Community Physicians: Lifeblood of the Preceptor Program

Robert Mortimore of Reedsburg, a preceptor to more than 50 SMPH medical students, guides his latest charge, DeAnna Friedman.

A summer as a volunteer in the emergency room at Tulane University Medical Center after high school gave Odinakachukw "Odi" Ehie, now a fourth-year medical student at the University of Wisconsin School of Medicine and Public Health (SMPH), her first real taste of patient-centered medicine.

"I wanted to ask the doctors all kinds of questions, like, ‘How did you come up with that diagnosis?'" says Ehie. "Medicine seemed really challenging and exciting, and the patients always seemed so grateful to the whole medical staff."

With that experience and three years of medical school under her belt, Ehie recently completed a six-week preceptorship under the tutelage of Chad Voskuil, MD, at the tiny Wild Rose Hospital and Clinic. With a population of 765, Wild Rose, Wisconsin, was a far cry from the hustle and bustle of urban New Orleans, but it provided an unforgettable primary-care learning opportunity nonetheless.

The preceptorships take place in more than 30 Wisconsin communities, towns scattered from the edge of the Mississippi to the shores of lakes Michigan and Superior-and everywhere in between.

The required program immerses fourth-year students in a community-based clinical environment, in a one-on-one relationship with a volunteer physician mentor. Through their preceptorships, students become proficient in providing patient care, learn to apply the principles of preventive medicine and experience firsthand the complexities of working collaboratively on a multi-disciplinary healthcare team.

Students consistently rank the preceptorship as one of their most valuable medical school learning experiences. Many preceptors have been volunteering their time and energy to the program for years, a clear indicator of its importance to them.

"The strength of the Preceptorship Program results from the excellence of our statewide community preceptors," says Jacob Prunuske, MD '00, MSPH, who directs the program. "These doctors volunteer their time and energy to teach our next generation of physicians. We are deeply indebted to our preceptors for their hard work and commitment to excellence in medical student education."

Developed long before the use of penicillin, incubators and high-tech diagnostic equipment, the UW program-created in 1926 by the school's first dean, Charles Bardeen, MD-is the oldest of its kind in the country. Bardeen was responding to the growing national recognition that medical students needed to learn to apply the science of medicine in community settings.

The program rapidly grew into one of the most popular aspects of medical education at UW. By the time Bardeen died in 1935, imitations had popped up across the country, and the preceptor concept became an important part of medical education nationally.

Community-Minded Physicians

The Preceptor Program exemplifies the "Wisconsin Idea" promoted by UW president Charles Van Hise, who hired Bardeen in 1904, Prunuske says.

"Van Hise believed that the work done by the university should improve the health, quality of life and environment of the entire state," he says. "Preceptorship students serve as ambassadors from the UW to their preceptorship communities, sharing their knowledge and experiences gained in lectures and on the wards."

In recent years, school leaders have broadened the scope of the preceptorship so that students develop a greater understanding of the value of community support in patient care.

"Doctors work to manage diabetes and high blood pressure; however many health problems, such as obesity or substance abuse, have underlying causes that must also be addressed at a societal level," Prunuske says.

By seeking out community resources-in addition to the advice of their physician mentors-students will gain insights into the relationships between clinical care, public health and the health of the community, Prunuske believes.

"We want our medical students to see that being a doctor doesn't begin when they walk in in the morning and end when they walk out at night," he says. "We want them to define their jobs as improving the health of the community along with the health of their patients."

Prunuske pushes students to discover the uniqueness of the towns in which they are training, urging them, for example, to explore cultural differences that may exist among residents, learn about the availability of local social services or delve into factors influencing patients' physical activities and eating habits.

Mentors Matter

Five medical students a year choose to follow Robert Mortimore, MD, on his daily rounds at the Reedsburg Area Medical Center about a one-hour drive northwest of Madison. An affable family medicine physician, Mortimore has mentored more than 50 SMPH medical students since joining the preceptorship program 11 years ago.

"This is the one time in a student's medical school training that they get out and see what front-line medicine is really like for an extended period," he says. "They soak up information like sponges."

The most common healthcare concerns among the 30,000 residents served by the medical center are diabetes, heart disease, back pain, hypertension, anxiety, depression, sore throats, ear infections and pneumonia. Ten family physicians, one pediatrician, one cardiologist, five nurse practitioners, two nurse midwives and one diabetic educator provide care at the center, a 40-bed hospital, assisted living center and nursing home.

