Title: FAMILY MEDICINE RESIDENCY TRAINING IN A RURAL COMMUNITY
1FAMILY MEDICINE RESIDENCY TRAINING IN A RURAL
COMMUNITY
- The 1-2 Rural Training Track Concept
- James R. Damos, MD
- Baraboo, WI
2Objectives 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
31970s 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
41970s 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
5FAMILY MEDICINE THE CHAMPION OF RURAL PLACEMENT
6THINGS 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
7SACRIFICE 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
8EXAMPLE - 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
9I 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
10RURAL 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
11WITH 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
12UW-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
13FIRST YEAR ROTATIONS - ROTATING
2 half days in clinic in Baraboo/week 3 wks
vacation
14SECOND 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
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.
16SAMPLE 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
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)
18OUTCOMES 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.
19DOES 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
20DOES 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
21NATIONAL 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
22HAS THE RESIDENCY HELPED THE COMMUNITY ?
- Residency Community care program - a win - win
program - Residents care for uninsured and underinsured
from Sauk County
23HAS 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
24IN 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
25BARABOOS 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
26BARRIERS 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
27OTHER 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)
28CONCLUSIONS
- 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
29CONCLUSIONS
- 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.
30PERSONAL 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)