Doctors Follow Rural Training Tracks to Small Town Practices

by Candi Helseth

Dr. Samantha Portenier came to Canyon County, Idaho, as a medical resident and never left. She exemplifies the success of a Rural Training Track (RTT), which aims to educate medical residents in rural environments so they will choose to practice medicine there. After graduating from the University of Nevada School of Medicine, Portenier completed her three-year residency through the Family Medicine Residency of Idaho (FMRI) RTT in Caldwell, where she is now the RTT site director and a practicing family medicine physician.

Gathering Cows

Dr. Samantha Portenier and her family (L to R, husband Ty, Samantha, and children Brady, Paige and Jessi Jane) gather cows on their ranch. Portenier, site director of the Caldwell RTT, chose to live in Idaho after going through the RTT program there.

Participating in the Caldwell RTT was the compelling factor that influenced her choice to practice in Idaho, Portenier said. A native of Washington state, Portenier and her husband are raising their three children on 20 acres in Idaho’s Treasure Valley, where they regularly ride horseback and attend rodeos. “I knew I wanted to practice in a rural area because there is such great demand for physicians there and I would get to provide a wide range of medical care and still live the rural lifestyle. But I hadn’t decided what specialties or specific interests I wanted. The RTT program solidified my decision, and coming back to Idaho reminded me of how much I like this area,” said Portenier, who completed her pre-med degree at Lewis-Clark State College in Lewiston, Idaho.

The first RTT in the nation, which still exists, began in Colville, Wash., in 1985 as the Family Medicine Spokane RTT, under the direction of Dr. Robert Maudlin. Today the Colville location is one of 16 family practice residency programs affiliated with the University of Washington School of Medicine’s Department of Family Medicine. Currently, 25 RTTs operate in 17 states. These residency programs are a proven model for addressing rural family physician workforce shortages, with more than 70 percent of graduates practicing in rural areas, according to Dr. Ted Epperly, past president and past board chairman of the American Academy of Family Physicians and FMRI program director. A 2010 University of Washington study concluded that graduates of rural residency programs are three times more likely to practice in rural areas than graduates of urban residencies.

“Over 62 million Americans live in rural America and there is a significant crisis in terms of having access to care for these people,” said Amy Elizondo, vice president of program services at the National Rural Health Association (NRHA). “There is a very uneven distribution of health care professionals and an acute shortage of primary care physicians in rural areas. If we can recruit and retain physicians to serve rural areas, we improve access for rural America.”

A three-year pilot program, the Rural Training Track Technical Assistance Demonstration Project (RTT-TA), is underway to improve outreach and sustainability for existing RTTs and to help start new RTTs.

RTT Successes in Idaho and Beyond

Caldwell Family Medicine Residency

Caldwell Family Medicine Residency of Idaho recruits and trains residents who are committed to rural and underserved Family Medicine.

Ninety-five percent of Caldwell RTT graduates have located in rural areas in the 16 years since it opened, Portenier said. Six currently practice family medicine in Caldwell and another three work within Caldwell’s referral area. RTT students spend the first year of residency at FMRI in Boise and the second and third years at Caldwell.

“We heavily recruit residents who are rural-oriented,” Portenier said. “We’ve had some who were not and we converted them. Part of it was that they really saw where the training we give them and the skills they learn are so needed in rural areas. I emphasize that in rural areas you can specialize in areas that particularly interest you. If you’re interested in obstetrics or geriatrics, you can do that. You can be involved in family medicine to the depth you want to be. And you can job share, be a part-time doctor or go 120 percent. Family practice welcomes everyone. It’s flexible.” The other advantage of rural living, Portenier said, is “knowing my neighbors and seeing them everywhere we go. In everything you do, you’re building life-long relationships.”

Idaho’s success has been strengthened by its relationship with the Idaho State Office of Rural Health and Primary Care (SORH), according to Dr. Dave Schmitz, RTT-TA Assistant Project Director, Idaho Rural Health Association president and a FMRI faculty member. The Idaho SORH has funded research and community training, including a product Dr. Schmitz researched and developed with Dr. Ed Baker at Boise State University. Their Community Apgar Questionnaire (no longer available online) provides a model for rural health facilities to better understand how to successfully recruit and retain physicians.

