learning opportunities to acquire knowledge, skills, and attitudes, which cannot be acquired in tertiary care settings. This includes exposure to common diseases, where hospital-based peers had a cross-sectional exposure to highly filtered illness [7]. Students learn to recognize the importance of treating people instead of “just a disease,” and they learn the significant impact the social environment can have on health and healthcare by developing a deeper awareness of the contribution of social and environmental factors in illness prevention, causation, and prognosis. A better understanding of how health and social services work also may lead to an augmented view of multidisciplinary care. Furthermore, offering a community orientation can be especially important to encourage students to enter primary care [8, 9].

Rural experiences and clinical placements have been shown to positively influence students to consider a primary care specialty and rural practice [10], with students who completed rural rotations being up to three times more likely to practice in a rural community, compared with the national average [11]. Students in prolonged rural placements were found to have increased patient contact, increased time in the clinical setting, and more time spent being supervised [12]. Furthermore, students in rural rotations have self-reported that their skills significantly increased in areas such as chronic disease management, patient education, health maintenance, and ability to handle undifferentiated and acute problems, with the largest gain in understanding health systems and the community during their rotation in a rural primary clinic [13]. Research has also shown that completing rural training experiences leads to better clinical decision-making in the context of the whole patient, their family, and available community resources [7].

The College of Medicine campus in Rockford, Illinois, offers a medical school curriculum with an additional community medicine-focused program: the Rural Medical Education (RMED) Program. The RMED Program is part of the National Center for Rural Health Professions. The RMED mission is “a medical education program designed to recruit students from rural areas, who will upon completion of residency training, return to rural Illinois as primary care physicians.” With research showing that a rural upbringing is the best predictor for a physician returning to a rural area to practice medicine, only students with a rural background are considered as candidates for the RMED Program [14–16]. Candidates considering the RMED Program participate in a dual application process, applying to both the University of Illinois College of Medicine (COM) and the RMED Program [17]. Potential students must follow the American Medical College Application Service (AMCAS) requirements as well as complete an RMED Program application and provide three letters of reference from the applicant’s rural home community [18]. Rural track students take the regular COM curriculum as well as the supplemental, required RMED curriculum.

In years 1–3, RMED students meet monthly to learn about community and public health as well as aspects of healthcare delivery in rural communities, where students participate in hands-on learning experiences including day-long rural shadowing experiences, field trips with a focus on handling farm accidents, and a two and one-half day trip to southern Illinois to meet with hospital and other healthcare providers to better understand the needs and resources for healthcare delivery in rural and small towns. In 2010, the RMED program was expanded to include rural pharmacy students and the breadth of interprofessional activities has increased regarding rural health professions shadowing and student educational projects in rural communities [19]. The capstone component of the curriculum is a fourth-year 16-week preceptorship where students live in a rural community, participate in primary care learning and healthcare delivery (in clinics and hospitals), and conduct a community-oriented primary care (COPC) project [17]. There are approximately 50 students per medical class assigned to the COM Rockford track; of these, from 13 to 20 students per year participate in the RMED Program’s rural track. There are currently 42 medical schools with a rural program for a select number of students in the USA. The RMED Program is one of the oldest rural programs [20].

Within this context, the objective of the present study was to compare the perceptions and attitudes of two student groups toward community health and interprofessional education at the University of Illinois College of Medicine at Rockford—one group in the regular curriculum only and the other group taking the regular curriculum but with the additional community medicine-focused program. The impact on RMED students from adding an interprofessional education component, increasing the complexity of the curriculum, was also assessed. As the goal of the RMED Program is to educate physicians who go back to rural Illinois to work as primary care physicians, this evaluation is not only important for future research, but also for internal evaluation of the program. With the increasing shortage of physicians in many rural areas of Illinois [21, 22], it is important to evaluate the potential of the success in educating students who appreciate and understand rural communities.

Methods

Setting and Subjects

This study was conducted over an 18-year period. All students enrolled in the RMED Program fill out a survey as part of the evaluation process for the RMED Program. The survey is administered in April of the students’ senior year; students enrolled in the regular medical school curriculum only complete the survey in their senior year. The first class of RMED students graduated in 1997, but the community survey was not developed until a few years later in 2000, when RMED and traditional program graduates initially participated in the survey. Due to changes in personnel, the survey was not administered in 2001. However, it has been administered consistently from 2002 to 2018, thus providing 18 years of M4 survey data (2000 and 2002 thru 2018).

