Agromedicine focus group: cooperative extension agents and medical school instructors plan farm field trips for medical students. (Original Article).

Background: Current medical education policy seeks to address the health care needs of underserved populations, among whom are individuals associated with agriculture.

Methods: This paper describes a focus group approach to planning farm field trips whereby medical students accompany agricultural extension agents to study the personal, occupational, and environmental health concerns of farmers.

Results: The resulting plan joins a state's cooperative extension system, medical school, and farm community in partnership to provide an experiential approach to agricultural medicine and rural health education.

Conclusion: The planning exercise and the field trips are successful examples of agromedicine, a partnership approach to preventive agricultural medicine involving professionals in medicine and in agriculture.

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There is a growing emphasis on medical education programs to meet health care needs of population groups at the fringe of modem medical care. (1) The farm community is one such group. (2) In addition to their presence among the underserved rural populations, farm communities are often isolated further by geographic distance and staunchly independent mindset. Across the country, some medical schools are attempting to tailor courses and programs to address the health care needs of farm communities in their service areas. (3) In this paper, we discuss the University of Alabama School of Medicine (UASOM) program to acquaint physicians with health care needs among this segment of society by introducing students to the agricultural extension agent role and requiring farm field trips.

Background

The agricultural community is of such importance to the nutritional and economic well-being of the United States that federal and state governments support land-grant universities with agricultural colleges and the nationwide Cooperative Extension System (CES). A major role of the CES is to staff each county or agricultural region of a state with agriculture agents to provide educational information to farmers. This information is based on university research and promotes productivity of U.S. agriculture. (4) In recent years, health among the farm community has emerged as a major factor in the productivity and survivability of farming enterprises. (5-7) Currently, the CES has embraced the strategy of expanding its role to reduce disease in communities, without specifying a special focus on farmers, farm families and workers, and others associated with production farming. (8,9) A preventive medicine partnership between agriculture and extension agents on one hand and medicine and rural physicians on the other is one option for mounting such a focus. This partnership is termed agromedicine. (10,11)

The UASOM, located in Birmingham, expanded to a three-campus system in the 1970s in response to rural and underserved communities of the state. Each of the two regional campuses provides clinical instruction for about 50 third-year and fourth-year students and maintains family practice residencies. The Huntsville regional campus has sought excellence in primary care, while Tuscaloosa has developed a major focus on rural primary care. In the 1990s, Tuscaloosa concentrated its rural commitment with a rural medicine educational pipeline starting in high school and proceeding through postgraduate medical education. (12) Important components of this longitudinal program are recruitment of rural candidates, programmed activities in rural communities with family medicine preceptors, and educational topics characteristic of the needs of rural populations.

Since 1996, the Tuscaloosa program has required third-year medical students to visit a farm with an agricultural extension agent as part of a 2-month rural family and community medicine experience. The students learn about extension agents' roles, farmers' concerns, and hazards associated with farming and the farm environment. Tuscaloosa students have responded so well to this experience (13, 14) that faculty at the main campus moved to include farm field trips in Birmingham students' rural medicine month. After an initial period in which 160 Birmingham students had joined Tuscaloosa students in the field trips, the rural medicine faculty called a planning session to review progress and to determine future directions for these agromedicine exercises.

Planning Methods

This planning session was a focus group discussion including key medical school faculty responsible for assigning students to farm field trips and extension agents responsible for scheduling and conducting the field trips. The focus group was convened at the Tuscaloosa County cooperative extension conference room and was hosted jointly by a Tuscaloosa medical faculty member and the local agricultural extension agent. The agenda included a welcome of participants and statement of purpose for the meeting, initial statement of expectations for the field trips, discussion by medical faculty including students' responses, discussion by agricultural agents including farmers' feedback, followed by unstructured dialog among agents and faculty. After the meeting, we reformulated expectations for the farm field trips and developed a summary of suggested actions indicated by the discussion.

Participants and Purpose

The Tuscaloosa County Cooperative Extension Agent welcomed participants, who made their own personal introductions. The District Agent over the several counties around Tuscaloosa was present. There were 3 medical faculty members, 1 from Birmingham and 2 from Tuscaloosa. County agents from 4 rural counties in the district were present, as well as an agromedicine research assistant from the Tuscaloosa branch campus. Thus, a total of 9 attended.

One Tuscaloosa medical faculty member explained that the focus group discussion was convened as a joint review of the agromedicine field trip program by medical faculty and extension agents. He noted that the field trips are important for medical students both in Tuscaloosa and Birmingham and that information from the focus group discussion would inform plans for future field trips. Consequently, the purpose of the discussion was to determine what adjustments should be made to enhance the farm field trip activities.

