Partnerships to Establish and Sustain Rural GME: Q and A with Melissa Brunsvold, MD of the University of Minnesota Medical School
This interview is part of a series featuring Sponsoring Institutions and programs providing rural graduate medical education (GME) experiences. The series was initiated following the 2022 ACGME Annual Educational Conference presentation on Medically Underserved Areas/Populations: Partnerships to Establish and Sustain Rural GME, available in the ACGME’s digital learning portal, Learn at ACGME. Note: an account (free to create) is required to access most content in Learn at ACGME.
Melissa Brunsvold, MD is an acute care surgeon focusing on emergency general surgery and surgical critical care at the University of Minnesota Medical School’s Department of Surgery. She has a passion for Extracorporeal Membrane Oxygenation (ECMO) in her clinical practice, and ECMO outcomes is one of her research interests. She serves as M Health System Medical Director for ECMO and as the vice chair for Education and program director of the general surgery residency. She is deeply committed to surgical education–another of her research interests.
The University of Minnesota Medical School’s general surgery residency program officially began in the 1930s—under the far-reaching leadership of Department of Surgery chair Owen H. Wangensteen—and has been educating and training surgeons and leaders in academic surgery ever since. Many historic surgical milestones have been accomplished by surgeons in the program, including the introduction of gastrointestinal suction tubes for bowel obstruction, the first successful open-heart surgery, and significant improvements in solid-organ transplantation (among an array of other advances). Early on, the program developed a reputation for training research-minded and clinically astute surgeon-scientists, many of whom became department chairs and division chiefs throughout the United States and beyond. The program was, and still is, known for its focus on applying scientific rigor and innovative research findings to the treatment of patients, particularly in tertiary care environments.
Seven years ago, the program created the rural surgery track, now formally named the University of Minnesota General Surgery Rural Track. It is an expansion of the Surgery residency, adding an 8th categorical “Rural Track” resident each year. The first three years of the rural track resident’s training is indistinguishable from the other six categorical residents. Like them, the rural track resident will be based for the first three years in the Twin Cities, with rotations at the University of Minnesota Medical Center and three Twin Cities integrated sites (i.e., Methodist, Regions, and the VA). In the 4th and 5th years of residency, the rural track resident will be based exclusively in rural experiences including Essentia Health in Duluth and elsewhere.
ACGME: What drew you to academic medicine and to rural GME specifically?
Dr. Brunsvold: Throughout residency and fellowship I had fantastic mentors in academic surgery. It became a career goal to follow in the footsteps of these thought leaders in education and research. I grew up in rural Minnesota and I see the surgeon shortage in rural areas throughout Minnesota.
ACGME: Describe the rural GME experiences within your program/Sponsoring Institution (e.g., types of sites, structure, curriculum, etc.).
Dr. Brunsvold: The general surgery residency rural training track at Essentia Health St. Mary’s Medical Center, located in Duluth, Minnesota, has full-spectrum general surgery education and training for practice in rural or urban settings. Our residents train with experienced physicians of diverse educational backgrounds and interests.
PGY-1, -2, and -3 rural training track residents will be based at the University of Minnesota Twin Cities campus and follow the rotation schedule of the traditional general surgery residency program.
In the rural training track, residents will complete their fourth and fifth year at Essentia Health St. Mary’s Medical Center. The rural track includes traditional general surgery residency curriculum with an emphasis on the wide variety of surgical health care required of surgeons in rural environments, including cesarean sections, gynecology, endoscopy, emergency and trauma surgery triage, stabilization and transport, and thoracic and vascular surgery.
Through video conferencing, faculty members and residents based at St. Mary’s Medical Center (in the Twin Ports) and the other sites attend weekly conferences held at the University of Minnesota in Minneapolis, including grand rounds and morbidity and mortality conferences.
ACGME: How did your Sponsoring Institution/program become involved in establishing rural GME experiences? (Include any applicable references to geographic/specialty workforce data.)
Dr. Brunsvold: Exploring the possibility of creating a rural surgery track was in response to a March 2011 report to the Minnesota Department of Health from the Rural Health Advisory Committee. That report identified a critical need for general surgeons in rural Minnesota (and in rural areas throughout the nation). Its recommendations included enhancing "workforce infrastructure," making "improvements in Minnesota's education, training, and residency programs," and fine-tuning "recruitment and retention." The need for general surgeons in rural areas was also identified by national surgical and educational organizations, such as the American College of Surgeons and the ACGME.
