Shovels in the ground, prepared for a groundbreaking ceremony at the Montana College of Osteopathic Medicine in Billings on Oct. 4, 2021 (Photo by Darrell Ehrlick of the Daily Montanan).
Which comes first: The doctor or the medical school in Montana?
That question is really part of the answer about how to solve Montana’s doctor shortage — it ranks 30th in number of doctors per capita, and many are older and beginning to retire, leading to an increasing shortage.
Some in the Montana medical community insist before more medical students, the Treasure State needs more doctors.
Others, like Rocky Vista University and Touro University, have decided the medical school, complete with several hundred doctoral students, is the way to solve the shortage. RVU, the for-profit, private school is investing more than $80 million in a campus that held a groundbreaking earlier this month in Billings.
Already established graduate medical leaders insist that the increased students at both RVU and in Great Falls at Touro University will overwhelm the already overworked, taxed medical providers in the state while the new medical schools insist creating more students will create a more robust medical community.
More students = more work or more help?
Medical schools – both allopathic, which produce MDs, or osteopathic, which produce DOs – take a similar route with nearly identical curriculum. It requires four years of classwork, followed by a residency and sometimes more training, if the doctor has a specialty or a sub-specialty.
However, the time in medical school isn’t contained to just the classroom – the final two years rely on clinical rotations in medical settings like doctor’s offices, clinics and hospitals. And it’s the bottleneck there that has raised concerns in Montana.
Doctors and healthcare leaders have spoken of the concern: While Montana needs more doctors, it also may not have enough doctors willing to teach medical students. Third- and fourth-year medical students must do clinical work with current practitioners, creating a huge demand for doctors at a time when healthcare systems are pushing providers for more productivity.
The problem has a nearly identical parallel in Montana nursing – more slots are being created, but several different programs are stymied by the lack of clinical training opportunities for the nursing students. A two-part series examined that shortage recently in The Billings Gazette.
But doctors also have an additional capacity problem as the number of residencies, regulated by Congress and reimbursement levels, remains static or only grows in numbers much smaller than the rising number of newly-created doctors graduating. The number of residencies – a requirement for doctors before they’re fully licensed to practice on their own – hasn’t grown much and so the pipeline for making more doctors constricts there, too.
Plenty of time to build the pipeline?
While local physicians and already established residencies in the state have expressed concern about the number of medical school graduates and the fewer number of residency slots, Dr. David Park, founding dean of Rocky Vista University’s Montana campus, said that number is often overstated because it captures all prospective residents, not just the ones trained in America.
“There are plenty of slots for all U.S.-trained MDs and DO school candidates,” Park said. “Montana needs more residency slots, period.”
Rocky Vista has three campuses — one in Utah, one in Colorado, and one in Billings. Even though steel and concrete already present an imposing and impressive structure in Montana’s largest city, the groundbreaking for the Montana College of Osteopathic Medicine was held last week with dignitaries and leaders, including Montana Gov. Greg Gianforte.
Park said that while the RVU medical students will need clinical rotations with already-established medical professionals, he said his organization will also work to develop new residencies in state.
“Montana needs more doctors. It needs more GME (graduate medical education) and more opportunities. The question is: Who will do it? Who will be the champion? Who will provide resources,” Park said. “This is a great opportunity for us, and you can expect that we’ll do it. We want to be engaged members of this community and work for a common purpose of better access of care.
“We’re in the Mountain West for a specific reason – it’s underserved and it needs rural and frontier medicine.”
Montana has had a partnership with the Washington, Wyoming, Alaska, Montana and Idaho medical program for decades. That graduate program trains doctors by having them spend the first two years of in-class medical training in their respective home state, and then rotate around the region and work in Seattle with the University of Washington for experience. This program trains about 30 doctors per year, many from Montana. It’s boasted great success at being able to retain and train new doctors, but some leaders in the medical industry say several hundred more medical students from Rocky Vista University or from Touro University, a medical school which just broke ground in Great Falls, could overwhelm the current, fragile health system and force future doctors to get out-of-state training, thereby lessening the statistical possibility they’ll return to practice medicine in Montana.
The medical programs in Montana remain on opposite sides of the discussion. Advocates for WWAMI agree there needs to be more doctors, but say the school already stretches the ranks of doctors who are willing to train a medical student, and more pressure from the start-up medical schools could cause the system to implode. Meanwhile, Park said it has a five-year window between now and when the students need clinical training, which allows the system to build the capacity.
Park maintains that in the other places RVU has set up, southern Utah and Colorado, they’ve begun to find new pipelines and practitioners in rural areas and the reason the system in Montana isn’t more robust is because the Treasure State has yet to have its own dedicated, full-time medical school, a claim which the WWAMI program disputes.
