Transcript family medicine residency training in a rural community

FAMILY MEDICINE RESIDENCY
TRAINING IN A RURAL
COMMUNITY
The 1-2 Rural Training Track
Concept
James R. Damos, MD
Baraboo, WI
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
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1970’s 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
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1970’s FP TRAINING DIFFERENT
• In 1970’s, other specialties
took interest in teaching family
medicine residents
“You need to know how to do this if
you are going to practice rural”
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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
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SACRIFICE OF COMMUNITY NEEDS
FOR SCIENTIFIC ADVANCES
• Scientific advances have lead to many cures
but rural community needs neglected (primary Care)
At expense
of
Heart Transplants
Brain surgery
Rural Primary Care
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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 MedicineMadison program
– St.Marys-Dean Venture
– AHEC
– St.Clare Hospital
– Baraboo Medical Associates
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FIRST YEAR ROTATIONS - ROTATING
Inpatient Medicine –
•Family Practice Inpatient Service-St.Marys/Madison
•Family Practice Inpatient Service at UW Hosp/Madison
•MICU/CCU Service at St.Marys/Madison
Pediatrics Service at St.Marys/Madison
Maternity care Service at St.Marys/Madison
Emergency Room at St.Clare Hospital in Baraboo
Newborn Care Rotation at St.Marys/Madison
Community Medicine Rotation in Baraboo (Hospice, Home Health, Jail, school district)
GENERAL SURGERY in Baraboo
2 half days in clinic in Baraboo/week; 3 wks vacation
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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
Seminar
morning
Sports
Med
Sports
Med
Sports
Med
FP
Clinic
Morning
Sports FP
Clinic
Med
Afternoon
Sports Sports Sports
Med
Med
Med
Night Call
Sat
Sun
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
Morning
FP
Clinic
Off
Post
Call
Afternoon
FP
Urgent
Care
Off
Post
Call
Night
On call
S
a
t
Madison
Seminar
morning
or via
polycom
Neurology
Specialty
Half-day
Rds
GYN
Specialty
Half-day
Off
ENT
Specialty
Half-Day
FP Clinic
FP
Clinic
Off
Off
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S
u
n
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 BarabooWisconsin 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
1970’s
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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 Wells—General Surgery
• Dr. Dave Jarvis (Family Medicine)
• Dr. Tom Stark (Family Medicine)
• Dr. Amy Delong (Family Medicine)
the residency
• Dr. Kansas Dubray (Med-Peds)
Majority teach in
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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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BARABOO’S SUCCESS HAS
INTERESTED OTHERS IN WISCONSIN
• Inquiries on starting RTTs from the following
hospitals and physician groups
•
•
•
•
Lancaster—Platteville
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
REASONS FOR CLOSING
– Lacrosse-Mayo program
EXPRESSED BY PROGRAM
• Antigo – closed
– UW-Wausau
DIRECTORS
• Menomonie – closed
– UW-Eau Claire
• Black River Falls – closed
– Lacrosse-Mayo program
• Mauston – closed
– Lacrosse-Mayo program
• Baraboo – still open
– UW-Madison
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 RTT’s
– 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 RTT’s 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)
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