Initial Statement of Expectations

A goal for Tuscaloosa students being prepared for rural practice is to understand the importance of the agromedicine partnership between medicine and agriculture to address needs and concerns arising out of agricultural lifestyles, environments, and products. The farm field trips introduce medical students to roles and personalities of cooperative extension personnel and orient them to the culture and risks of agriculture. The intent is to lay the groundwork for future collaboration among county agents and these students when they become physicians. In addition, the field trips introduce students to agricultural aspects of Alabama that most of them have not experienced, even though many come from small towns in the state.

The field trips are important to Birmingham students whose ambitions are generally directed toward specialty practice in urban areas. The Birmingham medical faculty member explained the value of medical students observing medical practice and the context of that practice away from the medical center, observing the various roles that physicians occupy in rural communities, observing differences and disparities among people and practices, and talking with people outside the isolating culture of the academic medical center. Although most of these students will have urban practices, they will have rural patients under their care, and they will interact with rural primary care physicians. The field trips provide this different perspective from the vantage of rural practice and through the eyes of county agents and farmers.

Medical Faculty Comments

The UASOM has not developed a required content for farm field trips, which are still innovative among medical schools. An agromedicine article by authors from the Medical University of South Carolina (15) offers a checklist of potential points of observation and discussion during these visits. The checklist is not a requirement for UASOM students, but it is a teaching tool that can be used to assist in discussions, particularly of the occupational and environmental health aspects of farming and processing of farm products.

Each year, 25 students on the Tuscaloosa campus are expected to schedule their own field trips by contacting the local county agent during the course of the required 2-month rural experience. This has worked well, which is probably a reflection of Tuscaloosa's small class size, 2-month block in the same rural community, and students' ability to develop familiarity and comfort with the local community. The field trips have been popular. For example, one student "discovered farming" on a field trip and was motivated by the experience to publish an article about preventive agricultural medicine. (13) Another student found mental health care of farmers and rural populations to be so limited and so far from the minds of the academic medical establishment that he focused his community medicine project on this topic and submitted an article for publication. (14)

On the Birmingham campus, approximately 110 students are assigned to the 1-month rural clerkship each year with primary care physicians in rural areas. The Birmingham medical faculty member had sent about 160 students out of Birmingham to participate in farm field trips during their required rural medicine month. Birmingham-based students have given farm visits mixed reviews, perhaps because so many of these students are oriented toward urban specialties. Approximately 75% of students said the field trips were good or worthwhile. They included a paragraph about the farm visit in the abstracts that they completed to describe their rural medicine experience. Most said it was a good experience. One negative remark concerned travel time from Birmingham to and from the farm. Shelby County, which borders Birmingham, quickly became inundated with students requesting field trips, thereby forcing the students to travel as much as 1.5 hours one-way to complete a visit. A small percentage said the experience was "a wast e of time." Again, this may be attributed to an urban specialty mindset that cannot be changed in the context of their current medical education experience. On a scale of 0 to 5, students ranked the farm visit at about 3.5, on average. Because of proximity and to expand the availability of field trip sites for rural experiences, some students have been allowed to make industrial site visits in lieu of farm visits in recent months.

Extension Agent Comments

The matter of disseminating field trips across the state and across farms, especially for Birmingham students, was an issue of primary concern to the agents. The district agent, whose district contains 22 counties closest to Birmingham, noted that he had been involved with the central state cooperative extension office in discussions about scheduling students in a way that does not inundate any one county. He explained the plan to share scheduling duties among district agents so that each of Alabama's four districts would take one-fourth of the year to schedule Birmingham student visits. He indicated that it would be desirable for Alabama's state extension office to prompt and support the other districts as their turns to schedule farm visits came up. He and the county agents recognized the need to plan visits in advance, especially because of the shrinking numbers of production farms in the state.

The county agents, all of whom had been active in conducting field trips, mentioned lack of structure in the field trip experiences. Most had not seen the checklist developed by the South Carolina agromedicine program. While each had usually accompanied students on their field trips, occasionally students were referred directly to accommodating farmers. Weather, peak times/seasons in farm activities, and unforeseen circumstances were all factors in scheduling visits. The farmers themselves are an important aspect of the visits. Planning should include responding to their needs as well as to the needs of the students.

