- Welcome everyone, Wednesday Nite @ the Lab. I'm Tom Zinnen. I work here at the UW-Madison Biotechnology Center. I also work for the Division of Extension, Wisconsin 4-H. And on behalf of those folks and our other co-organizers, PBS Wisconsin, the Wisconsin Alumni Association, and the UW-Madison Science Alliance, thanks again for coming to Wednesday Nite @ the Lab. We do this every Wednesday night by Zoom, 50 times year. Tonight it's my pleasure to introduce to you Laura McDowell. She was born in Hasting, Minnesota, and went to high school in Storm Lake, Iowa. Then she went to the University of Minnesota for her undergraduate, where she majored in physiology. She stayed on at the University of Minnesota to go to medical school there. 

 And then in 2017, she came to UW-Madison School of Medicine and Public Health to be the first-ever resident to go through the first in the nation Rural Program in Obstetrics and Gynecology. Tonight, she's gonna talk with us about the importance of rural training in medicine. Would you please join me in welcoming Laura McDowell to Wednesday Nite @ the Lab? - Thank you, Tom so much for that kind introduction. I am so excited to be able to speak with you all this evening about the importance of rural medical training. I have no financial disclosures, but certainly have benefited from many different rural training experiences in my medical experience, both in medical school and in residency, so I do have a bias towards them. As learning objectives for our time here together, my goal is that by the end of this talk, that we will be able to first analyze the pros and cons of rural practice, be able to evaluate why a shortage of rural OB/GYN providers exists within the United States, and lastly, that we will be able to discover ways to promote a solution to the rural physician shortage through training track learning. We will accomplish this today based off of this general outlook, an outline for our time. Throughout our time here, I will be interweaving my story through answering the different learning objectives with first focusing on background information for rural living, followed by rural obstetrics, the importance of rural medical exposure, and lastly, concluding our time with next steps. How I hope that we will be different by our time here today. So to start things off with my experience. 

 In the middle of my second grade year, my family moved to a small northwest town in Minnesota called Alvarado. At the time, it had a population of 356 people and was certainly a close-knit community. It took a little bit of time for my family to fully integrate into the community, but as we were five hours away from any of the rest of our extended family members, the community members truly took us in as their own. And I acquired many different grandparents, aunts and uncles, and cousins through this experience. It was through this time in Alvarado that I was able to see my parents engage in the community in a different way than how they had in our distant suburb of the Twin Cities in Hastings, Minnesota. Here, they were a part of various community organizations such as Lions, and both of them participated in an emergency response team, where they responded to various emergencies throughout the area and were a vital part to the community in that regard. It certainly brought them a lot of fulfillment and satisfaction being a part of the community, and I know that community members certainly respected them highly. Moving into high school, our family actually moved down to northwest Iowa to a town called Storm Lake, which is a town of about 10,000 mixed population in the northwest corner of Iowa. In Storm Lake, they have Buena Vista Regional Medical Center, which is a critical access hospital for the County of Buena Vista. It was here and in high school that I was discerning what my future would hold in terms of career paths. 

 I knew that medicine was a likely potential for me, and was trying to decide whether going on to being a nurse, a physician, or even a forensic pathologist would be what I would want to do. I was really interested in CSI as a kid. So through this experience with the hospital, I was able to shadow many different family practice physicians and also receiving care from them at points in time. And through those experiences, I chose to pursue medical school as my future goals moving forward. Arguably, one of the most impactful experiences of my formative years was when I was given the opportunity to travel to Tanzania, Africa for a month in the summer between my junior and senior years of high school. During this experience, I was able to engage with several different communities and organizations in Tanzania. Some of the highlighted experiences include time spent in a girls' secondary school outside of Chimala, Tanzania. I was also able to tour a rural hospital in southwest Tanzania, in addition to being able to take care of some kids that were affected by HIV, either themselves or that their parents had died from the virus. It was through this impactful experience that I felt charged to actually pursue global medicine initially in my career path. It wasn't until reflecting upon my time in Tanzania a few years in the future that I had determined that, you know, certainly there is a need abroad and underserved populations abound there, but there is a need here in the United States as well. 

