An innovative medical-school program pools resources to increase the supply of rural physicians in 5 Western states
As a first-year medical student in a state with no medical school, Pamela A. Fry is taking a circuitous route to a career as a small-town doctor.
It’s a journey that will take her from here to Seattle, then on to rural clinics in Alaska, Idaho, Montana, Wyoming, or Washington State. During her last two years of medical school, she may bounce among a handful of sites, delivering babies in one, treating alcoholics in another, caring for trauma patients in a third.
She hopes to end up where she began, in a small Montana town, surrounded by mountains and streams, within driving distance of her family.
Making it possible is a medical-education program that pools the resources of five sparsely populated Northwestern states, four of which have no medical schools of their own. The so-called WWAMI program, named for the participating states, provides a small but steady supply of primary-care physicians who are returning to their rural roots, where doctors are few and far between and where chronic diseases often go untreated. Today 172 of the program’s graduates are practicing medicine in Montana alone, and hundreds more are scattered in small towns throughout the Northwest.
“The program shows students that it is possible to do what many of them always wanted to do -- to return to their home towns to practice medicine,” says Dwight E. Phillips, a professor of anatomy at Montana State University, one of the institutions that provide first-year training. He is also interim director of the Montana portion of the program.
Students spend their first year of basic medical studies taking classes at the participating public universities in their own states. Each student also spends one morning a week shadowing a local primary-care physician. The following summer about 80 percent of the students participate in an optional four-week rotation working with rural physicians.
Then students from across the five states pack up and head for Seattle, where they spend their second year at the University of Washington School of Medicine -- the region’s only medical school. They spend their third and fourth years working in clinics in Seattle or in one or more of about 30 towns throughout the Pacific Northwest. There they learn alongside physicians in communities like Wrangell, Alaska; Whitefish, Mont.; and Pocatello, Idaho.
Everyone in the program takes the same courses and the same exams, and all of the diplomas come from the University of Washington. That’s a big draw for many students, since Washington is widely viewed as having one of the nation’s best medical schools for training primary-care doctors.
But every student who yearns to become a small-town doc has plenty of nagging worries: Will there be other physicians nearby to consult with in complicated cases? Will the town have decent jobs for spouses and good schools for kids? Will every waking hour be spent in the office or on call? Perhaps most important, will the income be enough to pay off medical-school loans of $100,000 or more?
The program tries to allay those concerns by linking students with a network of physicians who have faced such issues and have set up successful practices. It also provides financial incentives, including loan repayments, to graduates who work where doctors are scarce.
Dearth of Doctors
Thirty years after it began accepting students, the WWAMI program is seen as a success by educators. The idea was born in 1971, as educators and lawmakers were becoming increasingly concerned about the shortage of physicians in much of the Pacific Northwest, an area that covers more than one-quarter of the U.S. landmass but has only 3.3 percent of its population. The University of Washington got together that year with Washington State University, Montana State University, the University of Alaska at Anchorage, and the University of Idaho to find a way to produce more homegrown doctors. The University of Wyoming joined the group in 1996.
Over the years, the program has survived numerous challenges from legislators who chafed at the idea of blue-collar taxpayers helping foot the bill for white-coated physicians. But supporters say the program makes economic sense.
Jordan J. Cohen, president of the Association of American Medical Colleges, calls the joint effort “one of the most creative, forward-looking and successful programs to address the needs of rural medicine.”
“It has, among other things, made it possible to provide physicians for rural populations without having to duplicate the very expensive infrastructure of having separate medical schools in each state,” he says.
All of the participating students pay their home state’s tuition for the first year, and Washington’s in-state tuition for the next three. Their home states subsidize the additional cost of educating them -- an amount that’s slightly higher than the difference between the in-state and out-of-state tuitions. When Ms. Fry heads to Seattle next year, she’ll be paying the in-state tuition of $12,448, instead of the $29,388 she would have paid as an out-of-stater.
Small-Town Roots
The 20 first-year medical students who are taking classes at Montana State are typical of the program’s participants. Many of them grew up in small towns and plan to return to rural areas.
Ms. Fry hails from Lewistown, Mont., an agricultural town of about 7,000 people, where she learned not to take medical care for granted.
“I remember when our hometown surgeon retired and people had to travel at least 100 miles to get the next surgeon,” she says.. Patients traveling that far from home for the procedure very likely had to go through the difficult experience without family members nearby.
While Ms. Fry was in high school, she worked as an emergency medical technician, where she saw firsthand how difficult it can be to bring medical care to remote parts of the state.
One night, two campers who had been ice fishing hours from the nearest town were badly burned when their tent caught fire. The campers were being carried from a pickup truck to a small town’s ambulance in the middle of a blinding snowstorm when Ms. Fry’s unit got the call. That ambulance drove the campers across slippery, gravel roads to the better-equipped ambulance that Ms. Fry was riding in. Her unit then drove the young men more than 100 miles -- first to a small hospital in Roundup, Mont., where they were stabilized, and then to a larger hospital in Billings. After being treated in the emergency room there, the campers were flown to a burn unit in Salt Lake City.
The experience, harrowing as it was, illustrated an important lesson in how medical care is delivered in much of the Northwest. “You see how people in rural areas have to pull together, and how every link of the chain is important,” says Ms. Fry. “You have to depend on each other.”