Nationwide doctor shortage
The debate about medical schools, training opportunities and doctor shortages is a national conversation and Montana’s issues are an illustration of the problem. For example an article and research by the journal “Family Medicine” looked at the problem of doctor shortage and determined the problem wasn’t so much about creating more doctors through schools, but recruiting more physicians who would practice in rural and “frontier” areas like Montana.
In the article, “Targeted Medical School Admissions: A Strategic Proess for Meeting our Social Mission,” the authors point out that the number of medical students in the past 20 years has increased 30% in allopathic schools and 162% in osteopathic programs.
“Yet U.S. medical schools are enrolling fewer students from rural backgrounds,” it said.
That’s why Park believes RVU’s model will satisfy both problems, the lack of physicians and the need to train in rural areas like Montana. He said the mission of the now three-campuses is to recruit doctors and train them in the rural Mountain West, where the geographic density of doctors remains different than in urban or coastal areas.
Dr. Stephen Miller is the Associate Dean of Clinical Education for RVU. He’s set up programs in rural Maine, which was like Montana, short on doctors and clinical opportunities.
“We understand we have to build it,” Miller said.“We’ll have people study here, come back here and that will create more and more physicians.”
Miller admits that Montana doesn’t currently have the clinical capacity, and that’s why he’s working with providers across the border in Wyoming, just an hour away from the Billings campus. He also stressed that often rural providers are overlooked as training opportunities but that’s precisely the setting RVU specializes in – training doctors to practice in non-urban settings.
“We want students to envision being part of these practices – to see themselves there,” he said. “Students who are vested in a site for three or for years. They develop the identity of the people they’re close to.”
Miller said RVU encountered the same concerns traveling to other states, without overwhelming what was already established. Moreover, RVU –unlike other medical programs – has a proven curriculum and system that has worked in Utah and Colorado.
“That’s really hard to do well. We have a tried and true method,” Miller said. “This school actually lives its mission – we want to train rural doctors. We have a wilderness medicine program. We tailor the program for the area and the need.”
Programs target rural students, rural communities
The campus on Billings’ west-end is still largely in a field, just west of Shiloh Road. It stands where cornfields once stood, now within shouting distance of an REI outfitters and the behemoth Scheels store. It’s about seven miles away from the downtown medical corridor of the community, but nearby land is owned by SCL, and the two large healthcare systems, SCL and Billings Clinic, imagine a day in the not-too-distant future when they’ll both need west-end facilities nearby.
The multi-story building will have 135,000 square feet, or roughly two-thirds the size of the average Wal-Mart footprint. It will cost nearly $80 million to construct and support more than 300 jobs when it’s completed.
“There’s great demand, especially because of things like the pandemic. Already healthcare needs are growing with aging and growing populations,” Park said. “We’re recruiting and filling as many seats as we can with students who were born and raised here in Montana.”
The Family Medicine journal points out a shift toward recruiting more students from rural areas, but the results are too few and too new to say anything definitive.
“Little is known about the extent to which medical schools use targeted admissions approaches to both recruit and select the desired students. Even less is known about their … processes and the degree to which targeting is evidence-based,” the article concludes.
Statistics seem to starkly illustrate the problem: Even with an annual estimated spending of $15 billion on graduate medical education, the Association of Medical Colleges predicted a shortage of more than 124,000 physicians by 2024.
Urban areas also have more primary-care physicians than rural areas, with 84 for every 100,000 residents versus 68 per 100,000 in lesser populated areas. Moreover, 9-out-of-every 10 physicians in America practice in urban areas, while 2-out-of-every-3 pediatricians are in urban areas.
Yet statistics seem to present a different, but equally hopeful picture for Montana. Nearly 75 percent of medical residents wind up practicing medicine within 100 miles of where they trained, which is precisely why both Tuoro and RVU said dedicated facilities and programs especially for Montana, in Montana, are critical. In fact, in a study published by Family Medicine, Montana’s in-state rate was among the highest in the nation at 68.5 percent, eclipsed only by residents in Arkansas, Hawaii, Mississippi, and Texas.
Funding for the expensive graduate medical training also faces a wide disparity with the Journal of Graduate Medical Education reporting this year that 99% of all Medicare spending for training goes to programs in urban areas.
“Having a school with a committed campus will help. We have a need and it couldn’t have come at a better time,” said Gov. Gianforte at a groundbreaking ceremony in Billings recently.
Gianforte pointed out the statistics that show Montana ranks 30th in physicians per capita. Less than 15% of the doctors in state are younger than 40, and 1/3 of the doctors are older than 60.
