Rural Residency

Welcome to Season Four of This Rural Mission. We're excited to connect with you again and talk more about the wonderful things that rural communities have to offer and the impact our leadership and rural medicine students and graduates are making for these communities. I'm your host, Julia Terhune and let's get started.

Last season, we highlighted how COVID-19 affected residency, and I thought it might be time to talk about residency and what we as a college have been doing to impact the rural workforce.

Now residency, well medical education as a whole, was a totally foreign concept to me before I started with this job. In fact, that foreign understanding is actually something we're going to talk about again this season. Why am I spending so much time talking about this? Well, I think that if we all understood the complexity of training that our doctors undergo, we might better understand the necessity and the resource that they are, especially for our rural communities. So here it goes, here is my brief recap of how doctors are trained. Four years of undergraduate work, specifically in the sciences, test number one, the Medical College Admission Test, four years of medical school, two board tests, residency with board exams throughout their entire training, three years to seven years of residency, depending on what field they go into, plus possibly fellowships. No, they don't make a whole lot of money during this residency. No, they aren't done with their training. No, they haven't learned everything. Yes. They still are under the jurisdiction of other doctors. Yep. They're still learning. And yeah, it's a lot of work.

And all of this getting into undergrad, getting into medical school, and getting into residency is earned. It's not a given. You have to have the grades, the volunteering, the research, the personality, the drive, and then be accepted by the programs that you are applying to. It's a big deal. Now it's also a big deal to have a residency in a rural hospital. That's because residencies are sponsored by universities and housed in hospitals that can provide the number of faculty, aka other doctors, and clinical patients to help students finish their training, which means they need to have a lot of both of those things.

In Michigan, we have some rural residencies in family medicine. They are located in Marquette and Traverse City primarily. Midland also has a residency program, which at its start was rural, but the county's population has increased to turn Midland county urban. But that limitation of rural residency is changing, both in geography and in specialty. This is all thanks to the fantastic work of our legislators, medical schools, and hospital partners throughout the state. Thanks to a program called MIDOCs, M-I-D-O-C-S, more primary care doctors are being trained in rural and underserved urban areas than ever before. So let's hear about how this program came to be from Jerry Kooiman, our Dean of External Relations at MSU College of Human Medicine.

Yeah, so it goes back probably eight years ago, a number of medical school, government affairs folks got together and started talking about graduate medical education and the need for residency's really to be in parts of the state that we weren't training residents now, at that time. And in areas of residency focus that are lacking in the state of Michigan, in particular primary care. And so we began meeting, we met with legislators and began saying what if, and so the legislature gave us some planning money in one of the budget years. And we began to put together, out of research, our research in terms of what are the needs out there, just to make sure that we were data-driven, where are the parts of the state rural, urban, across the state and what are those disciplines that really are shortage areas for health professions. In the UP, psychiatry was their number one issue. In Traverse City in Northern Michigan psychiatry was their number one issue.

And then with Alpena it was a matter of, they had been wanting to start family medicine in Alpena for some time from Mid-Michigan health and so that became their focus area. So it's evolved the four medical schools are Central Michigan University, Western Michigan University, Wayne State University, and Michigan State University College of Human Medicine. And so, we presented that back to the legislature and to the budget office at the state and asked for $5 million from the state. $5 million would be contributed by the medical schools. And then we would apply for a two to one match from the Centers for Medicaid and Medicare and from the federal government. And so the idea is we would have $20 million, and that would be enough to fund residents from each of the colleges and medical schools for their entire cohort. So if someone's going into psychiatry, that $20 million would cover psychiatry for all four years for that cohort. Because we didn't want to leave it up to the legislature each year with the possibility that they didn't provide the funding we'd need, be liable for the full cost of that training.

Well, the CMS came in with a one to one match, and so we had to downsize the program. And so we're at five residents per medical school per year. We're actually asking the legislature for $6.4 million in this current budget process to get us up to six residents per institution. So total of 24 residents two of our residents are going into psychiatry in the UP. Two of our residents are going into psychiatry in Northern Michigan, and then one resident that's paid for by MIDOCs is going to Alpena through Mid-Michigan Health and Family Medicine. If the legislature gets us to $6.4 million in this coming budget year, we will be paying for two residents in Alpena. So that's the goal. We want to be to a point where it's sort of level funding and not ups and downs, which we've been at for the last four years.

If we can recruit medical school students from these areas of the state where there's a shortage, get them to go to our medical school and have them train in, say Midland or Marquette or Alpena, and then our own residency program, which is going to train them as residents in those areas. You're just adding up all of the reasons for a resident to eventually practice in that area. We're just trying to add reasons for them to stay in. And I think this is, it's building our own. It's much cheaper to invest in this at the front end than to have to pay huge signing bonuses, to get them to go to Alpena or to Marquette or to Traverse City, even. So that's why we're in it. I'm really excited that Michigan State, a number of our own students have chosen this program as a way to do their residency program, because that's really the intent.

So you heard it, this program is really in line with what our college is doing as a whole and what our college is all about. Not to mention it's meeting the mission of our leadership and rural medicine programs. And our leadership in rural medicine programs have influenced some of the direction of this program. We are all working together to make the MIDOCs program a success. In fact, our first psychiatric rural MIDOC students in Marquette started an LRM graduate. And this year we have a student piloting the family medicine MIDOCs program at Mid-Michigan Health Alpena through the Midland Family Medicine residency. Not only that, but that student piloting the program is a Leadership in Rural Medicine graduate and tipped into the Midland program, a program I'll explain, just a little bit. David Westfall is his name, Dr. David Westfall. And he is a pretty remarkable person. So let's get a bit of his mission and why he's doing what he's doing.