She can count on having at least one nearby doctor to count on: her fiancé and classmate, Luke Durling. He got an early start in the program, attending an on-campus summer session for promising high-school students who might not have considered careers in medicine.
Mr. Durling, whose father is a construction worker and mother a grocery-store clerk, grew up in Hamilton, Mont., a town of about 4,000. Ms. Fry’s father is a plumber and her mother a secretary. None of them graduated from college.
Many of Montana State’s first-year WWAMI students are the first in their families to earn college diplomas. They’re a close-knit group. Their single intramural sports team takes to the field for softball, touch football, and soccer. They get together for study sessions and potluck dinners. And while other Montana State students were out whooping it up on a recent Friday night, Ms. Fry and her classmates had organized a quiet evening in the anatomy lab, where they compared characteristics of their 10 cadavers in preparation for a forthcoming anatomy exam. (The low student-to-cadaver ratio is a source of satisfaction that only another medical student could understand.)
“We’re all very close,” Ms. Fry says. “It’ll be a neat resource to have when we become doctors. I may be the only doctor in town, and it will be nice to have someone who I can call or e-mail for advice.”
All of the first-year students are paired with upper-level students, who tell them what’s in store once they leave their home campuses and converge on Seattle. The approximately 180 second-year students are assigned to one of five academic groups, or “colleges,” each named for a geographic feature like Washington’s Mount Rainier or Idaho’s Snake River. Students are assigned randomly; a Wyoming student might end up with students from the four other states. The colleges are further divided into groups of six students, each with a faculty mentor.
Venturing Out
In the third year it’s time to split up again.
The students are required to spend at least six weeks in each of six required clinical rotations: family medicine, internal medicine, pediatrics, obstetrics/gynecology, surgery, and psychiatry. The clerkships are offered in dozens of towns and cities throughout the five states. A city like Boise, Idaho, or Spokane, Wash., offers several of the positions, so a student could stay in one place for most of his or her third year. (Everyone is required to leave Seattle for at least one rotation.) But for most students, the chance to jump from town to town is part of what makes the program so intriguing.
George Knight lived in all five participating states during his third year. “I wanted to get a feel for the entire Northwest and to see what medicine is like in different locations,” he says.
During his psychiatry rotation, in Anchorage, the hospital flew the students to two small villages, including Noatak, which is 70 miles north of the Arctic Circle, surrounded by mountains and accessible only by plane for most of the year. Many of the 200 or so village residents lived in shacks with their sled dogs as temperatures dipped below zero.
“Seeing that isolation and the conditions they lived in,” says Mr. Knight, a fourth-year student, “I had a much better appreciation of why so many people who I saw in the psychiatric hospital suffered from alcohol and substance abuse.” Despite the challenges of moving so much, the regional program loses only one or two students a year -- far below the 3-percent average dropout rate for medical schools nationally.
Robbing the Poor?
Despite glowing reviews from students, the program has its detractors.
Joe Balyeat, a Republican member of the Montana House of Representatives, has fought unsuccessfully to persuade his colleagues to cut the $3.2-million the state spends annually on WWAMI. If nothing else, he argues, students should be required to pay back the money, with interest.
The average Montanan should not have to subsidize the education of medical students who will end up earning some of the highest incomes in the state, he argues. “I believe it’s unjust for the poor to subsidize the soon-to-be-rich, especially when the state is $250-million in the hole,” Mr. Balyeat wrote in a Billings newspaper.
The program’s supporters counter that WWAMI accounts for less than 1 percent of the state’s annual budget. They also point out that the average graduate owes nearly $100,000 in loans, and that if the state aid were converted to loans, the students’ debt would almost triple.
Besides, the backers argue, the state is getting a good return on its investment. About 43 percent of the students who start the program in Montana come back to practice there. That is slightly higher than the national average for students graduating from state-supported medical schools. The rate tops 50 percent if the students who start out in other states and end up in Montana are factored in.
Although students are not obligated to return to their home states, Alaska and Wyoming require graduates to pay back a portion of their subsidies if they practice elsewhere.
Starting in November, the Montana program will be led by Linda Hyman, now an associate professor of biochemistry at Tulane University Medical School. “This program offers the best of all worlds,” she says. “It’s a small, intimate learning environment backed by the resources of the University of Washington.”
That’s largely what attracted LeeAnna Muzquiz, a member of the Flathead Indian tribe, who graduated from the program and returned this year to the reservation where she had grown up. She is the only physician at the tiny tribal health clinic in Ronan, Mont.
Dr. Muzquiz, who studied microbiology at Montana State University before entering medical school, credits the program with giving her the confidence she needed to succeed in medical school. “I had some struggles early on in college, and I was nervous about medical school,” she says. “It was far less intimidating being in a first-year medical-school class of 20 instead of 120.”
After focusing on American Indian health during her residency in Seattle, she decided to return to the reservation, where she had seen so many relatives struggle with chronic illnesses like heart disease and diabetes.
“I wanted to come back home and do what I could to improve the health care here and to provide some continuity of care,” she says. “It’s hard to keep physicians on reservations. Many of them come and do their time here and then settle somewhere else.”
She pauses. “For me, this is where I want to be,” Dr. Muzquiz says. “This is coming home.”
http://chronicle.com Section: Students Volume 50, Issue 17, Page A35
