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. 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

4. 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”

5. FAMILY MEDICINE – THE CHAMPION OF RURAL PLACEMENT

6. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

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)

15. SAMPLE WEEK ON 3 WEEK SPECIALTY BLOCK TIME - R2 YEAR No night call for the clinic practice. Night call dictated by the rotation FP Resident is on.

16. SAMPLE WEEK ON 5 WEEK FP Clinic block

17. 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%)

18. 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.

19. 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

20. 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

21. 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

22. HAS THE RESIDENCY HELPED THE COMMUNITY ? • Residency Community care program - a win - win program • Residents care for uninsured and underinsured from Sauk County

23. 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) • Dr. Kansas Dubray (Med-Peds) Majority teach in the residency

24. 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

25. 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

26. 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

27. 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)

28. 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

29. 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.

30. 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)