Instruments

The survey used for this research is part of the evaluation process for the RMED Program. The survey focuses on students’ perceptions and assessments regarding community health involvement and interprofessional education. The survey is distributed as an option either on paper or online. Participation in the survey is voluntary. Its administration has been approved by the University of Illinois College of Medicine Institutional Review Board.

The survey is based on past studies in medical education [23–26] related to the understanding of medical students’ views of community and interprofessional education. Much of the survey was based on the work of Pathman and colleagues [27] in “The Four Community Dimensions of Primary Care Practice.” Pathman et al. proposed and tested an organizing framework that identified four distinct categories of activities where physicians interact with their communities:

1. Identifying and intervening in the community’s health problems;

2. Responding to the particular health issues of local cultures groups when caring for patients;

3. Coordinating local community health resources in the care of patients;

4. Assimilating into the community and its organizations and examining the hypothesis that the community plays a role in support of physicians. The study conclusion lent support to the hypothesis that the community plays a role in the work of physicians that can be categorized into the four types of activities.

The survey used for this research contained questions relating to each of the four categories that Pathman et al. identified. The survey questions focused on:

1. Questions regarding students’ self-rated confidence in their abilities related to local communities, including being able to identify and intervene in local community problems. Questions were rated on a 5-point Likert scare, ranging from “not confident at all” to “very confident” and included “How confident are you in your abilities to understand the community’s perception of its health problems?” and “How confident are you in your abilities to engage community members in efforts to address a local health problems?”

2. Questions regarding specific issues of local groups focused topics discussed with patients during primary care rotations, like cultural or religious belief issues. Students were asked to indicate average patients seen per day where various issues were discussed, with questions including “With how many patients (or parents) do you discuss if they can afford medical treatments?” and “With how many patients (or parents) do you discuss their beliefs about their illnesses?”

3. Questions for self-rated familiarity with community health professions, programs, and resources, including social work, nutrition, psychotherapy, physical therapy, chiropractic, clergy programs, drug treatment center hospice, and women’s shelter. Answers were also rated on a 5-point Likert scale, ranging from “not familiar at all” to “very familiar.” There was an option for “not available in the community” related to each profession or program.

4. Questions about the students’ participation and involvement in the community and perceptions of feeling appreciated and accepted by the community. Students were asked to self-report first-year interest in becoming a part of the community, working directly with community members, and understanding cultural aspects of patient care. This was rated on a 5-point Likert scale, ranging from “not interested” to “very interested.” Questions included “When you started medical school, how interested were you in becoming part of your community?” Moreover, we included questions about involvement in community activities in years 3 and 4 of medical school. These questions were answered “yes” or “no.” Questions included “In the past two years, have you written or appeared in a health-related story in the local media?” This section also included questions for self-evaluations of the extent of students’ involvement in the community comparing years 1–2 with years 3–4 of medical school, asking students “Did you have any extended involvement in the community (three months or more) during the first two years of medical school” and “Did you have any extended involvement in the community (three months or more) during the last two years of medical school,” both questions were answered “yes” or “no.” Lastly, students were asked to rate the amount of contact they have had with physicians active in the community, using a 5-point Likert scale, ranging from “no contact” to “extensive contact.”

In addition to questions regarding students’ interactions with communities, we also looked at demographics: age, gender, race/ethnicity, and self-report of rural background. We included questions about self-reported amount of training in medical and healthcare issues during medical school. These questions were rated using a 3-point Likert scale, ranging from “none” (1) to “moderate/extensive” (3). Questions included “How much training did you have in rural medicine?” and “How much training did you have in how to identify health problems in the community?” The survey ended with the open-ended question “What has taught you the most about community medicine.” Answers to this question were coded into several different categories, including the RMED community preceptorship, their attendance at one of the University Primary Care Clinics, research, public health classes, a health course, other clinical experiences, or more than one class or rotational activity.

As our study is the first to use this survey, there are no data currently available regarding the validity of the survey used. However, with this survey being based on previous literature, we expect the face validity of our survey to be good and we expect our survey to measure what we aim to study.

Statistical Analysis

Data were analyzed using SPSS release 24.0.0.0 (IBM Corporation, Chicago, IL). Independent samples T tests were used to compare and identify statistically significant outcomes for RMED students and non-RMED students. Repeated measure comparisons were used to identify statistically significant changes over time for the first-year and fourth-year responses of the RMED students.

Results

Demographics of Respondents

A total of 196 RMED students (out of 268 graduating RMED students over 18 years) and 200 non-RMED students (out of 611 graduating non-RMED students over 18 years) completed the survey, resulting in a total of 396 fourth-year students completing the survey in their last year of medical school. For the RMED group, the vast majority of all students were Caucasian, while the group in the regular curriculum showed greater ethnic diversity. More students in the RMED curriculum had one or more children under the age of 18 at the time of the survey in their final year. As expected, a high percentage (91.8%) of the RMED group responded they had grown up in a rural area. A full demographic information overview is provided for each group separately in Appendix Table 1.

