What do family physicians do when the 1 million plus citizens of their state -- celebrated for its wide open spaces -- are starved for the kind of comprehensive health care that only family physicians can provide? In Montana, a group of energetic and like-minded health care professionals rolled up their sleeves and created, from scratch, the Family Medicine Residency Program of Western Montana.
Resident Saul Rivard, M.D., right, discusses a patient's care with Kevin Chin, D.O., a physician at the Partnership Health Center in Missoula, Mont.
"We thought if we could identify physicians who wanted to live in Montana and got them trained in Montana, they would stay in Montana," said Montana AFP President-elect Janice Gomersall, M.D., of Missoula, in an interview with AAFP News Now.
The five-year project, which began with a casual conversation in May 2009, included many parts, pieces and players, including the Montana AFP. "Even though we are a huge state, everybody knows everyone, and almost everyone lives in rural areas that need a doctor," said Gomersall.
"Many times we used our chapter influence to contact someone and get them involved. Several of our members sat on the organization board that came up with the planning. All of us had input," she added.
- Montana, by all counts a largely rural state, faces a critical shortage of primary care physicians.
- The Montana AFP partnered with other primary care forces in the state to create and launch the state's second family medicine residency program to help grow more family physicians in the state.
- The first class of 10 residents reported for training on July 1 in Missoula; the program had 600 applicants for its upcoming 2014 class.
Fast forward to 2013 when this new, untested program filled all 10 of its available slots in the first round of the National Resident Matching Program, known as the Match. The inaugural class of four women and six men began their training as family medicine residents in Missoula on July 1.
Identifying the Need
Montana doesn't have a medical school to call its own, but it is part of the University of Washington School of Medicine's WWAMI(www.uwmedicine.org) (Washington, Wyoming, Alaska, Montana and Idaho) program, which is a regional medical education program that pools resources to help train physicians in these five rural western states.
The Montana Family Medicine Residency, which is located in Billings, opened in 1995 to help alleviate the state's shortage of primary care physicians. The program has expanded to graduate eight residents a year, and nearly 70 percent of those graduates stay in Montana. But Montana's physician shortage is severe. Consider that among the state's 56 counties,
- all but one are considered "frontier" counties,
- 54 are designated as primary care shortage areas, and
- 11 don't have a single physician.
In addition, more than 19,000 Montanans live in counties with no primary care physicians, and nearly a quarter of the state's physicians are older than 60 and may retire within five years.
Ned Vasquez, M.D., of Missoula, the program director of the new residency, said, "Montana has been 50th in the nation for the number of GME (graduate medical education) residency slots, (two) per 100,000 people, for a long time. We're in the cellar."
"However, in a relatively short period of time, we managed to create a viable residency program that's attracted good, young budding family physicians to the state," he added. "And by doing that, we will provide a better pipeline of doctors for the rural communities."
John Miller, M.D., the new residency program's associate director for clinical operations and medical director of Partnership Health Center, a federally qualified health center that serves as one of the residency's five key clinical partners, ticked off the names of rural towns that would benefit from an influx of family physicians. "Plains (population 1,048), Ronan (1,871), Libby (2,628), Dillon (4,134) and Anaconda (9,328) all have critical-access hospitals that need to be staffed, and family physicians are the ideal people to staff ERs, labor and delivery, and see patients in clinic," said Miller.
"But it is so difficult for those towns to recruit with just the one residency program in Billings," he added.
Frank Reed, M.D., senior clinical professor of family medicine at the University of Montana and the rural program director for the new residency, put it this way: "Next week, our first resident goes out to Ronan, 60 miles from here, where family physicians do operative obstetrics and see Native Americans (from the Flathead Indian Reservation). That resident will get real-life exposure to family physicians who confidently perform Cesarean sections and provide care to underserved patients.
"Our sole purpose with this residency is to land people in the little communities in western Montana," he added.
Neonatal resuscitation training at Clark Fork Valley Hospital in Plains, Mont., is on today's agenda for residents, clockwise from right foreground, T.J. Sherry, M.D.; Kevin Kropp, D.O.; Harshida Chaudhari, M.B.B.S.; and Saul Rivard, M.D., as instructor Nerissa Koehn, M.D., far right, provides direction.