 And some of the communities that I had actually been a part of were considered a great part of the need in rural areas. And I felt called to be a part of that solution, to return to these rural communities that had so gratefully and kindly taken me and my family in. So we certainly will be talking a lot about rural here today. So I thought that it would be helpful for us to give a definition of what is rural? So if you were to look in Merriam-Webster's dictionary and find the definition of rural, it would come up with "of or pertaining to country, country people, or life or agriculture. " In a research aspect of rural, there are many varied ways to define rural. If you looked at the Census Bureau's definition, they essentially define rural as a negative of urban, where they describe urbanized areas as consisting of cities with populations of 50,000 people or more, and urbanized clusters consisting of 2,500 to just under 50,000 population. Essentially, populations that aren't included in the urbanized area or urbanized clusters are rural, consisting of their population, their housing, and adjacent territory. If you were to look at another different research way of defining rural and in terms of the core-based statistical areas shown here in this figure, they define rural based off of metropolitan and micropolitan statistical areas, with metropolitan statistical areas having the largest city within the county having at least 50,000 people or more. And they also associate their community ties, both financial, social, economic, as a part of their metropolitan status. In regards to micropolitan statistical areas, they are defined similarly to metropolitan. 

 However, their largest city size within the county consists of a population of between 10,000 to just under 50,000 with its associated community ties as well. Another way to define rural in the research realm is using the National Center for Health Statistics 2013 Urban Rural Classification Scheme of Counties. Here, they break down every U. S. county into six different subcategories, with metropolitan counties consisting of having the largest city, at least 50,000 people in population, ranging up to millions in population, with the definitions used including entirety of population within the county and metro-adjacent status. In terms of non-metropolitan or what we will consider to be rural for the remainder of this talk, those counties consist of micropolitan and noncore counties, where micropolitan counties have their largest city consisting of population greater than 10,000 to just under 50,000 people. Whereas noncore counties have their most populous city consisting of less than 10,000 people in population. So with this in mind, certainly not all rural areas are created equally. And as you can see here in this heat map, there are varying population densities within rural areas, with the most dense rural populations being closest to urbanized centers, as seen here with having the darker brown consisting of more dense rural areas. Additional rural statistics include from the 2010 Census Bureau that 60 million people in the United States at that point in time lived in rural areas, and they consisted of 19. 

3% of the population. Additionally, from this figure shown here, you can see that there are varying densities and percentages of rural residents within each state, with Maine actually having the highest percentage of rural residents at 61. 6%. Now that certainly was a surprise to me, I don't know about the rest of you. Ongoing statistics include that the rural landmass within the United States actually consists of 97% of the landmass in America, which is very surprising. But I think the converse is even more surprising, that 80% of the United States population lives within 3% of the United States landmass. Now, some of you astute people might be thinking, "Well, gosh, they just came out "with some updated 2020 census data at the end of April, why isn't that data included?" So by the time of this filming of this talk, they had not published any further breakdown of urban and rural statistics. So those are still to come and something that we can all look up together. This figure shows the National Center for Health Statistics 2013 Urban Rural Classification Scheme of Counties as broken down for all six categories. Again, as a refresher, we will be focusing on rural, consisting of the micropolitan and noncore counties, shown here in the two tones of green. 

 Other interesting statistics to note is that 28 million of the 60 million rural residents consist of reproductive-age women. And these 28 million women are composed of 35% of the entire U. S. reproductive-age population. So these are statistics for us to keep in mind for later on in the talk. So not only are geographic challenges an issue that rural Americans face, but according to the Centers for Disease Control and Prevention, they published this press release, noting that rural Americans are at a higher risk of dying from the five leading causes of death, which include heart disease, cancer, unintentional injuries, chronic lower respiratory disease, and stroke. Not only are rural Americans at increased risk of dying from these five leading causes of death, but they are noted to be sicker and older than their urban counterparts. They have higher rates of smoking, high blood pressure, and obesity. And when they do have leisure time, they are less likely to spend it in an active manner. When rural Americans are out driving, they're also less likely to wear seat belts, predisposing them to motor vehicle accidents. 