Table 1.

Demographics for fourth-year students of the RMED Program (n = 196) and regular curriculum (n = 200)

	RMED students		Regular curriculum students
	N a	%	N a	%
Mean age (years)	27.6		27.7
Gender
Male	101	51.8	99	50.0
Female	94	48.2	99	50.0
Ethnicity
Caucasian	185	95.9	99	50.5
Hispanic/Latino	1	0.5	30	15.3
Asian or Pacific Islander	7	3.6	42	21.4
African American	0	–	12	6.1
American Indian, Eskimo, or Aleut	0	–	1	0.5
Other	0	–	9	4.6
Multiple	0	–	3	1.5
Grew up in rural area
Yes	178	91.8	44	22.0
No	16	8.2	156	78.0

^aMay not add up to 196 due to missing data

Response Rates

Response rates varied between years. In general, response rates to the survey were higher for RMEDs than for non-RMEDs. The cumulative response rate during the 18 years of data collection was 73.1% for RMEDs and 32.7% for non-RMED students.

Survey Findings

Familiarity with Professions, Programs, and Resources in the Community in the Fourth Year

The survey asks students to self-rate their familiarity with several professions, programs, and resources in their community. In this case, familiarity referred to being familiar with the profession itself, not necessarily the specific medical professionals in the community. Our results showed that fourth-year RMED students were more statistically significantly more familiar with physical therapists, chiropractors, and clergy programs, while non-RMED students were statistically significantly more familiar with psychotherapists, drug treatment centers, and women’s shelters in their community. This difference could be explained by the absence of certain health programs and professions in the rural communities, suggesting that no availability of these services leads to less knowledge and familiarity. A full overview of the results is provided in Appendix Table 2.

Table 2.

Self-rated familiarity with community health professions, programs, and resources in the fourth year for RMED students and non-RMED students

	N	Mean scorea (SD)	p value
Psychotherapist	RMED (n = 168) Non-RMED (n = 196)	2.61 (1.13) 2.90 (1.32)	0.023
Nutritionist	RMED (n = 175) Non-RMED (n = 196)	2.83 (1.22) 3.04 (1.28)	0.115
Social worker	RMED (n = 188) Non-RMED (n = 196)	2.98 (1.29) 2.98 (1.20)	0.996
Physical therapist	RMED (n = 182) Non-RMED (n = 197)	3.51 (1.24) 3.16 (1.25)	0.007
Chiropractor	RMED (n = 182) Non-RMED (n = 196)	2.84 (1.29) 2.00 (1.14)	<0.001
Clergy program	RMED (n = 190) Non-RMED (n = 197)	2.94 (1.35) 2.48 (1.43)	0.001
Hospice program	RMED (n = 187) Non-RMED (n = 199)	3.35 (1.32) 3.35 (1.41)	0.976
Drug treatment center	RMED (n = 169) Non-RMED (n = 196)	3.21 (1.38) 3.71 (1.19)	<0.001
Women shelter	RMED (n = 168) Non-RMED (n = 194)	2.61 (1.17) 2.98 (1.31)	0.006
Pharmacist	RMED (n = 13) Non-RMED (n = 13)	4.15 (0.99) 4.08 (0.64)	0.816
Nurse practitioner	RMED (n = 13) Non-RMED (n = 13)	4.46 (0.97) 4.38 (0.77)	0.824
Physician assistant	RMED (n = 13) Non-RMED (n = 11)	3.62 (1.50) 3.82 (1.25)	0.726

^aStudents rated their self-reported familiarity with several community health professions, programs, and resources using a 5-point Likert scale, ranging from “not familiar at all” (1) to “very familiar” (5). A higher score demonstrates a higher level of familiarity

The RMED program was expanded to add interprofessional education (IPE) components that included rural pharmacy students in 2010, meaning that all students graduating in and after 2014 followed this revised curriculum. A separate analysis was done to assess any differences in self-rated familiarity with professions, programs, and resources in the community for students who were part of the revised IPE curriculum, compared to the students who graduated prior to 2014 and therefore did not participate in the IPE curriculum. Mean values showed slight differences, with the only statistically significant difference found being for self-rated familiarity with hospice programs. Students who graduated before 2014 rated their familiarity statistically significantly higher compared to students who graduated in and after 2014. A full overview of the results is provided in Appendix Table 3.

