GRADUATE MEDICAL EDUCATION: The Critical Link for Primary Care Workforce Development

1. GRADUATE MEDICAL EDUCATION: The Critical Link for Primary Care Workforce Development Judith Pauwels, MD Family Medicine Residency Network

2. Practicing Physician Medical Education Pipeline: What does it take to become a doctor? Fellowship training Residency Training (minimum of 3 years) Medical School (4 years) College (4 years) K-12 Education (13 years)

3. GRANDVIEW • Sollus Northwest • KENNEWICK • Trios Health • MOUNT VERNON • Skagit Regional Health • OLYMPIA • Providence Medical Group: St. Peter Family Medicine • PUYALLUP • East Pierce Family Medicine • Puyallup Tribal Health Authority • RENTON • Valley Family Medicine • RICHLAND • Kadlec Health System • SEATTLE • Group Health Family Medicine Residency • Swedish Family Medicine Residency - Cherry Hill • Swedish Family Medicine First Hill Residency • University Of Washington Family Medicine Residency • SPOKANE • Family Medicine Spokane • TACOMA • Community Health Care Tacoma • Tacoma Family Medicine • VANCOUVER • Family Medicine Of Southwest Washington • YAKIMA • Central Washington Family Medicine • Rural Training Tracks • COLVILLE • ELLENSBURG 17 Civilian Residencies from Skagit to Spokane

4. In a 2011 survey of Family Medicine graduates from 1997-2006 (N=616 of 1,123)regarding practice sites: • Among 2010 & 2011 grads: • 70% currently practicing in WA; 3% practicing in another WWAMI state • 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

5. 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 yearly • Graduate: only growing about 0.9%/year • AAMC projection of GME need: 4,000 additional slots per year nationally

6. 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

7. 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.

8. Rural Community-Based Medical Education Rob Epstein, MD Family Medicine Port Angeles

9. Rural Training Track • A Rural Training Track is a graduate medical residency program where the residents spend their first year in a larger urban program, then two years in a smaller rural location to complete their family medicine training. • Over half of the graduate physicians stay in the rural location, or in other rural areas.

10. Interprofessional Education • Rural Training Track sites train multiple other health care providers. • Medical students, Nurse Practitioner students, Physician Assistant students, and Family Medicine Residents in the same environment. • Health Care Teams and Patient Centered Medical Homes. • Longitudinal training: training in the same place for extended length of time.

11. Program Structure • 1st year in Seattle at Swedish Cherry Hill Family Medicine Residency Program. • 2nd & 3rd years in Port Angeles at Olympic Medical Center and a local Family Medicine Continuity Clinic.

12. Challenges • Rural hospitals have little or no financial margin to support residency training. • Rural physicians and clinics are also stressed, both by finances and by current workloads and under-staffing, leaving little or no margin to add teaching. • External support to offset the financial impact of adding teaching time can make or break the ability of a community to be a teaching site.