Rural MD Track Focuses on Underserved Populations and Under-Resourced Settings

April 12, 2023
VOL 25 NO 1

In Wisconsin, only seven percent of physicians have rural practices, according to the Wisconsin Council on Medical Education and Workforce in 2021.

Further, studies show that rural populations — compared to urban dwellers — are generally sicker, poorer, older, and more likely to be uninsured. With the goal of easing these disparities, the University of Wisconsin School of Medicine and Public Health launched the Wisconsin Academy for Rural Medicine (WARM) in 2007, with its first graduates entering residencies in 2011.

“We recruit medical students who intend to practice rural medicine and help improve health in rural Wisconsin,” says Joseph P. Holt, MD, director of WARM. “Our students emerge prepared for residencies in any medical specialty, as rural Wisconsin health systems need physicians in many specialties, particularly family medicine, internal medicine, and pediatrics.”

Madeline Brown, a third-year WARM student, exemplifies the trainee envisioned by program leaders. She dreamed of becoming a physician since her youth in Salem, Wisconsin. When she experienced a serious knee injury while playing varsity volleyball, she witnessed the expertise of medical professionals who helped her return to her sport.

Madeline Brown
Madeline Brown

Wanting to help patients in a similar way, Brown went on to earn a bachelor’s degree in biomedical science with a double-minor in chemistry and Spanish at UW-La Crosse. As an undergraduate, she shadowed medical professionals at Gundersen Health System and volunteered on medical and public health missions in Guatemala.

“I realized my ability to connect with people was a gift I could not let fall by the wayside. I loved meeting new people from different walks of life, learning from them, and figuring out ways I could give back to them,” she recalls. “I also loved the challenge that [pre-]medicine provided; it always pushed me to be a better person. I grew more conscientious of who I was because I knew who — and what — I wanted to become.”

Brown adds, “The fact that the school integrates public health into its curriculum was a huge draw — I wanted that extra knowledge, because I realized the better I understand the community around me and which factors determine their health, the better doctor I can be.”

Hailing from a small town and wanting to eventually live in a small community “where everyone knows everyone,” with ample outdoor recreation nearby, Brown chose the WARM program.

“The program matched my lifestyle and goals, including how and where I want to raise my family, all while striving to combat the growing shortage of providers in rural Wisconsin,” says Brown, whose training is based in Marshfield, Wisconsin, with clinical rotations in several small towns.

The program matched my lifestyle and goals, including how and where I want to raise my family, all while striving to combat the growing shortage of providers in rural Wisconsin.

– Madeline Brown

Noting that continuity of care is a “must-have” in her career, she says, “WARM’s training has exceeded my expectations. Smaller clinics and health care teams allow for more one-on-one teaching and hands-on experiences — anything from joint injections to catching babies — and I’ve enjoyed every bit of it.”

Brown continues, “I am most interested in family medicine because it will allow me to build strong relationships while caring for a variety of patients — kids, adults, whole families, elderly people. The field is conducive to being a ‘jack-of-all trades,’ as there isn’t always the ability to refer out, especially considering how far some patients would have to travel to get to another facility. I feel most passionate about promoting healthy lifestyles and empowering patients to set goals and make lifestyle changes to reach those goals.”

Further, Brown wants to incorporate teaching and/or mentoring into her career because many dedicated mentors have helped her along the way. She shares gratitude for her strong support system, including her family, fiancé, friends, former coaches, and more.

Four Campuses

The four-year WARM program — a subset of the School of Medicine and Public Health’s MD program — accepts 26 medical students per year. Each student spends Phase 1 of the curriculum at the main campus in Madison and spends Phases 2 and 3 at one of the following locations:

  • Aurora BayCare Medical Center, Green Bay
  • Gundersen Health System, La Crosse
  • Marshfield Clinic Health System, Marshfield

WARM students also complete clinical rotations in small towns. Dozens of physicians play crucial roles as volunteer preceptors throughout the state.

Statewide Core Days

All WARM students participate in intensive “core days,” during which they gain hands-on experiences they will use throughout their careers. All Phase 2 WARM students hone ultrasound skills in Marshfield and participate in a mock disaster drill in La Crosse. And Phase 3 WARM students learn Advanced Wilderness Life Support (AWLS) in Green Bay.