Table 3.

Difference in self-rated familiarity with community health professions, programs, and resources between RMED students graduating before and after 2014, when the interprofessional education (IPE) curriculum was added

	N	Mean scorea (SD)	p value
Psychotherapist	2000–2013 (n = 115) 2014–2018 (n = 53)	2.50 (1.15) 2.85 (1.05)	0.082
Nutritionist	2000–2013 (n = 120) 2014–2018 (n = 55)	2.85 (1.27) 2.80 (1.13)	0.803
Social worker	2000–2013 (n = 130) 2014–2018 (n = 58)	2.98 (1.23) 3.00 (1.43)	0.915
Physical therapist	2000–2013 (n = 124) 2014–2018 (n = 58)	3.40 (1.23) 3.76 (1.25)	0.068
Chiropractor	2000–2013 (n = 125) 2014–2018 (n = 57)	2.70 (1.30) 3.12 (1.26)	0.043
Clergy program	2000–2013 (n = 132) 2014–2018 (n = 58)	2.89 (1.39) 3.07 (1.26)	0.391
Hospice program	2000–2013 (n = 130) 2014–2018 (n = 57)	3.52 (1.36) 2.96 (1.15)	0.008
Drug treatment center	2000–2013 (n = 116) 2014–2018 (n = 53)	3.29 (1.24) 3.02 (1.62)	0.230
Women shelter	2000–2013 (n = 116) 2014–2018 (n = 52)	2.69 (1.17) 2.44 (1.16)	0.205
Pharmacist	2000–2013 (n = 0)b 2014–2018 (n = 13)	- 4.15 (0.99)	–
Nurse practitioner	2000–2013 (n = 0) b 2014–2018 (n = 13)	- 4.46 (0.97)	–
Physician assistant	2000–2013 (n = 0) b 2014–2018 (n = 13)	- 3.62 (1.50)	–

^aStudents rated their self-reported familiarity with several community health professions, programs, and resources using a 5-point Likert scale, ranging from “not familiar at all” (1) to “very familiar” (5). A higher score demonstrates a higher level of familiarity

^bSeveral professions were added to the survey after 2014, making it impossible to compare results

Participation and Involvement in Community

Students are asked if they agree or disagree on different aspects of being active or involved in the community. Students in the RMED Program were significantly more likely to feel appreciated by their community, feel accepted by their community as “one of them,” and agree they have valued friends in their community. A full overview of the results is provided in Appendix Table 4.

Table 4.

Comparison of participation in community for year 4 RMED students and year 4 students of regular curriculum

	N	Mean scorea (SD)	p value
Active in community organizations	RMED (n = 195) Non-RMED (n = 199)	3.17 (1.69) 2.97 (1.75)	0.25
Become involved in community issues that are important to me	RMED (n = 195) Non-RMED (n = 199)	3.94 (1.36) 3.82 (1.47)	0.402
Have received formal recognition for my work in the community.	RMED (n = 195) Non-RMED (n = 199)	2.47 (1.55) 2.44 (1.63)	0.855
Feel appreciated by my community	RMED (n = 195) Non-RMED (n = 197)	3.95 (1.80) 3.45 (1.24)	<0.001
Feel accepted by my community as “one of them.”	RMED (n = 195) Non-RMED (n = 198)	4.24 (1.14) 3.49 (1.43)	<0.001
Active in my community.	RMED (n = 194) Non-RMED (n = 198)	3.72 (1.50) 3.52 (1.54)	0.202
Have valued friends in my community	RMED (n = 194) Non-RMED (n = 198)	4.53 (0.99) 4.09 (1.40)	<0.001

^aStudents rated their self-reported level of participation in the community using a 3-point Likert scale, ranging from “disagree” (1) to “agree” (3). A higher score demonstrates more participation in the community

Furthermore, students were also asked if they had participated in specific community activities in the past 2 years. Students in the RMED Program were more likely to have sought to identify their community’s major health problems and to have gathered data on a health problem in their community. Students in the regular curriculum were more likely to have participated in a community health fair and to have volunteered their expertise to a community organization. A full overview of the results is provided in Appendix Table 5.

Table 5.

