GRADUATE MEDICAL EDUCATION: The Critical Link for Primary Care Workforce Development Judith Pauwels, MD Family 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 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

Among 2010 & 2011 grads: – 70% currently practicing in WA; 3% practicing in another WWAMI state In a 2011 survey of Family Medicine graduates from (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 yearly Graduate: only growing about 0.9%/year AAMC 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 Medical Education Rob Epstein, MD Family Medicine Port Angeles

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

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

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

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