A federal grant enables two UMKC programs to stretch, and produce more of the doctors in the shortest supply.
Sheena Spielberg, M.D., had many memorable experiences as an internal medicine resident at UMKC, including a 13,000-mile round trip to Beijing to observe the Chinese health care system.
Other recent residents also traveled to get experience, learning about rural practice in Missouri towns 40 to 75 miles away.
And Spielberg got some of her best lessons only a few thousand feet from Hospital Hill, making house calls. One day, she and an attending physician, Mat Strasser, D.O., visited a patient who lived near Truman Medical Center Hospital Hill. He weighed more than 600 pounds and used the oven in his kitchen to heat his dwelling.
“It was really interesting to see how much better care you can provide if you go into somebody’s home,” said Spielberg, now the medical director of the Blue Clinic at TMC Hospital Hill. “Patients come to the clinic and they don’t know their medicines. They didn’t bring their blood sugar log. You go out to them, and all their medicines are there. You can kind of see the way they live.”
Spielberg, a graduate of the Saint Louis University School of Medicine, applied for residency programs knowing she wanted to go into primary care. She is interested in nutrition, fitness and other aspects of preventive medicine.
“Once you get to specialty care,” she said, “people in general have the disease, they have the problem, and now you’re coming in on the back end and trying to fix it.”
Spielberg was among a cohort of UMKC School of Medicine residents whose placements were supported by a federal program. In 2010, the Health Resources and Services Administration created the Primary Care Residency Expansion to help address the shortage of primary care physicians. According to an Association of American Medical Colleges study released last year, the United States will face a defi cit of up to 31,000 primary care doctors by 2025.
The program provided $168 million over five years to fund additional residents in general pediatrics, general internal medicine and family medicine at training sites around the country. UMKC’s family and community medicine and internal medicine programs won grants to add two residents each per year, starting in 2011.
The directors of the residency programs shaped their curriculums to better train the residents supported by the expansion program. Todd Shaff er, M.D., MBA, director of UMKC’s family and community medicine residency program, emphasized rural experiences.
“Where do we need more doctors in the United States? It’s in rural America, basically,” he said.
The internal medicine residency program expanded its primary care track to include a journal club, a culturally and linguistically appropriate services curriculum, and the patient home visits. “That’s a really formative experience for the trainees, seeing [patients] out of our sort of sterile environment at the hospital,” says David Wooldridge, M.D. ’94, director of UMKC’s internal medicine residency program.
For Spielberg, the appeal of the primary care track was choice. Residents on that track have an easier time scheduling electives.
“I had a lot more flexibility to do what I wanted and really get more of an education in primary care, rather than rotating as much through some of the subspecialties or in-patient rotations,” she says.
Spielberg took electives in sports medicine, orthopaedics and dermatology. She said her dermatology experience gave her the confidence to perform skin procedures that another internal medicine doctor might refer to a specialist.
And the China trip? The expansion program allowed residents to use part of the grant money to pay for travel, which allowed her to spend four weeks studying health care in the world’s most populous country.
The Chinese have entire hospitals devoted to certain specialties, she said, and she spent the most time in Beijing with a prominent interventional cardiologist.
“They are definitely behind when it comes to using the latest medicine,” Spielberg said, but “they are very efficient. Patients are very grateful for the care they get.
“To see a regular doctor for a clinic visit, patients have to line up early in the morning and take a number; there are no appointments. When you go in to see your doctor, you are often in the room with another patient and doctor.”
The hierarchy built into the culture means a patient, student or resident wouldn’t question or challenge a physician, she said. That differs greatly from the U.S. questioning and debate that Spielberg prefers “because it is how we learn.”
Spielberg, who joined Truman after working in private practice for a year, remains committed to primary care. She is working with the nursing director of the primary care clinics at TMC Hospital Hill on the clinics’ recertification as patient-centered medical homes.
“My biggest thing is trying to get these clinics here to function in a way that is better for patient care,” she says.
Pathways to primary care
As Shaffer designed the experience for residents supported by the expansion program, he had a few goals in mind.
The first was the most obvious: Train more primary care doctors.
“We are really going to be short of primary care doctors in the future,” Shaffer says. “There’s a huge shortage looming. All doctors in general, but especially in primary care.”