Comparison of participation in community activities in the past 2 years for year 4 RMED students and year 4 students enrolled in regular curriculum

		Yes (%)	No (%)	p value
Participated in a community health fair	RMED (n = 195) Non-RMED (n = 198)	117 (60.0%) 142 (71.7%)	78 (40.0%) 56 (28.3%)	0.014
Spoken to a community group about a health issue	RMED (n = 195) Non-RMED (n = 199)	159 (81.5%) 156 (78.4%)	36 (18.5%) 43 (21.6%)	0.437
Written or appeared in a health-related story in the local media	RMED (n = 195) Non-RMED (n = 199)	60 (30.8%) 58 (29.1%)	135 (69.2%) 141 (70.9%)	0.726
Attempted to identify your community’s major health problems	RMED (n = 194) Non-RMED (n = 199)	143 (73.7%) 105 (52.8%)	51 (26.3%) 94 (47.2%)	<0.001
Worked with a community group to address a local health problem	RMED (n = 194) Non-RMED (n = 199)	127 (65.5%) 126 (63.3%)	67 (34.5%) 73 (36.7%)	0.658
Gathered data on a health problem in your community	RMED (n = 194) Non-RMED (n = 199)	147 (75.8%) 110 (55.3%)	47 (24.2%) 89 (44.7%)	<0.001
Provided non-paid expert testimony	RMED (n = 194) Non-RMED (n = 199)	8 (4.1%) 10 (5.0%)	186 (95.9%) 189 (95.0%)	0.67
Volunteered your expertise to a community organization	RMED (n = 194) Non-RMED (n = 199)	81 (41.8%) 105 (52.8%)	113 (58.2%) 94 (47.2%)	0.029

Capabilities within the Community

When asked about their capabilities within the community, students in the RMED Program showed significantly higher scores on most domains. Out of the 15 domains, RMED students showed significantly higher scores on 12 of the domains. The biggest differences were observed for students’ confidence in their ability to engage community members in efforts to address a local health problem, their ability to recognize when patients are having problems with their transportation to their office, their ability to become an active part of the community, and their ability to build relationships in the community. Students enrolled in the regular curriculum rated their confidence in their ability to recognize when cultural differences between them and their patients affected their communication statistically significantly higher. Two of the domains showed no statistically significant differences. A full overview of these results is provided in Appendix Table 6.

Table 6.

Difference in self-rated capabilities within the community between RMED students and non-RMED students

		Mean scorea (SD)	p value
Be a positive force in the community	RMED (n = 193) Non-RMED (n = 200)	4.36 (0.70) 4.08 (0.86)	< 0.001
Use the tools of epidemiology to understand the health needs of the community	RMED (n = 193) Non-RMED (n = 200)	3.68 (0.94) 3.42 (1.03)	0.007
Understand the community’s perception of its health problems	RMED (n = 193) Non-RMED (n = 199)	3.88 (0.79) 3.55 (0.88)	< 0.001
Engage community members in efforts to address a local health problem	RMED (n = 193) Non-RMED (n = 200)	3.88 (0.79) 3.43 (1.01)	< 0.001
Use data to document the effects of a community health intervention	RMED (n = 193) Non-RMED (n = 200)	3.80 (0.87) 3.56 (0.97)	0.011
Employ the full-range of community health services for your patients	RMED (n = 192) Non-RMED (n = 200)	4.02 (0.88) 3.62 (0.96)	< 0.001
Work collaboratively with health workers in the community	RMED (n = 192) Non-RMED (n = 200)	4.33 (0.75) 4.04 (0.87)	0.001
Locate the health resources available in your community when patients need them	RMED (n = 192) Non-RMED (n = 200)	4.22 (0.82) 3.94 (0.91)	0.001
Recognize when patients are having problems with transportation to your office	RMED (n = 192) Non-RMED (n = 200)	3.80 (0.89) 3.33 (0.96)	< 0.001
Know about health issues important to particular patient populations	RMED (n = 192) Non-RMED (n = 200)	4.00 (0.81) 3.89 (0.82)	0.185
Recognize when cultural differences between you and your patients affect your communication	RMED (n = 192) Non-RMED (n = 200)	3.94 (0.84) 4.17 (0.79)	0.005
Understand the health belief of your patients	RMED (n = 192) Non-RMED (n = 200)	3.92 (0.79) 3.77 (0.86)	0.080
Work in the community on issues that are important to you	RMED (n = 192) Non-RMED (n = 200)	4.23 (0.72) 3.87 (0.96)	< 0.001
Become an active part of the community	RMED (n = 192) Non-RMED (n = 200)	4.46 (0.65) 4.05 (0.95)	< 0.001
Build relationships in the community	RMED (n = 192) Non-RMED (n = 200)	4.52 (0.65) 4.10 (0.95)	< 0.001

^aStudents rated their self-report abilities on a 5 point scale, ranging between “not confident at all” (1) and “very confident” (5). A higher score demonstrates a higher level of self-rated confidence

The RMED program was expanded to add interprofessional education (IPE) components that included rural pharmacy students in 2010, meaning that all students graduating in and after 2014 followed this revised curriculum. A separate analysis was done to assess any differences in self-rated capabilities for students who were part of the revised IPE curriculum, compared to the students who graduated prior to 2014 and therefore did not participate in the IPE curriculum. Mean values for each variable showed small differences when comparing pre- and post-2014 RMED graduates; however, no statistically significant differences were observed. A full overview of these results is provided in Appendix Table 7.