 Rural Americans also have a higher rate of poverty, they have less access to healthcare, and are less likely to have health insurance. In fact, according to the Kaiser Family Foundation, 24% of the non-elderly rural population utilize Medicaid services for their primary payer. Now, it is known that Medicaid reimbursement is actually less than what private insurance pays, but I think it's helpful for us to actually have the breakdown of these numbers. So it is known that Medicaid pays on average 87 cents on the actual dollar spent for cost of care. So hospitals that primarily are taking patients that have Medicaid insurance are losing money for the care that is provided to these individuals. In regards to comparing reimbursement rates from private insurance to Medicaid, private insurance is known to reimburse double what Medicaid does for in-hospital inpatient services. And on the outpatient side of things, private insurers are known to pay about two to two and a half times more than what Medicaid reimburses for those same services. So hospitals that are providing majority of their care to individuals with Medicaid are certainly at a burden, as they're operating at a financial deficit. Next, we'll focus our time on our first learning objective, which is analyzing the pros and cons of rural practice. Certainly, there is individual variation between what is considered a pro and what is considered a con of rural practice, but we'll break those down in just a little bit here. 

 So according to the American Association of Medical Colleges, several physicians have noted varying reasons of why they would not choose to practice in a rural setting, including that there's an increased call burden for physicians that practice in a rural area, as they typically have less partners to share the call requirements for their job. Additionally, rural physicians are known to be on average about 51 and a half years old, and therefore nearing the age of retirement. So if there are concerns for retirement and call burden and recruitment of new physicians, this can further worsen the issue of call for the remaining rural doctors. If the physician has a working spouse, sometimes it can be challenging to find meaningful work for that spouse in a rural setting. If they have children, there's a concern of having decreased structured learning opportunities for their children, especially in the high school setting as some rural areas do not offer advanced placement or PSEO classes. In regards to the rising medical tuition and debt concerns in regards to reimbursement for physicians, this is increasingly becoming a concern for some medical students and residents, and the feasibility of actually being able to practice rural medicine in the future and be able to get out of debt. And lastly, there is this generalized culture within medicine that there is special significance placed on those individuals that choose to specialize and subspecialize, causing some medical students to potentially think a career in family medicine or general practice as not being advantageous enough for them. So looking into some of the literature about one of these challenges of rural practice, I wanted to dive a little bit deeper into the concerns of medical tuition costs and debt. In 1970, the government noted that this could be a potential problem for individuals choosing to practice in a rural or underserved setting, and so created the National Health Service Corps Loan Repayment Program in 1970. This program primarily relied off of discretionary appropriations prior to the passage of the Affordable Care Act in 2010, which actually designated funds for this program specifically, allowing the program to become more stable in terms of paying tuition and stipends for these individuals. 

 So the National Health Service Corps was actually created for healthcare professionals to receive funds to pay for their medical schooling or healthcare schooling in exchange for a predetermined number of years of service in a rural or underserved area that was designated based off of a number system, with having more destitute or resource poor, underserved, and rural areas having a higher number on the scale. Research behind the National Health Service Corps Loan Repayment Program shows that having a National Health Service Corps physician in an underserved area does attract on average, an extra two non-National Health Service Corps physicians to the area; however, despite this additional recruitment, it does not result in the area losing its underserved designation. Therefore showing that there are other issues afoot that are not just related to primarily physician shortage. Moving into some of the advantages of rural practice that many rural practitioners have noted as a reason for why to practice rural medicine is that they enjoy living in a small town in a social sense, having that sense of belonging and being able to be a community leader in the community that they care for. Additionally, practicing in a rural setting allows for clinical autonomy and being able to practice at the top of the physician scope and training. Looking into some research into physician satisfaction with rural practice, the study pictured here on the left by Pathman et al. demonstrated that the greatest satisfaction for physicians practicing in rural areas comes from the patient-physician relationship. And also, that this relationship gives them much fulfillment in terms of responding to a need in this underserved community. They also note that clinical autonomy is something that they hold professionally important to them, and then they just generally enjoy living in a small town setting. Now, the study on the right by Cutchin reported physician retention in addition to how they integrate into the community. 

 And he noted that there are many different factors with the physician themselves and the certain, you know, physical environment of the community that affect integration. I think most importantly, what he points out in this paper is that integration and retention actually start from the very initial recruitment. So when that physician is coming into a rural community, they are trying to see if they can envision themselves within that rural community. And so, it's important even from the get-go, when you have a learner in a rural community to try to welcome them in, to give them a positive experience about rural medicine. So with this understanding of the background of rural healthcare and its members, in addition to different physician factors of why people would want to practice rural medicine, I'd like to integrate my experience back into our time here together. So growing up, I did live in at least two smaller Midwest communities and wanted to experience what the big city life would be like. So in pursuing my undergraduate studies, I decided to attend the University of Minnesota in the Twin Cities. I certainly received a great education from this university and I would not have traded that experience for anything. But during my time there, despite being involved in many small groups, I still felt isolated from community in a way that I hadn't felt before, growing up. And I came to realize that I truly craved that connectedness in rural communities that I just wasn't experiencing in the city. 

