FAMILY MEDICINE RESIDENCY TRAINING IN A RURAL

COMMUNITY

The 1-2 Rural Training Track Concept

James R. Damos, MDBaraboo, 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

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“You need to know how to do this if you are going to practice rural”

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)

Heart Transplants Brain surgery Rural Primary Care

At expense of

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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 struggleto get their residents experiencespertinent to rural practice

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Rural champion status fading

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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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/MadisonMaternity 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

FIRST YEAR ROTATIONS - ROTATING

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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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Mon Tues Wed Thurs

Fri Sat Sun

Morning SportsMed

FP Clinic

Seminar morning

SportsMed

SportsMed

Afternoon SportsMed

SportsMed

SportsMed

Sports Med

FP Clinic

Night Call

SAMPLE WEEK ON 3 WEEKSPECIALTY BLOCK TIME - R2 YEAR

No night call for the clinic practice. Night call dictated by the rotationFP Resident is on.

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SAMPLE WEEK ON 5 WEEK FP Clinic block

Time Mon Tues

Wed Thurs Fri Sat

Sun

Morning FP Clinic

Off PostCall

Madison Seminar morning or via polycom

NeurologySpecialty Half-day

GYNSpecialtyHalf-day

Rds Off

Afternoon

FP Urgent Care

OffPostCall

ENTSpecialtyHalf-Day

FP Clinic FP Clinic

Off Off

Night On call16

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 practice19

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 practiceThomas 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)• Dr. Kansas Dubray (Med-Peds)

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Majority teach in the residency

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– 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 26

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 needs28

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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