Geisinger Lewistown Hospital resides in a rural, agricultural area of Pennsylvania that serves a needy population. Patients are older, sicker and more socially and economically marginalized. A subset of the population, the Amish, are disproportionately affected by rare genetic diseases.
Family physician Mandy Maneval, MD, PhD, knows that rural medicine can be a hard sell. A physician practicing in a community with limited resources and few specialists, often needs a jack-of-all-trades mentality to help their patients. That’s why she helped conceive a residency program designed to hone this unique skill set.
Rural medicine, much like family medicine in general, challenges you in different ways, every day, said Dr. Maneval, co-founder and director of Geisinger’s Lewistown Family Medicine Residency Program.
“Our goal always has been to train people who want to graduate and work in a rural region with a broader scope of training, offering more procedural training, more time in the ICU. Those are the things we offer here. The residents really like that style of practice. They recognize that’s a unique opportunity.”
Geisinger is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
The Lewistown Family Medicine Residency Program is a collaborative effort between Geisinger and the Family Practice Center, a large, physician-owned primary care group in Central Pennsylvania. “For many years, our leadership said, ‘We should start a residency program to meet the needs for primary care physicians in our community.’ In 2018, that’s when we finally decided to do it,” said Dr. Maneval.
The program initially had four family medicine residents per year, training for three years. A substantial grant from the U.S. Health Resources and Services Administration in 2020 allowed Dr. Maneval and her colleagues to expand the residency program to six residents per year.
“Now in our fifth year, we see trends emerging,” she said.
Many of the program’s residents know country life firsthand. They grew up in a rural area in the U.S. or some other part of the world. Some originated from Central Pennsylvania or went to college in the state. Or, they had some type of rural experience as part of their medical school training. All these factors likely solidified their choice of career, said Dr. Maneval.
While 15% of the U.S. population lives in rural areas, only 12% of primary care physicians work in rural areas, and that share dips to only 8% in all other specialties, according an AMA Council on Medical Education report whose recommendations were adopted by the AMA House of Delegates in 2021.
Among other things, the AMA is asking the Accreditation Council for Graduate Medical Education review committees to consider adding exposure to rural medicine, as appropriate, to encourage the development of rural program tracks in training programs and increase physician awareness of the conditions that pose challenges and lack of resources in rural areas.
“For the nearly 60 million people who live in rural communities across America, persistent inequities continue to place barriers on access to medical care—resulting in devastatingly higher rates of mortality and preventable hospitalizations for this patient population,” AMA Trustee Scott Ferguson, MD, said at the time. “There is a clear, urgent need for more physicians to serve in rural America to help close existing gaps in patient care. The AMA is dedicated to addressing the root causes of health inequities for the rural patient population, and this policy is one step closer to removing those obstacles to care and achieving optimal health for all.”
Most of the inpatient medicine training and rotations take place at Geisinger Lewistown Hospital, a century-old community hospital that serves a large area. Geisinger plays a significant role in expanding the training offerings for residents.
If a training module is not available at Lewistown, the resident can seek opportunities at other Geisinger locations. Lewistown for example doesn’t have an inpatient pediatric unit. Residents can travel to Geisinger’s Danville location to complete that training.
Fifteen minutes from Lewistown, two continuity clinics in Mifflintown, Pennsylvania, offer residents the opportunity to care for their own panel of patients during the entire duration of their residency.
Residents may end up working in a community that doesn’t always have a specialist next door.
The Lewistown program is different in that it recognizes this reality—and all of the realities of rural medicine—and offers this experience to its residents as part of their training. “If you practice in an area with fewer resources, you have to meet that need for your patients and that can get uncomfortable,” she acknowledged.
A resident may end up seeing an Amish patient with a rare genetic disease in their daily practice. Or they’ll learn how to handle insulin if a patient needs endocrinology care, but the hospital doesn’t have an endocrinologist and the patient isn’t able to travel far to see a specialist.
Having a broad network of specialists to call for help is important. The residency program teaches its physicians how to build that network and rely on Geisinger’s specialist partners.
“That’s what I love about Geisinger. You can reach out of any doctor and they’re always so helpful and appreciative,” said Dr. Maneval.
The program, to date, has graduated 13 residents. Five stayed in the immediate community, either with Geisinger or at a family practice center. Eight overall have remained in Pennsylvania, although one person pursued a fellowship in HIV in California.
Ideally, the goal is to promote rural careers. However, “we always said we were looking to train doctors in underserved communities,” and that’s where most of the residents have set up practice, added Dr. Maneval.
To attract more students to the program, Dr. Maneval would like to hire more faculty and work toward introducing future doctors to rural medicine sooner rather than later.
Medical students exposed to rural medicine are more likely to choose it as a career option, said Dr. Maneval. “We need to reach out earlier, even to students in college. We can’t wait until students are in their fourth year of medical school and expect that they’re going to match to train in rural care.”