 So fortunately for me, when I was pursuing medical school, I was actually selected to go to the University of Minnesota in the Duluth campus, which has a special emphasis on training rural physicians and physicians that are interested in Native American health. Through my first two years of lecture-based studies in Duluth, they also provided all of the medical students an opportunity to go out to different rural communities in both Wisconsin and Minnesota for us to spend time with a rural, a family practice doctor, understanding what practice life is like for these rural physicians. It was through this time that I was able to apply what I learned in medical school in an actual clinic setting. Seeing patients, obtaining their histories, performing a physical exam, generating different differential diagnoses, and attempting to come up with plans. I certainly benefited from this experience from a medical aspect, but from a social and interpersonal aspect, I felt great joy in caring for community members again, and was hooked on this experience. So through my time in the Rural Medical Scholars Program, I knew that I wanted to pursue rural medicine as my future, in my future career. In my third year of medical school, all of the students were given an opportunity to either pursue our further clinical studies in the Twin Cities or to participate in a longitudinal integrated clerkship, called the Rural Physician Associate Program or RPAP. Due to my desire to practice in a rural setting, I chose to participate in RPAP and was selected to have my nine-month experience in Hibbing, Minnesota, where I was able to work with several different family practice, general surgeons, pediatrics, and obstetrics and gynecology physicians. Through these experiences, I was able to see their patients in clinic and follow them throughout their care process, either seeing them again in clinic, going to the operating room, or my most favorite, getting to participate in their labor and delivery experience. Through this kind of longitudinal and continuity of care, I was hooked on that kind of patient-physician relationship and knew that I wanted to continue that in my further practice life. 

 And so through this experience, I chose to pursue a career in obstetrics and gynecology. So moving on to our second learning objective for today, my hope is that we will be able to evaluate why a shortage of rural OB/GYN providers exists in the United States. In 2018, the American College of Obstetrics and Gynecology, which is the governing body of all OB/GYNs, put forth this committee opinion entitled Health Disparities in Rural Women, that showed that only 6. 4% of the OB/GYN workforce worked in rural locations. Now, if you remember from back in earlier on in the talk, 35% of reproductive-age women actually live in these rural areas. So this is certainly a discrepancy in terms of population, well, physicians caring for that population. In addition, from the Department of Health and Human Services, they published this policy brief in May of 2020, where they had noted that currently, there's a shortage of 9,000 OB/GYN providers that exist at this time and is only anticipated to be getting worse, projected to have a 22,000 OB/GYN physician deficit by the year 2050. What is even more staggering is that 50% of the counties within the United States actually do not have an OB/GYN provider. And due to this shortage, it causes about 10 million women to need to travel long distances to receive basic routine prenatal care. So if a woman were to have additional complications in her pregnancy that required more frequent visits, this becomes even more of a burden, especially for those that are challenged with transportation and other issues in their social lives. 

 So how do we fare here in Wisconsin? So out of the 72 counties that make up the State of Wisconsin, 46 of those counties are considered rural, which again are the micropolitan and noncore counties, shown here in the two tones of green. Out of the counties within Wisconsin, there are 20 counties that actually do not have an OB/GYN provider. And 19 of those counties are considered rural, two of them micropolitan and 17 of those being noncore counties. So lastly, I would like for us to focus our time on discovering ways to promote solutions to the rural physician shortage through training track learning, which is our final objective for today. According to the Centers for Medicaid and Medicare Services and the Rural Report put forth by the American Hospital Association, there were four overarching reasons for why different rural obstetric units were closing their doors. And they included issues regarding the low obstetric volume, low reimbursement, having a lack of skilled providers, and the expense of keeping those providers trained as being four overarching areas that were needing to be addressed. So since the medical community can actually do something about these latter three options, I would like to focus our time on these latter three reasons for why OB units are closing in rural areas. First off, with low reimbursement, we discussed earlier that Medicaid actually pays only 87 cents on the actual dollar of costs provided for patients, therefore causing hospitals to operate at a financial deficit. In addition, it's helpful to know that actually 51% of rural deliveries are funded by Medicaid. So this is affecting many, many rural hospitals all across the nation. 