“I feel like a matchmaker,” Schmitz said. “I work beside our residents and know them well. Then I get to send them out to environments that will be a good match for them. Idaho has been a type of test lab where we’ve developed an inventory of knowledge that we can use now to help other states. We couldn’t have achieved this without the Idaho SORH.”

Persisting Challenges

Despite the proof that they produce results, RTTs are under utilized, unevenly distributed throughout the United States and in jeopardy. In the last 10 years, 10 RTT programs have closed.

“Every RTT lives on the edge in terms of funding,” said RTT-TA Project Director Dr. Randall Longenecker, who is also rural program director of the Ohio State University RTT based in West Liberty, Ohio. “In general, RTTs are small, have limited faculty and are vulnerable to personnel changes, a bad year for recruiting, loss of funding, and many other factors beyond their control. And each RTT has unique needs. They all share the common ‘1+2’ formula but these rural areas have to adapt the model according to the local resources and challenges they have to work with.”

Dr. Longenecker well understands the challenges. The OSU RTT he has overseen for the last 13 years is slated for closure in December. The local hospital can no longer financially support the program because the hospital’s revenue sources have dwindled.

“A basic problem with RTTs is that they don’t get direct funding,” Longenecker elaborated. “With the current system, funding goes to the major academic center or urban health care facility sponsor and flows through them, at their discretion, to the RTT. With all the forces aligned against RTTs, I marvel at how many we still have in the United States. The challenges are complex and difficult. If they weren’t, these issues would have been resolved long ago.”

RTT-TA Opportunities

The RTT-TA program aims to improve the future of RTTs. Approved under President Obama’s Improving Rural Health Care Initiative, RTT-TA is funded by the Health Resources and Services Administration’s Office of Rural Health Policy (ORHP). ORHP defines an RTT as a “1+2 program” where the first year of family medicine residency training takes place in a central, usually urban, site and students spend the last two years at rural training sites, which may accept up to four medical residents per year.

NRHA leads the partnership anchored by project directors and field offices. Other key partners include the National Organization of State Offices of Rural Health (NOSORH), the Rural Health Information Hub (RHIhub) and the Washington-Wyoming-Alaska-Montana-Idaho Rural Health Research Center (WWAMI).

RTTs have proven that a medical teaching program can be scaled to a size that fits rural communities, Schmitz said. And the more rural the community, the more dependent its residents are on a primary care provider.

“We have a real opportunity here to redefine the importance of primary care being foundational in rural workforces,” said Epperly, who also serves as an RTT-TA core consultant. “Right now, only 9 percent of physicians are choosing to practice in rural areas while 20 percent of the population lives there. RTTs offer a way to give family physicians a broad scope of practice, which they need practicing in a rural area, and to get them to stay in those rural areas.”

Family physician graduates are on the increase for the first time in several years, he added. In the last two years, medical students choosing family medicine specialties increased by 8 and 11 percent respectively. Epperly credited the increase primarily to federal supports and a shift in attitude toward primary care.

As RTT-TA project director and assistant project director, Longenecker and Schmitz are coordinating the three-year pilot project. By engaging the expertise of RTT program directors, faculty and staff throughout the nation, the partner organizations plan to collect comprehensive information to better understand the collective forces challenging RTT models and develop solutions that will strengthen existing RTTs and encourage development of new RTTs.

“This is the first time a major analysis is being done to assess what rural training tracks look like, how they sustain themselves and what policy issues they face,” Elizondo said. “This project will help us see the whole gamut of what it takes for RTTs to be self-sustaining.”

Positive outcomes are already underway, Longenecker said. RHIhub has developed a web portal that provides a virtual library of tools, information and timely access to technical assistance for RTTs, medical students, faculty providers and other stakeholders. Current RTT program directors and respective directors of the State Offices of Rural Health met in Ohio in February to work with RTT-TA partner leaders to identify areas of priority. New RTTs are opening. FMRI has opened a second rural site, the Magic Valley RTT based out of Boise with rural locations at Jerome and Twin Falls, Idaho. Another RTT is slated to open in Weimar, Texas, by fall.

RTT-TA partner leaders believe the time is ripe for change. This pilot project, Schmitz said, will pave the way for what needs to happen to solidify current RTTs and support new RTTs that will improve distribution and usage throughout the United States. Ultimately, that will result in improved primary care for rural Americans.

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