Chronology of Success
Ensuring the success of the residency program was a task that fell on many shoulders. A bird's eye view of the chronology helps explain all that was accomplished.
A series of meetings in 2009 and 2010 ensured the support of local family physicians. Much of 2011 was spent developing curriculum, hiring faculty, gaining approval of the Montana Board of Regents for University of Montana sponsorship of the residency and completing the accreditation application.
The program was accredited by the Accreditation Council for Graduate Medical Education in October 2012, but not soon enough to secure a listing in the Electronic Residency Application Service (ERAS) computer system that residents rely on for individual program information.
"We had to be creative about recruiting our first class since we weren't listed in ERAS and there was no obvious way for people to know we existed," said Vasquez. "We made sure we had a good website up and running" and alerted all of the U.S. allopathic and osteopathic medical schools.
In addition, the yet-to-be accredited residency program had a strong showing at Bartle Hall during the AAFP's 2012 National Conference of Family Medicine Residents and Medical Students in Kansas City, Mo. The convention hall effectively serves as a giant display case for residency programs seeking to snag interested students.
"We went into the recruiting season not knowing what would happen," said Vasquez. But the program's marketing push paid off with 142 applicants, 60 of whom secured interviews. The rest is history.
The five main residency program partners work together to ensure a high level of clinical care and a variety of practice experiences for residents. Those partners are Partnership Health Center in Missoula, which houses the residency; three hospitals, including St. Patrick Hospital and Community Medical Center in Missoula and Kalispell Regional Medical Center, located 145 miles to the north; and the University of Montana in Missoula.
Resident T.J. Sherry, M.D., engages with his patient at the Partnership Community Health Center. The Missoula clinic serves many patients with complex medical histories, which makes it a rich learning venue for family medicine residents.
Funding -- which has jumped from an initial start-up cost of $971,000 in 2009 to a proposed budget of $6.7 million when the residency is fleshed out with its full cadre of 30 residents -- is derived from a delicate web that includes federal GME dollars, state and federal grants, and revenue from the residency clinic.
Residents Show Pioneer Spirit
Resident Saul Rivard, M.D., of Missoula, counts himself among the lucky first 10 residents. Born and reared in Livingston, Mont., Rivard said he felt family medicine's tug in high school.
During his third year at the Warren Alpert Medical School at Brown University in Providence, R.I., Rivard heard rumors of a possible start-up residency program opening in Missoula. "I kept my eyes and ears open for more information," he said.
"I went through the interview season and applied to a number of programs, but I was lucky enough to match here," said Rivard. He described the experience of helping mold a fledgling program as both exciting and terrifying. Above all, he relished the challenge. "Maybe that's part of the pioneering spirit I grew up with in Montana.
"The hard work had been done before (the residents) ever set foot in Missoula, and the program was already structurally sound," Rivard added. He lauded the strong and solid core faculty. "They empower me," said Rivard. "And they want this to succeed as much as we do."
FACTS ABOUT THE MONTANA AFP
Chapter EVP: Linda Edquest
Number of chapter members: 472
Location of chapter headquarters: Helena
2014 annual conference: Chico Primary Care Conference, June 19-20, Chico Hot Springs
Resident T.J. Sherry, M.D., also a native Montanan, hails from tiny Frenchtown, population 1,825.
"I love the experience of rural medicine because I can wear many hats … from the emergency room, to rounding on patients like a hospitalist, to seeing clinic patients. And then I may deliver a baby at 5 o'clock that night. I love the variety," said Sherry.
He is secure in his residency choice. "I have absolutely no regrets," said Sherry. "It's quite the honor to be thought of as someone who could help develop a residency program."
Bright Future Ahead
Reed set up and oversees a frontier and rural advisory committee tasked with matching community needs with residency requirements. "In other words, instead of imagining what is needed out in rural areas, we will take ongoing feedback from people that is based on our residents' rotations out there," he said.
The future looks bright for the program, according to Reed. "We've already, in just our second year, filled all of our interview slots with tier-one candidates. Two days into it, we had 600 applications for this year."
Montana AFP President Larry Severa, M.D., of Billings, said he was excited at the prospect of watching the new program expand the outreach of family medicine in the state. "Family medicine is the foundation of excellent care, and we embrace family physicians trained in our state who will serve and lead in Montana now and in the future," said Severa.
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