 In terms of, you know, this issue being known, it's well-known in the scientific realm, but I wanted to focus a little bit more on what the general population knowledge is of this health crisis. This magazine article from Time magazine, published back in November of 2020, is actually a magazine clipping I received from my aunt this past fall regarding the concerns of Medicaid expansion or lack thereof and the association of rural hospital closures. As you can see here in this bar graph from the study period of 2013 to 2017, rural hospitals that did not have Medicaid expansion within their states were more susceptible to having their rural OB units close. You can see here that Wisconsin is highlighted as one of those states that has not expanded Medicaid. Fortunately for Wisconsin, at least at the time of this published article, there were only one. . . There was only one OB unit that had closed its doors as of 2017 at that point. However, according to the Wisconsin State Journal, this article published back in 2019, they had reported that there were 11 rural hospitals that had closed their doors in the preceding decade, with the most recent closures occurring in 2017 in Grantsburg and Ripon. They also noted that there were 35 hospitals within Wisconsin that were at risk of closing their obstetric units within the next upcoming years. 

 And they reported that there were five hospitals that were going to be closing their doors, but they hadn't given an exact closing date. So just by the time of that published article, there weren't a significant number of OB hospital closures, but as time has gone on, certainly there are ongoing effects of not expanding Medicaid and primarily affecting these rural hospitals that are struggling to keep their doors open. The figures shown here on this slide are from a article published by Hung et al. that describes access to obstetric services declining over the last decades. They show here highlighted within the state of Wisconsin in the dark blue counties that those are the counties that actually lost full obstetric services for the entire county over this study period. The counties that are considered rural that did not have obstetric services throughout this entire study population are shown in medium blue, whereas the rural counties that had ongoing OB services are shown in light blue. In Wisconsin currently, we actually still do not have Medicaid expanded for the entire state. In regards to having a lack of skilled providers as a reason for OB unit closures, certainly this is an area of great concern, and there are so many articles out on the internet about personal stories of women that have had their OB units close, and what that has caused them to do. Highlighted from the video that is depicted here on the right is a woman's story of being in active labor in the Arrowhead of Minnesota. She had to drive an hour and a half to the nearest OB unit to be able to deliver her baby. 

 However, unfortunately she was in the active throes of labor and was not able to make it to that OB unit, and so had to deliver at a hospital that no longer provided OB services. So they were not equipped to take care of her and her newborn baby. In terms of ways that we as a medical community and a community at large can help provide skilled providers to these rural areas is by allowing exposure for rural training in medical school and residency as a potential solution. Fortunately in 2017, the University of Wisconsin-Madison OB/GYN department created the first-ever rural OB/GYN training track in the nation. Through this training track, residents that participate in it, which include one resident per year, is that six months of their four years in residency are spent in four different rural communities pictured here. We have gone to Portage, Monroe, Waupun, and Baldwin for our time here. And this consists of about 12. 5% of our time in residency. Of note, two of the sites actually have solo practitioners, meaning that they are the only OB/GYN on call for their entire service and hospital, and sometimes even county or two, whereas the two other sites have two or four providers respectively. So it allows the resident to get an understanding of what it is like to live and practice in a rural area as being a solo provider or being a partner within a practice that is certainly different than an academic center. 

 In regards to the expense of maintaining provider training as the final area of issue with rural OB unit closures, I wanted to focus on two main questions I had about this. How much does it actually cost to keep a provider trained in obstetric emergencies specifically? And is it actually effective to perform this training? So looking at the article by Yau et al. , they broke down costs of providing simulation training for obstetric emergencies into startup costs and variable costs, which are considered to be annual and recurring costs. They noted that overall, the total cost was about $200,000 to provide this simulation training, and the majority of that cost came from releasing their attendees and trainers to go to these simulation sessions. In regards to cost-effectiveness, this article published by Van de Ven et al. showed that certainly doing simulation training is cost-effective, but only when it is repeated in repetition, and that repetition at least needs to be completed once. So you complete the training and then you complete another training further down the line. So hopefully so far, I have been able to talk with you all about the importance of adding providers to the rural workforce, not only in OB/GYN but throughout all of the specialties within medicine. There is quite a bit of evidence that exposure to rural medicine is one of the ways that individuals decide to pursue medicine. One of my rural preceptors actually grew up in a major Midwestern city and ended up practicing in that major Midwestern city following residency. 

