GRADUATE MEDICAL EDUCATION:

The Critical Link for Primary Care Workforce Development

Judith Pauwels, MDFamily Medicine Residency Network

Practicing

Physician

K-12 Education(13 years)

College(4 years)

Medical School(4 years)

Residency Training (minimum of 3 years)

Medical Education Pipeline:

What does it take to become a doctor?

Medical Education Pipeline:

What does it take to become a doctor?

Fellowship training

17 Civilian Residencies

from Skagit to Spokane

GRANDVIEWSollus Northwest

KENNEWICKTrios Health

MOUNT VERNONSkagit Regional Health

OLYMPIAProvidence Medical Group: St. Peter Family Medicine

PUYALLUP

East Pierce Family MedicinePuyallup Tribal Health Authority

RENTONValley Family Medicine

RICHLAND Kadlec Health System

SEATTLEGroup Health Family Medicine Residency

Swedish Family Medicine Residency - Cherry Hill Swedish Family Medicine First Hill Residency

University Of Washington Family Medicine Residency

SPOKANEFamily Medicine Spokane

TACOMACommunity Health Care Tacoma

Tacoma Family Medicine

VANCOUVERFamily Medicine Of Southwest Washington

YAKIMA

Central Washington Family Medicine

Rural Training TracksCOLVILLE

ELLENSBURG

•Among 2010 & 2011 grads:– 70% currently practicing in WA; 3% practicing in another WWAMI state

In a 2011 survey of Family Medicine graduates from 1997-2006 (N=616 of 1,123)regarding practice sites:

• 45% are practicing in communities of less than 50,000; 14% in communities of less than 5,000

• 34% spend ≥50% time practicing in an underserved setting (FQHCs, Rural Health Centers, etc.)

• 69% of graduates (excluding military programs) currently practicing family medicine are practicing in a WWAMI state or Oregon; 49% are

practicing in the state where they trained• 51% currently practicing in WA state; 8% in other WWAMI states

GME: the need for new programs

June 2013 NEJM analysis of undergraduate vs graduate medical education positions:Undergraduate:

MD increasing 30% to over 21,000 students by 2016

DO colleges increasing by over 200% to over 21,000 students in 2012

IMGs: about 12,500 yearlyGraduate: only growing about 0.9%/yearAAMC projection of GME need: 4,000

additional slots per year nationally

Why is state support critical?Challenges to developing new programs:

Start-up costs PRIOR TO being able to tap into ongoing federal and practice revenue streams

Specific needs for development of more rural sites

Mandated AOA program transformation to ACGME will have unreimbursed costs similar to start-ups

Challenges to existing primary care programs:Adaptation to the “new health care world”: rules that support resident training in new models of care

Primary care reimbursement models“Safety net” practices

Why is state support critical?Finances are not why a community starts a

residency training program, nor the only factor in the decision to do so.

However, they ARE a critical factor in determining the viability of developing and sustaining a successful program.

Primary care/family medicine training is not cheap, and it depends upon government sources of funding to make it affordable for communities.

Rural Community-Based Rural Community-Based Medical EducationMedical Education

Rob Epstein, MDRob Epstein, MD

Family Medicine Port AngelesFamily Medicine Port Angeles

Rural Training TrackRural Training Track

A Rural Training Track is a graduate medical A Rural Training Track is a graduate medical residency program where the residents spend residency program where the residents spend their first year in a larger urban program, their first year in a larger urban program, then two years in a smaller rural location to then two years in a smaller rural location to complete their family medicine training.complete their family medicine training.

Over half of the graduate physicians stay in Over half of the graduate physicians stay in the rural location, or in other rural areas.the rural location, or in other rural areas.

Interprofessional Interprofessional EducationEducation

Rural Training Track sites train multiple other Rural Training Track sites train multiple other health care providers.health care providers.

Medical students, Nurse Practitioner students, Medical students, Nurse Practitioner students, Physician Assistant students, and Family Physician Assistant students, and Family Medicine Residents in the same environment.Medicine Residents in the same environment.

Health Care Teams and Patient Centered Health Care Teams and Patient Centered Medical Homes.Medical Homes.

Longitudinal training: training in the same Longitudinal training: training in the same place for extended length of time.place for extended length of time.

Program StructureProgram Structure

11stst year in Seattle at Swedish Cherry Hill year in Seattle at Swedish Cherry Hill Family Medicine Residency Program.Family Medicine Residency Program.

22ndnd & 3 & 3rdrd years in Port Angeles at Olympic years in Port Angeles at Olympic Medical Center and a local Family Medicine Medical Center and a local Family Medicine Continuity Clinic.Continuity Clinic.

ChallengesChallenges

Rural hospitals have little or no financial Rural hospitals have little or no financial margin to support residency training.margin to support residency training.

Rural physicians and clinics are also stressed, Rural physicians and clinics are also stressed, both by finances and by current workloads both by finances and by current workloads and under-staffing, leaving little or no margin and under-staffing, leaving little or no margin to add teaching.to add teaching.

External support to offset the financial impact External support to offset the financial impact of adding teaching time can make or break of adding teaching time can make or break the ability of a community to be a teaching the ability of a community to be a teaching site.site.