Dialogue About the Field Trips

This unstructured discussion was initiated with the question of what seemed to be the enjoyable aspects of the field trips to each type of participant--students, farmers, county agents, and medical faculty. The agents had observed that students seemed to be enthusiastic about the health concerns specific to agriculture, such as pesticides, heat stress, and mechanical injuries. The medical instructors thought that, on the whole, the students appreciated the opportunity to see things different from usual medical practice and enjoyed being on a farm and talking with people whose backgrounds differed from their own. The agents noted that farmers appeared to enjoy engaging students in discussions about their opinions on pesticide use and risks and about other topics relative to farm operations. The farmers were observed to "welcome the students like family" and to share with the students their values, noting how current society seems so often to take farms and agriculture for granted. The agents enjoyed meeting th e students with their different backgrounds and experiences. The medical instructors were gratified by the opportunity to show students the world beyond the confines of their medical educational experience, which often is confining both mentally and physically. They also enjoyed getting out to see farm operations and to meet with the farmers and agents.

The agents noted that some structure to the field trips would be helpful. The agents' role in conducting the field trips would be facilitated by answers to questions about what the students want to see on the field trips, what agents are responsible for in these field trips, and what feedback from the students about the field trips can be made available to the agents and farmers. The following specific comments emerged and were endorsed by the group:

* Write thank-you notes to farmers after visits.

* Build in flexibility to accommodate the fact that farmers and agents are at times limited in the personal attention they can give to students, even though a visit may have been scheduled well in advance. At times, either the farmer and or the agent may take the lead role in instructing students on a field trip.

* Consider formulating a menu of options for field trip experiences, explaining what a field trip may be like.

* Note the similarities of the farming operation and other production industries, such as the need for around-the-clock responsibility.

* Mental heath aspects of agriculture may be an issue to discuss.

* The Tuscaloosa students' articles on preventive agricultural medicine (13,14) could be sent to farmers and agricultural leaders to show what students can learn about farming.

* Feedback from students about field trips should be made available to the agents and the farmers. Consider formulating abstracts in a way that they could be so disseminated. Consider submitting articles from the field trips to magazines and newsletters read by farmers and agricultural constituencies.

* Be aware of the common experience of rural doctors and farmers in working with an increasing population of Hispanic persons.

* Pesticide issues are a large concern for farmers in the current environmentally sensitive context.

Reformulating Expectations for Field Trips

On the broader scale, the medical faculty members wish to provide students with an experience away from the academic medical center to see and experience various communities from which patients come. They want to get students out of the medical center mindset for a while. The faculty members are also trying to produce physicians who appreciate the special context of rural living and medical practice. Visiting farms with a county agent for a few hours is a good exercise. They want students to observe the proud and independent lifestyles of farmers, their distance from medical care, and the environment and circumstances within which they work. It is helpful for the students to interact with farmers and farm families to hear the stories of the farmers--their concerns, aspirations, and expectations of the health care system. Also, it is important for students to recognize that farmers are often isolated from the academic medical center and from opinions and viewpoints that emanate from urban culture. The students should be receptive to farmers' questions and comments that probe students' opinions as a representation of nonrural society.

Some of these students will become rural physicians and in the future may work with county agents to develop agromedicine programs of preventive medicine for farmers, farm families, and farmworkers. The medical faculty members want students to see how agricultural extension professionals interact with the farm community and have influence to help prevent injuries, illnesses, and toxic exposures associated with agriculture. Therefore, it is important that the students spend time with the agricultural extension agents--to hear about their roles in the rural and agricultural community, to see the agent interact with the farmers and community, and to witness the agent's familiarity with farm operations and risks.

The medical faculty would like students to see why the farm and related processing operations may be hazardous. Thus, they want students to visit some farm workplaces to observe and discuss how issues related to individual behavior, machinery, environments, plants, animals, chemicals, and weather may pose risks. They want students to hear how agricultural sciences and medicine are helping to address these risks and about ideas that agents may have concerning these issues. In some cases, visiting an industrial site can substitute for a farm visit.

Summary of Suggested Actions

On the basis of this discussion, the group reached a consensus in recommending six action steps to sustain and improve farm field trips for medical students:

1. Before a field trip is planned, develop and provide extension agents an outline of what may be involved in a farm field trip.

2. Require of students that at the beginning of or in advance of the field trip, they present the agent with a statement of personal expectations for the field trip; and after completing the field trip, they prepare and submit to the agent a statement of how well their expectations were met.

3. Provide agents, who may share with farmers, the student abstracts summarizing their rural medicine experience or the parts of those abstracts relating to farm visits.

4. Publicize this agromedicine activity and reports of specific experiences among a readership that includes the agricultural community.