 It wasn't until later on in his career that he made a change and decided to practice in a rural setting. He told me during one of our times together, one of our months together, that he wishes that he would have known about rural practice from the get-go because he would have participated and been a rural physician from graduating residency. So I think that that further highlights the importance of providing that exposure, especially to people that don't come from a rural background, as not all of us have that opportunity. In addition to providing that much needed rural exposure, I think the other issue is that we need to do better as a medical society of recruiting individuals that are going to be more apt to stay in rural practice. And evidence has shown that that comes from people that are from a rural background. Unfortunately, according to Health Affairs, an article published regarding the 2017 Medical School matriculating class demonstrated that 28% of those medical school matriculants had actually decreased in percentage of rural background. So rural medical school matriculants only accounted for less than 5% of the actual matriculated class of 2017. And if you were from a minority and rural background, you accounted for less than 0. 05% of the matriculating class. So with this in mind, I'd like to transition back into my time with rural medicine. 

 So certainly after completing medical school, my hope and dream was to pursue rural medicine as an OB/GYN. And much to my surprise and delight, I was selected to be one of the residents for the rural training track here at the University of Wisconsin-Madison. I was so overjoyed the day that I opened my match day letter with overwhelming feelings of happiness and relief. I had really, really wanted to come here so, so badly. And certainly through my time here, it has impressed me beyond my wildest imagination. I have learned so much through this program by having the dichotomy of learning and practicing in a high acuity, large volume academic center, and comparing that with what rural practice is like. I like to term it the rural reality. 'Cause certainly there are vast differences in how you practice medicine in an academic institution and in a rural institution. And it was helpful for me to see how people did that and how I was going to potentially integrate my knowledge and experience into my future rural practice. So this educational experience has been hands down, one of the most beneficial to me in my entire education. 

 So I have alluded certainly to some qualities that are found in different rural physicians, but this article published by Robert Tate further emphasizes some other qualities that are shown in rural providers, that being male gender, having lived in a rural location, or attended a rural high school. In addition, having had rural training in either medical school or residency were associated with having rural providers stay practicing in a rural area. This systematic review published in 2017 further breaks down the different potential factors for rural retention and their degree of importance. As you can see here, one of the highest degrees of importance is having a rural background. So it is important for us to be recruiting individuals that are from rural backgrounds to have them go back and serve their rural communities. However, for individuals that don't have that same opportunity to be from a rural background, having them have exposure to rural training in medical school and residency was shown to be a moderate degree of importance, and certainly is something that the medical community can do and would be important for us to continue that. From the systematic review, it showed that physicians that had graduated from a rural training track were found to be 44% likely to stay in that rural location or practice in a rural area, which is certainly better than 0% having not gone through a training track experience like that. So now some of you are probably with me and saying, "Okay, yes, I understand how this is important, "having rural exposure to get rural providers into areas, I get that. " But for my experience, in my interview trail for residency, I went around to different Midwest towns and to see where I wanted to pursue residency. And one of those interviewers actually told me that, you know, having rural exposure and rural practice was not gonna be important. 

 I was told that only good things were to be learned from the academic center and that I wouldn't learn anything from being out in a rural community, so that that be a waste of my time. And I think contrary to what the evidence says, that, you know, this person's statement was incorrect. We know that having exposure to medical training, both in medical school and residency, is one of the ways for us to address this rural physician shortage. Specifically, in regards to medical schools, ways that we can be better include that only 21% of medical schools actually provide that much-needed exposure to rural training and practice in medical schools. And there are only 8% of medical schools that actually express a commitment to providing rural physicians in the future. So these are areas of improvement for medical school. In regards to residency training, as of 2016, there were 99 family medicine rural training tracks, there were 11 internal medicine rural training tracks, and 11 general surgery training tracks. And if we had added on 2017, there would be one OB/GYN rural training track. And I know that this has been expressed wholeheartedly by the University of Wisconsin-Madison OB/GYN Department, that we hope to not be the only one in the nation. We want to have many more OB/GYN training tracks across the country to address this rural physician shortage, especially for OB/GYN. 