Table 7.

Difference in self-rated capabilities within the community between RMED students graduating before and after 2014, when the interprofessional education (IPE) curriculum was added

		Mean scorea (SD)	p value
Be a positive force in the community	2000–2013 (n = 133) 2014–2018 (n = 60)	4.43 (0.72) 4.33 (0.68)	0.344
Use the tools of epidemiology to understand the health needs of the community	2000–2013 (n = 133) 2014–2018 (n = 60)	3.80 (0.82) 3.63 (0.98)	0.248
Understand the community’s perception of its health problems	2000–2013 (n = 133) 2014–2018 (n = 60)	3.85 (0.76) 3.89 (0.80)	0.762
Engage community members in efforts to address a local health problem	2000–2013 (n = 133) 2014–2018 (n = 60)	3.85 (0.84) 3.89 (0.77)	0.717
Use data to document the effects of a community health intervention	2000–2013 (n = 133) 2014–2018 (n = 60)	3.83 (0.91) 3.78 (0.86)	0.705
Employ the full-range of community health services for your patients	2000–2013 (n = 132) 2014–2018 (n = 60)	3.98 (0.93) 4.04 (0.86)	0.692
Work collaboratively with health workers in the community	2000–2013 (n = 132) 2014–2018 (n = 60)	4.35 (0.76) 4.32 (0.75)	0.785
Locate the health resources available in your community when patients need them	2000–2013 (n = 132) 2014–2018 (n = 60)	4.15 (0.86) 4.26 (0.81)	0.403
Recognize when patients are having problems with transportation to your office	2000–2013 (n = 132) 2014–2018 (n = 60)	3.98 (0.85) 3.72 (0.90)	0.058
Know about health issues important to particular patient populations	2000–2013 (n = 132) 2014–2018 (n = 60)	4.00 (0.78) 4.00 (0.83)	1.000
Recognize when cultural differences between you and your patients affect your communication	2000–2013 (n = 132) 2014–2018 (n = 60)	3.97 (0.78) 3.92 (0.87)	0.747
Understand the health belief of your patients	2000–2013 (n = 132) 2014–2018 (n = 60)	3.95 (0.72) 3.90 (0.82)	0.694
Work in the community on issues that are important to you	2000–2013 (n = 132) 2014–2018 (n = 60)	4.23 (0.70) 4.23 (0.73)	0.989
Become an active part of the community	2000–2013 (n = 132) 2014–2018 (n = 60)	4.43 (0.70) 4.48 (0.64)	0.667
Build relationships in the community	2000–2013 (n = 132) 2014–2018 (n = 60)	4.55 (0.65) 4.51 (0.65)	0.675

^aStudents rated their self-reported abilities on a 5-point Likert scale, ranging between “not confident at all” (1) and “very confident” (5). A higher score demonstrates a higher level of self-rated confidence

Medical Training

Students were asked to rate how interested they were when they started medical school, in becoming part of the community, working directly with community members, and the cultural aspects of people’s health. Students in the RMED Program were more statistically significantly more likely to have interest in becoming part of their community and working directly with community members outside of the office when they started medical school than non-RMED students. A full overview of the results is provided in Appendix Table 8.

Table 8.

Comparison of interest in several domains at the start of medical school of year 4 RMED students and year 4 students in regular curriculum

	N	Mean valuea (SD)	p value
Becoming part of your community	RMED (n = 193) Non-RMED (n = 200)	4.27 (0.92) 3.57 (1.10)	<0.001
Working directly with community members outside of the office	RMED (n = 193) Non-RMED (n = 200)	3.96 (1.06) 3.43 (1.16)	<0.001
Cultural aspects of people’s health	RMED (n = 192) Non-RMED (n = 200)	3.55 (1.11) 3.74 (1.18)	0.104

^aStudents were asked to rate their interest using a 5-point Likert scale, ranging from “not interested” (1) to “very interested” (5). A higher score demonstrates a higher interest for each question

Students were asked to rate how much training they had during medical school related to several domains. Students in the RMED Program scored significantly higher on most domains, most noticeably on the domains concerning training in rural medicine, underserved population, learning how to identify health problems in the community, and how to work with communities around health issues. A full overview of the results is provided in Appendix Table 9.