The latter is led by Michael Medich, MD, a retired emergency medicine physician at Aurora BayCare Medical Center, Green Bay, and an adjunct clinical professor in the UW Department of Emergency Medicine. He also is the regional director of the WARM program and director of medical education at Aurora BayCare Medical Center and BayCare Clinic.

Michael Medich
Michael Medich

“I have a passion for emergency medicine, and it fit well with my personality and interests,” says Medich, who grew up in a small town in northern Minnesota; earned his medical degree from the University of Minnesota School of Medicine, Minneapolis, including training at Royal Infirmary Hospital, Scotland; and completed an internal medicine internship and emergency medicine residency at Spectrum Healthcare, Grand Rapids, Michigan.

Medich has been a preceptor for medical students throughout his more than two decades at Aurora BayCare, and he began teaching WARM students there in 2009. Because that center does not have residents, WARM students work directly with attending physicians.

An avid outdoors person and longtime volunteer in Scouts BSA, Medich has participated in medical missions in Nepal, Trinidad, Nicaragua, Haiti, and Honduras. He stresses that physicians can be called into service in low-resource settings anytime, anywhere, near or far from home.

For example, he says, “I was hiking in the Black Hills with my son and girlfriend, and we came across a guy who had fallen 30 feet from a cliff, four hours from the trailhead. He had multiple broken ribs that caused a lung injury, two breaks in one arm, and likely hypothermia. We were able to call ahead for EMS and carry him out to safety. If we had not found him, he probably would have died.”

Initially, in 2021, Medich and Jacqueline Clem, medical education program manager, Aurora BayCare Medical Center — another avid outdoors person who has witnessed accidents while four-wheeling in Oregon — developed a pilot AWLS course for Green Bay WARM students. In fall 2022, the popular course became a required core day for all WARM students from across the state in their final year of medical school. AWLS includes a three-year certification for those who pass the written and hands-on skills exams.

For the intense, 20-hour AWLS course — which earned a student rating of 4.8 on a 5-point scale for teaching effectiveness — Medich led a team of emergency physicians, along with paramedics from De Pere Fire Rescue, to teach activities in which students used items like canoe paddles, tarps, sleeping bags, and ski poles to care for mock patients who acted out serious injuries and illnesses that could happen in the wilderness.

Advanced Wilderness Life Support course participants carry a person on a backboard
Participants in the fall 2022 Advanced Wilderness Life Support course carry a mock-patient on a stretcher they improvised using available supplies.

Medich points out that medical students receive excellent training in hospitals and clinics that have ample resources, and in the AWLS training, they learn skills that could be helpful in situations like power outages or supply shortages, or in any low-resource setting that requires creative thinking and using what you have on hand to provide medical care.

Trevor Gauthier, Brock Gilsdorf, Danielle Hurst, and Christopher Karow — all in their final semester of WARM in Green Bay — participated in the course.

Gauthier, who grew up near Green Bay and aims to practice anesthesiology in a rural area around there, recalls, “Collaboration with our peer learners, understanding the unique pathologies that present in a wilderness setting, and thinking outside the box to make do with the resources available to us — these are some of the main themes of this course.”

Understanding the unique pathologies that present in a wilderness setting, and thinking outside the box to make do with the resources available to us — these are some of the main themes of [the AWLS] course.

– Trevor Gauthier

Calling the AWLS course “one of the highlights of my time as a WARM student,” Hurst says, “I enjoy many outdoor activities, including scuba diving, hiking, and water sports. I can see these skills being useful in those scenarios, and in counseling patients before they go on a big adventure!”

As someone who hails from northeast Wisconsin and hopes to enter a general surgery residency in that region through a couples match, Hurst wants to improve care for underserved patients.

About the AWLS course, Karow says, “We learned how to manage conditions like heat stroke, hypothermia, and various traumas. We also covered how to manage animal attacks, burns, drownings, and much more. Through hands-on sessions, we were able to put into practice the skills we learned in the lectures and discussions to prepare ourselves to address the real-world situations we may encounter.”

Trainee Reflections

Karow, who plans to practice pediatrics in northeast Wisconsin, notes, “During my rural medical training, I have witnessed the incredible value a rural physician can provide the communities they serve. Rural physicians are able to meet patients where they’re at and utilize the resources available in their communities to meet patients’ needs.”