“The solution isn’t very complicated,” Gianforte said. “Montana is the perfect place to train. These communities are worth it. The result will be more good paying jobs and a more prosperous state.”
1,000 percent increase
Yet even though more doctors are needed in Montana from practicing physicians to medical students, the state’s medical community could see an expansion in the number of students increase by 1,000% in less than a decade, a number that is troubling for physicians already taxed by the COVID-19 pandemic, which has stretched medical resources thinly for the past two years.
Park admits that currently, Montana would not be ready for a 1,000 percent increase in medical students, and has said RVU will likely need training sites beyond the state’s borders. But Park and other RVU officials have been working for the past two years to meet with doctors and rural medical sites to build relationships.
“We have four years to do that,” Park said.
He also said teaching at a clinical site is also not like teaching in a classroom. Medical students will already be trained and will need experience in doing things like the intake of a patient’s medical history and a health assessment that involves routine things like blood pressure or work with a stethoscope.
“We don’t expect teaching in the traditional sense,” Park said. “We’re talking about observation and feedback.”
He said the benefit of having RVU already established in Colorado and Utah mean that the Montana campus won’t have to reinvent the wheel.
“It’s highly unlikely that all 30 rotations will be in Montana,” Park said. “We have many students coming from Idaho, Colorado, Utah and Wyoming and many of those students will want to do their clinical rotations closer to home.”
Barry Kenner is the graduate medical education coordinator for the Western Family Residency based in Missoula. Residencies exist in Missoula, Hamilton and Ronan. He said part of the complexity of training is based in funding – residencies are expensive to start and maintain. He also said not all doctors can be teachers.
“Not all want to teach and some who are not good teachers,” Kenner said. “We had one doctor here who said, ‘If I had wanted to teach, I would have stayed in Seattle (where the WWAMI program is located).’”
That, in turn, constricts the pipeline for future medical students even more.
The other challenge with training physicians in rural areas is another matter of numbers – this time it’s not money, but experience.
“Part of the challenge of training in a rural setting is getting enough clinical exposure that it’s meaningful. In some cases, seeing just three patients a day is not going to be robust enough and the capacity is not unlimited,” Kenner said. “These sites are fragile.”
For example, Kenner told the story of a rural husband-wife doctor couple who loved to teach and worked in a rural setting. They were excellent candidates for graduate medical education, but when they left, the program struggled.
“Not all practitioners embrace students. Not all facilities want students. We really don’t know the capacity, but we know it’s not unlimited and it’s fragile,” Kenner said.
Then there are the politics. Many medical training schools – regardless of whether they train doctors, nurses or some other medical specialty – work years to establish a training site, then guard them zealously.
“You’re pressing sites hard when you place students there,” Kenner said. “You have to understand that you’re asking them to do more. You have to convince them that they’re making a commitment to the future.
“Those that have embraced it have understood that the financial impacts are not always positive, but it’s about workforce development.”
Still, the rapid increase of medical students and expanded – bordering on exploding – pipeline of doctors-in-training will mark a radical shift. Within the next four years, Montana will go from having one part of a medical school to two in-state campuses plus the WWAMI program.
“I can’t imagine two schools in this state,” said Kenner, who has spent his entire career in the Montana hospital and healthcare industry.
The politics of medicine
That pressure also doesn’t factor in some of the politics of medical schools in Montana.
Healthcare organizations, like Billings Clinic, the largest in the state, have publicly stated their commitment to the WWAMI program, which leaves students in the RVU program in limbo. Meanwhile, rival healthcare organization SCL, which will likely merge with healthcare giant InterMountain Health Care, has pledged support for the RVU program in its St. Vincent system in Billings and beyond. Touro, the New York-based university in Great Falls, has partnered with Providence, making graduate medical training for doctors a matter of choosing sides for now.
However, Billings Clinic pulled out of a partnership with RVU in March after a controversy that erupted when two officials, including Dr. Clinton Adams, the president of RVU, made derogatory comments that ended the partnership, as reported by The Billings Gazette. Those comments including comments made about Touro’s Jewish affiliation and referred to one female at the Clinic as “token.”
That wasn’t the only headwind RVU faced in Billings, though. In May, 51 physicians wrote a letter that appeared in The Billings Gazette saying that RVU should “pause its aggressive, investor-driven timeline.”
The doctors, many from Billings Clinic, said that more investment was needed in residency programs, and that practitioners are already committed.
“Those of us involved in medical education are already stretched,” the letter said. “We cannot solve the physical shortage by simply creating more medical students. Currently, there are more medical school graduates than there are internship and residency opportunities.”
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