FAMILY MEDICINE RESIDENCY TRAINING IN A RURAL COMMUNITY

1
FAMILY MEDICINE RESIDENCY TRAINING IN A RURAL
COMMUNITY

• The 1-2 Rural Training Track Concept
• James R. Damos, MD
• Baraboo, WI

2
Objectives for next 15 Minutes

• Background information that spurred RTT
  development nationally and in Wisconsin
• Share Baraboo RTT curriculum
• Discuss successes and barriers
• Make personal recommendations

3
1970s FP TRAINING DIFFERENT

• My training in Family Medicine was different
• FP training had strong rural focus
• 100 of our faculty had had extensive rural
  practice experience

4
1970s FP TRAINING DIFFERENT

• In 1970s, other specialties took interest in
  teaching family medicine residents

You need to know how to do this if you are
going to practice rural
5
FAMILY MEDICINE THE CHAMPION OF RURAL PLACEMENT
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THINGS HAVE CHANGED

• Science expanded and has lead to many cures
• Specialization in medicine has flourished
• Specialization has lead to many new physician
  fellowships .
• There is competition for
  learning
• Turf disputes

7
SACRIFICE OF COMMUNITY NEEDS FOR SCIENTIFIC
ADVANCES

• Scientific advances have lead to many cures but
  rural community needs neglected (primary Care)

At expense of
Rural Primary Care
Heart Transplants
Brain surgery
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EXAMPLE - RURAL MATERNITY CARE

• Two thirds of obstetric deliveries in rural
  communities are by family physicians/nurse
  midwives (Obstetricians locate urban)
• On my joining UWDFM in 1987 lack of obstetric
  teaching for rural practice
• Advanced Life Support in Obstetrics (ALSO) course
  (skills course for rural docs)
• IMPORTANT - Rural Hospitals beginning to close
  their OB doors

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I ALSO NOTED WHEN I JOINED UWDFM IN 1987

• Internal medicine and pediatric residents
  sub-specialize instead of primary care few
  locate rural
• Obstetricians are largely urban
• General surgeons are now breast surgeons, GI
  surgeons, thoracic surgeons etc. declining
  numbers locating rural
• Orthopedists specialize in ankle, knee etc.
  declining numbers locate rural

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RURAL PRIMARY CARE CHALLENGES

• Even in family medicine, specialization is
  developing (Prestige, respect)
• Sports medicine
• Geriatrics
• Palliative Care
• Preventive Cardiology
• Substance abuse
• Academic Medicine
• Integrative Medicine

Family Medicine residencies struggle to get their
residents experiences pertinent to rural practice

Rural champion status fading
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WITH THIS BACKGROUND, ENTER BARABOO RTT

• First year in a urban medical center
• 24 months in a rural apprenticeship with time
  away for specialty rotations and other
  educational events

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UW-BARABOO RTT

• Started in 1996 with our first 2 residents
• Successful community-academic partnership between
• University of Wisconsin Dept. of Family
  Medicine-Madison program
• St.Marys-Dean Venture
• AHEC
• St.Clare Hospital
• Baraboo Medical Associates

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FIRST YEAR ROTATIONS - ROTATING
2 half days in clinic in Baraboo/week 3 wks
vacation
14
SECOND AND THIRD YEARS A RURAL APPRENTICESHIP

• Last 2 years in Baraboo 13 eight week blocks
• Each eight week block sub-divided into series of
• Subspecialty rotation (3 weeks)
• Family Medicine practice apprenticeship combined
  with subspecialty half day rotations at St. Clare
  Hospital with visiting sub-specialists
• (5 weeks)

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SAMPLE WEEK ON 3 WEEK SPECIALTY BLOCK TIME
- R2 YEAR
Mon Tues Wed Thurs Fri Sat Sun
Morning Sports Med FP Clinic Seminar morning Sports Med Sports Med
Afternoon Sports Med Sports Med Sports Med Sports Med FP Clinic
Night Call
No night call for the clinic practice. Night call
dictated by the rotation FP Resident is on.
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SAMPLE WEEK ON 5 WEEK FP Clinic block
Time Mon Tues Wed Thurs Fri S a t Sun
Morning FP Clinic Off Post Call Madison Seminar morning or via polycom Neurology Specialty Half-day GYN Specialty Half-day Rds Off
Afternoon FP Urgent Care Off Post Call ENT Specialty Half-Day FP Clinic FP Clinic Off Off
Night On call
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OUTCOMES BARABOO GRADS 1999-2010

• 16 Graduates of Baraboo through 2010
• 13 have entered rural practice (81)
• 8 have remained in rural practice in Wisconsin
  (50)
• 12 Baraboo grads are practicing maternity care in
  rural areas (75)
• 3 Baraboo grads are performing emergency (not
  repeat) Cesarean Sections in rural communities
  (19)

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OUTCOMES BARABOO GRADS 11 YEARS

• 5 Baraboo grads provide colonoscopy screening
  (not diagnostics) in rural communities (31)
• 4 of the graduates practice in the
  Baraboo-Wisconsin Dells area and have become
  teaching faculty in the Baraboo RTT residency
  program. (25).
• One more is pending signing with us.

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DOES TRAINING IN A RURAL COMMUNITY HURT RESIDENT
EDUCATION?