He continues, “I’m passionate about helping patients form lifelong healthy habits. I’m also passionate about the ways in which public health initiatives can improve children’s health in an entire community, even more so in rural communities.”

Gauthier shares, “A huge strength of the WARM program is that it allows medical students like me to train in the towns and hospitals where they are considering working one day. Many of the physicians I worked with in Green Bay were graduates of the WARM program. I think this is a testament to the effectiveness of the program in training physicians who not only want to live and work in Wisconsin, but who are passionate about training the next generation of physicians who share the same aspirations.”

He continues, “In the WARM program, a lot of our public health work has been with rural communities. For example, several classmates and I worked with the Diabetes Prevention Program through the YMCA of Door County to create and deliver a presentation to participants about the development of diabetes, its effects on the body, and how lifestyle changes work to prevent the disease and its sequelae. Medicine, public health, and rural health — as a student in the WARM program, I have gained valuable experience in each of these domains.”

Gilsdorf’s choice of career was deeply influenced by the health care his father received between his diagnosis with Stage IV kidney cancer and his death, shortly after Gilsdorf’s high school graduation — at which he was the valedictorian. He was grateful that the health care team made it possible for his dad to be able to attend the graduation ceremony — a goal he had set for himself.

“In the years since my dad’s passing, I have come to realize that when a patient and their family are in their most vulnerable moments, and there is seemingly nothing left to offer, physicians always have their humanism and the ability to respect and honor their patient’s wishes. This display by my dad’s physician and health care team is one that I hope to offer my patients and their families during their toughest days,” says Gilsdorf, who plans to enter internal medicine and return to northeastern Wisconsin “to help care for the family and friends of those who raised me and helped make me who I am today.”

Alumni Experiences

Calling himself “the dinosaur of the program,” H. Clay Dean, MD ’11, FACS, was among the first WARM cohort; he completed his medical education in Marshfield and Rice Lake. Following completion of a general surgery residency at Iowa Methodist Medical Center in Des Moines, Dean became a general surgeon at Sauk Prairie Healthcare in Prairie du Sac, Wisconsin — less than 50 miles from where he grew up.

Reflecting on his choice to enroll in WARM, he notes, “The program’s values and goals lined up well with my aspirations as a future rural physician. I felt like my training allowed me to hit the ground running when starting my residency. It allowed me to have autonomy with patient care and take ownership of the patients I was following. It also allowed me to experience multiple practices from tertiary care to community-based.”

Noting that he, his wife, and two sons love living in rural Wisconsin, Dean continues, “A rural practice is vastly different from an urban practice or tertiary-center practice. Experiencing the interactions my attendings had with their patients and understanding their concerns has helped me better serve my patients in my current practice. … Not always having substantial resources in a rural community but still being able to provide my patients with great surgical care is a challenge, but one that rural general surgeons have to be able to adapt to.”

On the opposite side of Wisconsin, Breanna O’Neil, MD ’17, grew up on a farm near Plymouth, Wisconsin, and practices general surgery nearby in Manitowoc County. Like the Dean family, O’Neil, her husband, and their two sons love living a rural lifestyle in the Badger State.

Originally planning to become a veterinarian, O’Neil changed course when her mother was diagnosed with breast cancer and encouraged her to “pursue medicine and take care of cancer patients.”

O’Neil says, “I saw the need for doctors to care for patients in rural Wisconsin, and I knew that I wanted to ultimately practice in this setting.”

She continues, “Through the WARM program in Green Bay, I got exposure to a variety of community practice environments in rural Wisconsin, and training in social issues that impact health care uniquely in rural areas.”

Noting that rural general surgeons do everything from trauma care to appendectomies to cancer care, she says, “Fewer and fewer general surgeons want to go into a rural practice, and I think one reason is that they haven’t had the opportunity to see a rural community practice during medical school. I love operating and being able to make patients feel better by fixing a hernia or taking out a gallbladder. Nothing is more rewarding than knowing I gave my patients another wedding or graduation or visit with grandchildren by surgically treating their breast cancer or other condition. I hear all the time how grateful patients and their families are to have health care available close to home.”