5. Involve the Alabama Cooperative Extension System with focus group sessions similar to this one in each of the other Extension districts and provide for coordination of field trips from the state office. Advocacy for this proactive planning was so uniform among the group that we discussed ways that planning might be accomplished statewide. There was a consensus that the impetus for this planning must come from the state's central Cooperative Extension office. The group advocated a central coordinator who could work with medical school instructors and district agents to prepare schedules. The group agreed that such coordination would help promote good feelings for the field trips among the agents and farmers. A conference call involving state office, district agents, and medical school instructors was suggested as a way to start.

6. Present information about these agromedicine field trips at annual meetings of county agents and at CES State Coordinators meetings.

At present, the University of Alabama School of Medicine and the Alabama Cooperative Extension System are taking these actions. We think that this approach is a useful way for medical education to address the special needs of the farm community. This planning exercise was a utilization of agromedicine, the partnership of medical and agricultural professionals, to address agricultural health.

Accepted December 18, 2001.

References

(1.) Council on Graduate Medical Education: Twelfth Report: Minorities in Medicine--AAMC Statement (DHHS Publication No. HRSA-97-54). Rockville, MD, U.S. Health Resources and Services Administration, 1998.

(2.) Donham KJ, Mutel CF. Agricultural medicine: The missing component of the Rural Health Movement. J Fam Pract 1982;14:511-520.

(3.) Wheat JR, Donham KJ, Simpson WM. Medical education for agricultural health and safety. J Agromed 2001;8:77-92.

(4.) Ratchford CB. Knowledge in action: The University of Missouri's extension network. Ann Am Aced Pal Soc Sci 1993;529:59-70.

(5.) Merchant J, Kross B, Donham K, et al: Agriculture at Risk. A Report to the Nation, Oakdale, University of Iowa, National Coalition for Agricultural Safety and Health, 1989.

(6.) Myers ML, Herrick RF, Olenchock SA, et al (eds): Papers and Proceedings of the Surgeon General's Conference on Agricultural Health and Safety (DHHS [NIOSH] Publication No. 92-105). Washington, DC, U.S. Government Printing Office, 1992.

(7.) Schenker MB: Preventive medicine and health promotion are overdue in the agricultural workplace, in 1995 Wellness Lectures: The California Wellness Foundation and the University of California. Berkeley, UC Printing, 1995, pp 101-124.

(8.) U.S. Department of Agriculture. Research, Education, & Economics: Strategic Plan. Available at: http://www.reeusda.gov/ree/ree2.htm. Accessed November 18, 2002.

(9.) Siewe YJ: Empowering cooperative extension educators for heart health education. J Extension 2001;39(3). Available at: http://joe.org/joe/2001june/tt5.html. Accessed November 18, 2002.

(10.) Schuman SH, Caldwell ST: A User's Guide to Agromedicine: The South Carolina Model. Amsterdam, Harwood Academic Publishers, 2000.

(11.) Wheat JR. An introduction to agromedicine. J Agromed 1999;6:5-9.

(12.) Wheat JR, Nagy CM, McKnight JT, et al. Alabama agromedicine program: Rationale, proposal, and supportive study. J Agromed 1994;1:63-82.

(13.) Waits JB, Wheat JR. Preventive agricultural medicine: A medical student's perspective on an important component of rural community health, J Agromed 1999;6:11-25.

(14.) Tabereaux PB, Wheat JR. Preventive agricultural medicine: A student's perspective of farmers' mental health. J Agromed 2001;8:33-43.

(15.) Hamadeh G, Caldwell S. A curriculum in agricultural medicine for medical students. J Agromed 1994;1:53-62.

RELATED ARTICLE: Key Points

* Agromedicine, a partnership between agricultural and medical science professionals, provides an approach to studying the health of the farm community.

* Medical faculty and agricultural extension agents can form effective focus groups to develop learning exercises for medical students to study personal, occupational, and environmental health concerns of farmers.

* Farm field trips can provide agricultural health learning experiences that are mutually satisfying to medical students, medical faculty, agricultural extension agents, and farmers.

From the Department of Community and Rural Medicine, University of Alabama School of Medicine Tuscaloosa Program, Tuscaloosa, AL.

Supported in part by the National Institute of Environmental Health Sciences (NIEHS) Environmental and Occupational Medicine Academic Award (No. 5 K07 ES00310-05) and a grant from the Alabama Family Practice Rural Health Board, Montgomery, AL.

Reprint requests to John R. Wheat, MD, MPH, Box 870326, Tuscaloosa, AL 35487-0326.

Copyright [c] 2003 by The Southern Medical Association

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