Students can work side-by-side with emergency room doctors, cardiologists, surgeons or family physicians, Mortimore says.

"There's a whole range of opportunities in how they can spend their time here. They become part of the healthcare team," he says, adding that students live in a furnished apartment about one mile from the hospital. "They pick up bits and pieces from each doctor. That's how they create their own style."

Learning is a two-way street, though, with senior physicians cramming in a few lessons of their own, says Mortimore.

"You know what this is?" he says, pulling his personal handheld computer from his lab coat.

"It's hard to practice medicine without the Internet and information sources these days," he says. "The students teach me the newest ways to find information on the Internet."

Adds Mortimore with a smile, "I probably learn more from them than they learn from me."

Mortimore applauds the work of SMPH officials and students.

"Over the years, I've been more and more impressed with the students coming out of the medical school," he says.

Close to Home

Jason Wells chose to work with John A. DeGiovanni, MD, a general surgeon at Sauk Prairie Memorial Hospital in Prairie du Sac, about a 25-minute drive northwest of Madison.

Wells, who plans to become a pathologist, devoted 12-hour days as he assisted DeGiovanni and others in the OR and postoperatively, focusing on controlling patients' pain.

"Dr. DeGiovanni knows everyone in town," Wells says. "They know he's a really good surgeon."

In his future practice, Wells will spend most of his time in laboratories analyzing tissues to help determine treatment and management of diseases. Still, he passed the summer observing and assisting with colonoscopies, gallbladder surgeries, bowel resections, gynecological and orthopedic procedures, replacement of catheters for chemotherapy and a tonsillectomy.

"It's important that students get involved with as many physicians and learn as many procedures as they can," Wells adds.

He selected Prairie du Sac's 36-bed hospital so he could stay closer to Madison, where he and his wife, Janelle Wells, MD, live. Like many preceptorships, which help students develop both professionally and personally, Wells' experience at Sauk Prairie Memorial should serve as an important springboard into residency training.

"We're currently in the process of looking at residency programs with a couples match," he notes.

Smallest Community

On the last day of the program at Wild Rose's 25-bed facility, Ehie consulted with a 65-year-old retired high school chemistry teacher who had had knee and hip replacements and was wrestling with obesity and diabetes.

"I don't need anything else except a 20-year-old body," she remembers him grumbling.

"I wish you luck in your practice," he added. "Tell me, though, why do they call it a practice?"

Without hesitation, Ehie lobbed an explanation.

"Medicine is always a learning field," she said. "You never know everything. So you are always practicing."

Although Ehie plans a career as an anesthesiologist, she sought out a family practice preceptorship to gain an understanding of bread-and-butter medicine.

"It's already helped me," she says. "I was involved in obstetric procedures, internal medicine and the emergency room. I had never done a spinal until this rotation."

Ehie also learned the importance of factors that might not be top-of-mind to all physicians.

"There are financial and social barriers," she points out. "Vegetables and good protein are more expensive than a fast-food burger and fries you can buy for less than $5."

Voskuil agrees that economics play a pivotal role in his patients' health.

"I see a lot of people on state aid," he says. "It makes my job more challenging. If they have to drive one hour to get a cardiac stress test, it might cost $10 in gasoline."

Voskuil says Wild Rose has helped him stretch as a physician.

"I step out of my comfort zone frequently, but that's how you learn," he says. "That's one of the things that brought me here."

He relies on information he digs out of the American Family Physician, a peer-reviewed journal published twice a month.

"Be sure to keep on reading and you'll do fine," he advises his students.

Prescription: Experience

The preceptorships take place primarily in rural settings across Wisconsin, but the school also offers rotations in medium-sized cities, such as Green Bay, La Crosse and Eau Claire, as well as one urban rotation in Milwaukee. Here students work alongside volunteer family practice physicians in inner-city community clinics, where the vast majority of the patient population is underserved and minority.

Physicians in this setting may encounter cases that are not typically seen in rural clinics, says program director Prunuske, but community-oriented care remains front and center.

"With the help of seasoned mentors who volunteer in the preceptor program, SMPH medical students are gaining the valuable experiences they need to become superior doctors, no matter what the setting," he says. "Active physicians who care about their communities are the lifeblood of the program."

by Maggie Rossiter Peterman
This article appears in the fall 2008 issue of Quarterly.