The general surgery residency is five years in duration. Beginning in July 2013, the program's second-year residents began to spend an additional rotation (about five weeks long) with Essentia Health, working and learning at St. Mary’s Medical Center in Duluth and at the Virginia/Eveleth Hospital. The program added the Essentia Health rotation to explore the possibility of creating a rural surgery track in the program, with the specific purpose of preparing surgeons with an interest in living and working in a rural setting.
ACGME: Describe the internal and external partnerships that have been important in establishing and sustaining these experiences.
Dr. Brunsvold: Two partnerships in particular have supported our rural track. First, the U of M Medical School’s Department of Surgery leadership partnered with the residency program to financially support its initial prospects and ongoing success of the track. Second, the strong professional connections among surgeons across health systems have guided opportunities for residents to gain exposure and develop cultural competencies needed to provide surgical care to these particular populations.
ACGME: Describe the challenges you have experienced in developing and sustaining rural GME partnerships and experiences; and explain how you have overcome them.
Dr. Brunsvold: Prior to support from the Minnesota Department of Health Primary Care Expansion Grants, fully funding this much-needed expansion was essentially out of reach. Funding was cobbled together, including a donation of two years' funding from the general surgery preliminary residency program. In addition, Essentia Health agreed to fund one full-time-equivalent resident position to allow expansion of the third-year residency class. In 2016 and 2017, the program was awarded one of the Primary Care Expansion Grants from the Minnesota Department of Health. This partially offset the cost of funding for the fourth-year rural track resident for three years. Obviously, this stopgap solution cannot continue; robust, reliable funding is critically needed to sustain the rural surgery track and to meet the surgical needs of rural Minnesota on an ongoing basis.
ACGME: Describe some of your program’s/Sponsoring Institution’s outcomes since establishing rural GME experiences, including the impact to the surrounding community.
Dr. Brunsvold: The first resident to be matched as a PGY-1 into our program graduated in June 2020. He entered practice in Willmar, Minnesota. His position fully meets the desired outcome of our program as Willmar is rural, with a growing population of persons of color as seen in the linked demographic data: https://statisticalatlas.com/place/Minnesota/Willmar/Race-and-Ethnicity#figure/relative-race-and-ethnicity. Our 2021 rural track graduate is in a private practice position in Wisconsin. Our current 5th-year rural track resident has accepted a position in private practice in a small town in northern Minnesota. Recordings from our virtual information sessions to learn more about the program can be found here: https://med.umn.edu/surgery/education-training/residency/general-surgery/virtual-recruitment.
ACGME: What advice do you have for those interested in establishing rural GME experiences?
Dr. Brunsvold: Foster a strong partnership with the community hospitals in the areas you hope to serve. Hospital partners have helped us leverage funding, applied for supporting grants, and helped with a recruitment and hiring network for graduates.
ACGME: Describe the resources that have helped your program/Sponsoring Institution to establish rural GME experiences.
Dr. Brunsvold: The availability of the Minnesota Department of Health grant has provided needed funding to sustain residents in this rural track, as well as Essentia Health and the U of M Medical School’s Department of Surgery support to help with supplement funding, if needed. In addition, the ability to virtually connect with rural track residents, no matter where they are practicing in Minnesota, has allowed for consistency in communication and educational experiences for all residents in the full general surgery program.
ACGME: Is there anything else you would like to add?
Dr. Brunsvold: The U of M Medical School’s Department of Surgery is a founding member of the Northern Plains Rural Surgery Society that has as a major goal the development of a robust and sustainable workforce pipeline in rural surgical practice. Jeffrey Chipman, MD, Executive Vice-Chair of Surgical Specialties and Division Chief of Critical Care/Acute Care Surgery in the Department of Surgery and the incoming rural track resident attend the annual meeting to promote this important initiative. Our program has gained a reputation as a leader in this area, and we have seen similar programs initiated at the Mayo Clinic, University of Wisconsin, and Sanford Health.
Email muap@acgme.org if you want to get in touch with Dr. Brunsvold. Is your Sponsoring Institution/program already providing rural GME experiences and want to be featured in a future post in this ACGME Blog series? Respond to this short questionnaire to share what you’re doing and provide input on how the ACGME can engage stakeholders in this important work. Visit the MUA/P web page to learn more about the ACGME’s efforts.