• Baraboo grads improve all 3 years on in-training
  exams that we monitor
• Baraboo grads have passed their AAFP board exams
• Graduate surveys tell us they feel well trained
  for rural practice

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DOES TRAINING IN A RURAL COMMUNITY HURT RESIDENT
EDUCATION?

• Baraboo has become a procedure capital of FP
  residency training in WI
• Interesting phenomenon - Specialists teach
  Baraboo residents similar to 1970s

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NATIONAL DATA ON RTTS IS SIMILAR TO BARABOO

• 76 of RTT graduates are practicing in rural
  America
• 65 are providing obstetrical services
• Half are performing cesarean sections
• Graduate surveys state well trained
• Residents report they have learned procedures
  pertinent to rural practice

Thomas C. Rosenthal M.D. et al
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HAS THE RESIDENCY HELPED THE COMMUNITY ?

• Residency Community care program - a win - win
  program
• Residents care for uninsured and underinsured
  from Sauk County

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HAS THE RESIDENCY HELPED THE COMMUNITY ?

• Recruitment of physicians to Baraboo since RTT
  opened in 1996 (Hard to recruit prior to 1996)
• 1996-2010 physicians locating in Baraboo
• Dr. Cheryl Gehin (Family Medicine)
• Dr. Jennifer Orkfritz (Internal Medicine)
• Dr. James Damos (Family Medicine Program
  Director)
• Dr. Eric Hamburg- (Internal Medicine/Critical
  Care)
• Dr. Kristin WellsGeneral Surgery
• Dr. Dave Jarvis (Family Medicine)
• Dr. Tom Stark (Family Medicine)
• Dr. Amy Delong (Family Medicine)
• Dr. Kansas Dubray (Med-Peds)

Majority teach in the residency
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IN ADDITION, BARABOO GRADS LOCATING IN BARABOO

• Dr. Christina Hook (Family Medicine) Baraboo RTT
  grad (UW Med School)
• Dr. Tim Deering (Family Medicine) Baraboo RTT
  grad (Vanderbilt School of Medicine)
• Dr. Stuart Hannah (Family Medicine) Baraboo RTT
  grad (Vanderbilt School of Medicine) Future
  program director
• Dr. Jamie Kling (Family Medicine) Baraboo RTT
  grad (Des Moines Osteopathic)
• Dr. Bridget Delong (Family Medicine) Baraboo
  RTT grad for 2011 (UW Med School) Soon to sign
  hopefully

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BARABOOS SUCCESS HAS INTERESTED OTHERS IN
WISCONSIN

• Inquiries on starting RTTs from the following
  hospitals and physician groups
• LancasterPlatteville
• Mineral Point Dodgeville,
• Monroe
• Waupaca
•  Some willing to pay bonuses early to M3 and M4
  med students
• Med students hail Black River Falls and Mauston
  as excellent teaching

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BARRIERS TO RTT TRAINING

• Baraboo is the only surviving RTT in Wisconsin
• Prairie du Chien closed
• Lacrosse-Mayo program
• Antigo closed
• UW-Wausau
• Menomonie closed
• UW-Eau Claire
• Black River Falls closed
• Lacrosse-Mayo program
• Mauston closed
• Lacrosse-Mayo program
• Baraboo still open
• UW-Madison

REASONS FOR CLOSING EXPRESSED BY PROGRAM
DIRECTORS Few applicants interested Academic
community partnerships fell apart or never
developed fully Financial support lacking Lack
of urban-based physician champions
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OTHER BARRIER TO RTT TRAINING

• ACGME is becoming a barrier to stand alone RTTs
• Increasing documentation requirements
• Lack of rural physician time to document
  everything
• Most of ACGME requirements written for urban,
  hospital-based, or specialty residencies (not
  apprenticeships)

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CONCLUSIONS

• RTT Educational Advantages
• RTTs work as an educational model. Students
  enlightened by working in rural community
• RTT rural laboratories offer excellent
  experiences for rural practice (case mix, lack of
  competition for experiences, rural role models)
• RTTs are successful at placement into rural
  practice
• RTT training is competent and pertinent
• RTT educational concept is 100 responsive to
  rural community needs

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CONCLUSIONS

• RTT Disadvantages
• There are many barriers to stand alone RTT
  development
• Strong community-academic partnerships needed.
  Not enough of these currently.
• Not enough urban physician champions for rural
• ACGME bureaucracy a barrier to stand alone RTTs
• Faculty financial support is lacking (tasks mount
  without compensation).
• Current bill coding inhibits teaching (1st assist
  at C-section)
• With so few programs, it is unlikely RTTs will
  make a big impact on the rural crisis. They can
  help, however.

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PERSONAL RECOMMENDATIONS FOR FP RESIDENCY
TRAINING IN WISCONSIN

• Support what you have already in Baraboo. The
  Madison-Baraboo RTT has been successful
• Make Baraboo an integrative program of 24 months
  so only one PIF and site review
• Capture the specialists in Baraboo. They like
  teaching
• Consider the integrated RTT model using current
  core family medicine programs
• _ Communities are reaching out. Capture them as
  integrated RTT sites
• Integrate the WARM program more with the FP
  residency piece (mix rural residents/WARM
  students/Rural faculty)