Table 9.

Comparison of amount of training in several fields during medical school for year 4 RMED students and year 4 students in the regular curriculum

	N	Mean valuea (SD)	p value
Outpatient medicine	RMED (n = 192) Non-RMED (n = 199)	2.97 (0.16) 2.96 (0.19)	0.602
Rural medicine	RMED (n = 192) Non-RMED (n = 199)	2.98 (0.12) 2.25 (0.71)	<0.001
Inner-city medicine	RMED (n = 192) Non-RMED (n = 200)	1.70 (0.67) 1.77 (0.67)	0.321
Underserved population medicine	RMED (n = 192) Non-RMED (n = 200)	2.73 (0.47) 2.59 (0.54)	0.004
Use of community health services in patient care	RMED (n = 193) Non-RMED (n = 200)	2.52 (0.52) 2.45 (0.57)	0.219
Patients’ use of unconventional home remedies	RMED (n = 192) Non-RMED (n = 200)	2.10 (0.51) 1.94 (0.56)	0.002
How to identify health problems in the community	RMED (n = 193) Non-RMED (n = 199)	2.66 (0.50) 2.29 (0.60)	<0.001
How to work with communities around health issues	RMED (n = 193) Non-RMED (n = 200)	2.60 (0.52) 2.23 (0.65)	<0.001
Ways physicians become accepted into their communities	RMED (n = 193) Non-RMED (n = 200)	2.48 (0.59) 1.94 (0.74)	<0.001
Cultural issues in health care	RMED (n = 190) Non-RMED (n = 200)	2.55 (0.59) 2.47 (0.55)	0.152

^aStudents were asked to rate how much training they had received using a 3-point Likert scale, ranging from “none” (1) to “moderate/extensive” (3). A higher score demonstrates more training was received

Most Valuable Aspect of Training

Only students following the RMED curriculum were asked what aspect of training taught them the most about community medicine. Of the 328 students who answered, 35.7% felt that the 16-week RMED rural medicine rotation was the most valuable. Twenty-two percent answered that their attendance at one of the University Primary Care Centers (UPCC) was most valuable. (Note: these UPCC clinics in areas near Rockford were closed several years ago because of financial issues; thus, the more recent graduating classes were not able to have this UPCC experience). Another 22.0% of the students answered that other clinical experiences taught them the most about community medicine. Other answers included multiple responses including research rotations, a health course during the second year of medical school, and a course in public health. A full overview of the results is provided in Appendix Table 10.

Table 10.

Descriptive statistics for “What aspect of your training or what experience has taught you the most about community medicine?”

	N (%)
RMED preceptorship	117 (35.8%)
Training in UPCC	72 (22.0%)
Research	11 (3.4%)
EPC	4 (1.2%)
Other clinical experiences	72 (22.0%)
More than one of the clinical experiences above	46 (14.1%)
Public health course	5 (1.5%)

Discussion

Our results suggest that the RMED Program has been successful in causing students to become more aware of the community they are part of or in which they have worked, which would be expected to result in more participation and appreciation of the community. In comparing RMED students and non-RMED students on the variables looking at community appreciation and understanding, we were able to evaluate the success of the additional community medicine-focused program. Our results support that the additional community medicine-focused program that only RMED students follow has been successful in educating students who have better perceptions and attitudes toward community health, when compared to students who did not follow the additional program. Students in the RMED Program are more likely to have interest in becoming part of their community and working directly with community members outside of the office. Being more aware of the community will logically also lead to feeling more appreciated by the community and feeling accepted as part of the community. Furthermore, feeling more confident in one’s ability to make a difference and be part of the community in several domains supports these feelings of appreciation and awareness too. Additionally, our results are consistent with previous research showing that rural experiences influence students toward primary care specialties and rural practice [10].

We did not find RMED students to be more familiar with several health care professions, programs, and resources within their community, compared to non-RMED students. However, this is not surprising as both RMED and non-RMED students may equally know of and work with other health professionals. Since an interprofessional education curriculum was added to the RMED Program in 2010, we compared the classes graduating before 2014 with the classes graduating in 2014 and after. The results indicated that the ratings on questions related to understanding and appreciating rural communities remained high. However, the increased complexity of the IPE curriculum and the addition of rural pharmacy students did not significantly impact RMED students’ ratings on any question.