The second goal: Train doctors in rural medicine. In outlying areas, the doctor shortage is even more pronounced. That’s in part because residents tend to settle near where they train, and training sites are usually in larger cities.
With that in mind, Shaffer took out a map of Missouri and began marking smaller cities within a 60-mile radius of Kansas City. He remembers thinking: How do I get my people out there?
Shaffer looked for spots where he could deploy the grant-supported trainees for some of their rotations. He developed a relationship with a surgeon who works in Lexington and Richmond, towns 40 to 50 miles east of Kansas City. He also found an emergency room in Clinton, 75 miles southeast of the city, that was busy enough to keep the trainees occupied.
The Primary Care Residency Expansion program encouraged residency program directors to provide community-based clinical rotations. “The grant allowed me to get people outside of this facility and have them do a lot more of their training in a rural area,” Shaffer says.
He held a separate match for the residents supported by the grant. Dylan Werth, M.D. ’12, accepted one of the positions after completing his B.A./ M.D. at UMKC.
Werth says he became interested in family medicine as he started going through his clerkships in medical school.
“I liked a little bit of everything,” he said. “So that led me down the family practice pathway.”
While in residency, Werth did a rotation with the rural surgeon Shaffer had found. He also worked in the ER at Golden Valley Memorial Hospital in Clinton.
“Everything came there, because it was the closest hospital” in its region, he said.
In addition to the experiences in rural Missouri, residents supported by the grant were able to take courses most trainees can’t afford. Werth traveled to San Diego for a week of rural medicine training. Another resident in the program took a wilderness medicine course and now practices in Montana.
Shaffer says the nine other grantfunded residents in the family medicine program practice or plan to practice in Missouri.
Cory Offut, M.D., began practicing this summer in Houston, the county seat of Texas County in south-central Missouri. Houston was one of the rural locations where Offut trained during his grant-supported residency, which he completed in 2016.
Offut said he liked the broad scope of family medicine. He was in a rural track program in medical school at the University of Missouri-Columbia and had delivered 75 babies by the time he graduated.
“I was torn in med school between OB and pediatrics, so then family practice just kind of fell into it,” he says.
Werth sees patients now at a practice in Independence owned by Saint Luke’s Health System. Before that he worked at a clinic in Pleasant Hill, 20 miles south of Truman Medical Center Lakewood, where the UMKC Department of Community and Family Medicine is based.
“I think the more diverse the group the better.”
Rural areas aren’t the only places that need doctors like Werth. One day, he met a new patient who said she had driven 50 minutes from her home in suburban Kansas City.
“She came out to see me in Pleasant Hill because it was the first clinic that she could get in before a month as a new patient,” Werth says.
Better than before
The Primary Care Residency Expansion program ended earlier this year. Residents who had been supported by the grant are continuing to train at UMKC. But this summer, the first-year classes fell back to their pre-grant levels. Still, there are 42 family and community medicine residencies total, and 63 in internal medicine.
Wooldridge, the internal medicine residency program director, said the grant made it easier to find medical school graduates who hoped to do primary care. Most applicants choosing the internal medicine program, he said, indicate they plan to enter specialties, which correlate with higher pay and more prestige.
“We want to have a diverse population of residents,” he said. “I want to have people who are generalists through and through. I want to have people who want to do cardiology. I think the more diverse the group the better.”
With the grant ending, Wooldridge said he worried that it would be harder for the program to attract medical school graduates who wanted to practice primary care. But he thinks the program is stronger than it was before. A Yale-designed outpatient curriculum was so popular with residents in the primary care track that Wooldridge expanded it to the larger program.
“The differential between our primary care track and the standard track is much narrower than it was a few years ago,” he says. “Everyone in the program is getting a better primary care education.”
Shaffer wishes that the state of Missouri spent more resources to keep primary care physicians. He’s become accustomed to watching the graduates of his program go to work in Kansas and Colorado because those states have robust school loan repayment programs, which Missouri lacks.
“When people graduate from school, their biggest worry is their loan repayment,” he said.
The demand for primary care, in Missouri and elsewhere, is expected to grow as the population ages and generalists retire. And “the number of primary care physicians continues to drop,” Shaffer said.
Add in that training can take up to a decade, he said, and the primary care physician shortage predicted for 2025 and beyond needs to be addressed now.
“You can’t just say, ‘Let’s flip a switch and next year we have more primary care doctors,’ ” Shaffer said.