 So hearkening back to these four reasons for obstetric unit closure with specific emphasis placed on these latter three, I wanted to move into next steps of how I hope that we can be different from our time here today. In regards to having a lack of skilled providers as a reason for the rural physician shortage, as a medical community, we need to increase the number of rural medical training exposure, both in medical school and residency throughout the United States. And that is something that can be done on both a medical school and a resident level. In regards to the expense of maintaining provider training, it is important for us to establish relationships between the academic centers and rural hospitals in order to share the burden of simulation training, but also to exchange knowledge and to have that working functional relationship, as there is much cross-communication between urban and rural hospitals and clinics. So to wrap up our time here today, we will be going through our learning objectives. And so first, I hope that through our time here today, that we've been able to analyze the pros and cons of rural practice, certainly understanding that different individuals view a pro and a con differently. In terms of challenges of rural practice, call burden, concerns around a working spouse and educational opportunities for children, the issues around medical debt, and valuation of specialization and subspecialization in medicine have all been listed as challenges for rural practice pursuits. In regards to advantages of rural practice, living in a small town in a social sense, having a sense of belonging, being a community leader, and having clinical autonomy and practicing your full scope of training have all been listed as advantages for many physicians in these rural areas. In regards to our second learning objective, where we were evaluating why a shortage of OB/GYN providers exists in the United States. I hope that we have been able to discuss issues regarding a lack of resources for care and reimbursement for both hospitals and physicians as one of the reasons for the shortage, specifically that having a lack of exposure to rural training and experience is one of the ways that the medical community can certainly address this issue. 

 And in addition, knowing that this lack of exposure and lack of skilled providers is one of the reasons why these obstetric units are closing their doors. In terms of retaining physicians, this is another area that communities need to look at in terms of keeping the rural physicians that they have currently and recruiting those to come and join their communities. Lastly, I hope that we have been able to discover ways to promote solutions to the rural physician shortage through training track learning. Providing that much needed exposure to both medical students and residents is one of those avenues for reaching this objective. And then to help different hospitals actually maintain their ability to keep their obstetric units open by creating a collaboration between rural and urban hospitals in regards to simulation training and knowledge exchange. Last, but certainly not least, I would like to think so many people and especially the people that are listed here. Dr. Jacques has been my mentor over these last four years in residency here in Madison. She is an outstanding provider and both clinically and personally, I have learned so much from her. I am grateful for all that she has provided me in terms of knowledge of what medicine is like outside of the hospital, and certainly she was a huge part of creating this presentation that you have seen today, so thank you so much to her. 

 To Doctors Rice, Hartenbach, and Spencer for having the vision to see the need for this rural OB/GYN training track, I will be forever indebted to you all. And for having that vision to keep it moving forward and expanding across the country, for being collaborative mentors for other residencies across the country. I am so thankful for all of the hard work and dedication that you have put in to make this a reality, especially for me, but hopefully for other people in the future. To the OB/GYN department, faculty, staff, I am grateful to you all for all that you have taught me over these past four years, clinically, interpersonally, and you all have truly shaped me into the young physician that I am today. To the rural training site physicians and staff, I am so thankful and appreciative of your warm welcome to me to your different communities, and for allowing me to take care of your community members. That has been one of the most life-giving experiences of residency for me, and I am so thankful for your kindness in that way. To my current PGY4 class, I would not have been able to make it through residency without all of you, so thank you for all of the support and listening ears that you have provided. To residents past and present, I am grateful to you all for helping me make it through residency. It's a pretty grueling experience and you've definitely helped pick me up by my bootstraps when times were really tough, so thank you. Ah, to my parents, family and friends, oh, I would definitely not be here today without your support and guidance. 

 Thank you so much for supporting me throughout, especially these last eight years of medical training. I would not have been able to make it through without your support and encouragement, especially to my parents who have helped me continue to have the vision of what I initially sought out medicine for in the first place when I lost that vision. I am so grateful to you all in so many ways. And a special thank you to all of you listening to this talk today. I am so grateful that you have taken the time to listen and absorb the different reasons of why medical training is important. And I hope that it has charged you to think about different ways that you can advocate for addressing the rural physician shortage in the future. Thank you, and have a wonderful evening.