Past research has shown that students who have previously lived in rural locations are more likely to prefer or consider family medicine rather than another specialty as their career choice [28]. This is supported by research showing that a rural upbringing increases the likelihood of a physician returning to a rural area to practice medicine [14–16], which supports the RMED Program’s objective of recruiting rural students who upon completing residency return back to rural Illinois to work as primary care physicians. Offering students the opportunity to shadow rural primary care physician and later work clinical with a rural primary care physician enables students to adjust and refine their perceptions of what it takes to be a rural physician. Since 2019, the RMED Program has added rural family medicine clerkships during the M3 which are expected to further strengthen understanding of rural primary care practice. Other research has shown that exposure to rural clerkships and rotations positively influenced students’ opinions about rural primary care in several ways. After the clerkship, students held more positive opinions about rural physicians’ medical expertise, and they rated a rural physician’s expertise higher than that of an urban/suburban physician [29].

Research has shown that prior rural residence is the strongest predictor of choice of a rural career, with extended rural exposure during medical training being another significant predictor [30]. This emphasizes that the metaphor of the rural pipeline should be used for future effective selection of students who are likely to practice rural medicine, as the RMED Program currently does. The RMED Program at the College of Medicine Rockford campus strives to recruit students who grew up in rural Illinois, while also looking at students from other rural areas across the USA. Furthermore, the 16-week rural preceptorship during the fourth year is a good example of prolonged rural exposure during medical school, which further increases the likelihood of medical graduates choosing to work in a rural area [31]. This is supported by comparative results looking at the percentage of rural track students that chose a primary care residency after graduating medical school, while also comparing the percentage of rural track graduates practicing in a rural area. Out of the 29 rural tracks that were compared, the rural track of the University of Illinois ranked respectively seventh and fifth [32]. Results also showed longer rural experience is positively related to the percentage of graduates practicing in rural areas. This supports that offering most, if not all, clinical months in rural practice during medical school could be the key in educating future rural physicians.

Previous research supports that interprofessional education leads to better knowledge and understanding of how roles and tasks are shared within a team. Furthermore, pilot programs where interprofessional education was evaluated led to students increasingly agreeing that interprofessional education should be a core part of their pre-service training [33]. Moreover, research has shown that interprofessional education is likely to improve learners’ knowledge and attitudes. As interprofessional education involves teamwork and working with other professionals, research has shown that interprofessional education also includes explicit attention to non-clinical skills, like communication and conflict resolution [34]. This is supported by previous research, showing that interprofessional education was successful in improving medical students’ skills, knowledge, and perceptions concerning interprofessional practice [35]. However, our results did not show significant changes when comparing students’ groups before and after the implementation of our interprofessional education curriculum. Although interprofessional education was not the major focus of our study, our results show that there is still much to learn on how to successfully implement interprofessional education and how to develop programs that effectively increase students’ attitudes, knowledge, skills, and behaviors related to short-term and long-term processes in interprofessional teams.

Limitations

The main limitation of this study is that all data were collected from students from one program, meaning that the results only represent the University of Illinois RMED Program. However, multiple previous studies have shown that rural exposure during medical school positively influences students and graduates to choose rural medicine. As shown in our demographics, the vast majority of the RMED students are Caucasian. This is in line with recent numbers showing that rural areas are not as racially or ethnically diverse as the nation overall [36]. Because there are a limited number of spots for RMED students in each class, we have a relatively small sample size, knowing that data has been collected over an 18-year period. This might negatively affect the reliability of the results found.

In conclusion, our results are in line with earlier research and succeed in demonstrating that rural exposure and interaction leads to students being increasingly aware of rural community issues, while also increasing the likelihood of students choosing to practice rural medicine during their career. Results do indicate the successful outcomes of the RMED Program related to curriculum objectives, especially when looking at the differences in appreciation and understanding of the community surrounding our students. Further research should focus on the development of more successful and effective interprofessional education, seeking to strengthen students’ awareness of health care professions and programs in their community and how to efficiently use these surfaces to provide the best possible patient care in their community.

Author Contribution

All authors contributed to the study conception and design. Material preparation and data collection were performed by Michael Glasser and Martin MacDowell. Data analyses were performed by Dana Jungbauer. The first draft of the manuscript was written by Dana Jungbauer and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Data Availability

Not applicable.

Declarations

Ethics Approval and Consent to Participate

This study was approved by the University of Illinois College of Medicine Institutional Review Board on 01/06/2006. The reference number is 84410-14. Informed consent was obtained from all individual participants included in the study.

Consent for Publication

Consent for publication was obtained from all individual participants included in the study. Participants were informed that all data collected would be anonymous.

Conflict of Interest

The authors declare no competing interests.

Code Availability

Not applicable.