But you stayed true to your goals and your mission throughout medical school, now in residency, you are a tenacious human David, good job.

That may be even more so than you realize. I have wanted to go to med school since I was in middle school. So the idea that I didn't necessarily get accepted into medical school my first time around wasn't something that was going to deter me. A lot of my family, friends are all sort of in awe that I have gotten to this point where I'm graduating from med school now, because I never gave up on any of that. I applied for medical school five times and during med school, I struggled with my prep for step one, a little bit. So I ended up taking an extra year there as well, but none of that has... It's been a struggle, but it's nothing that I've seen as insurmountable. And I've just taken the challenge and found the best way to address it.

What's kept you motivated?

So my original aspirations for going to med school, were when I was growing up, I lived in a rural area where there weren't enough physicians. And when your parents are filling out documents for school, they usually ask who your primary care provider is and most of my friends just put closest in that spot because they didn't have an actual primary care provider. A couple of them did, but the number of physicians was nowhere near enough to meet the needs of the community, so that was really something that I always wanted to address. And it was a big part of why I chose primary care to go into as well as my background in public health. But seeing that need was something that I always wanted to help with. And I thought that when I didn't get into med school, okay, I'm going to continue to do that.

But maybe this public health thing might be another avenue that I can help address those things. And I found that when I graduated from my Master's in Public Health. It's a lot harder to get into the realm where you would be helpful in those sorts of situations. Getting into administrative positions, you need so much experience that you can't get without experience. So it just makes it a lot more challenging. And I started doing the sanitarian thing as a way of gaining some of that experience, but it wasn't as fulfilling as I wanted it to be. And it wasn't a bad job, but it wasn't what I wanted to do with my life. So that additionally just spurred me to continue reapplying for med school and get the goal that I had set out for initially.

And what drew you to the MIDOCs program in Alpena?

That was actually you, Julia. You told me about it at some point, and I didn't know anything about it at that point. So I started looking into it and it was like, well, this is what I want to do anyways. Always been interested in working in rural northern Michigan. And when I found out about the program is everything just sort of fell into place. So after I met with Dr. Hill, it just sort of felt like the right fit. Since then, I've gotten to know the residents a lot, and it's a very cooperative feel to it, working on their inpatient service over my fourth year, which is one of the requirements of TIP. I got to interact with a lot of the residents, the current residents, and they all worked very well together. There was a very sort of relaxed, open environment between them and things just went very smoothly. So that just sort of solidified my decision that this is where I wanted to be. So, I mean, there's incentives for the program that were enticing, but like I said, they all are just kind of the cherry on top. It's what I wanted to do anyway, working in a rural area, moving further north has always been my goal. The fact that there's a loan reimbursement associated with it is just sort of a bonus.

For more than six years. I have had the pleasure of getting to know and work with the Midland Residency Program and the staff. They have been a tremendous partner in our clinical medical education goals at the Midland Regional Campus. And in the past six years have matched seven of our Midland Rural Community Health graduates into their program. Six of those students have entered the residency through the TIP program. The TIP program stands for The integrated Program. It's something that students apply for in their third year of medical school. It's a partnership between our rural residencies and our medical schools. Students apply knowing that they want to be a family medicine doctor and that they want to work with that specific residency. If accepted to the program, students get a chance to work with faculty at the residency and do rotations there throughout their last year of medical school.

They then agree to rank that residency first during match match. Match is how you get a residency, going back to that discussion about applying and being accepted. Plus there is a financial incentive, which is always nice. Now the MIDOCs program is great, but like David said, it's not just these incentives that bring students to the residency. It's the people. People like Dr. Hill, Dr. Hill is the director of the Midland Residency Program and her colleague, Denise Sheldon is the coordinator. They work really hard to make the residency the place it is today, Dr. Hill is also a graduate of this residency. And like many students, she wasn't necessarily going to stay in this small town, but I think we won her over.

Yeah. I say this to applicants, I feel and I recognize that I am biased about this place. I think that Family Medicine is such an incredible opportunity and having gone to medical school on the east coast and come out here, the training in general in the Midwest is so good. And there are so many good opportunities, but I really do think it's, a lot of times it's where do you fit in? Where do you feel like these continue my people? And so we just would like the opportunity for people to take a look and say, wow, what we do during interviewing is no different than what we do any other time of year. We all look the same. I think we all act the same. And so I think when people feel just that genuineness within the group.

People ask me sometimes what's the story? How did you get here? Why are you still here? I saw in the pamphlet or the booklet that you've been here a long time. And it's so funny, I still remember Bob Lashant, he was a Program Director at the time, kind of making me eat crow after that for so many years and say, tell the applicants how you weren't going to stay and then you stayed. And all he meant by that, he wanted, it was a positive thing, but I came here and was at my last interview and was like, yeah, okay. My husband had a job opportunity. I'll just tell him I don't like it. And Bob, again, the world is such a small place, but Bill Wadland, who'd been the Department Chair for a long time, was my advisor at the University of Vermont when I was in medical school and I had gone to him and I said, "So, hey my husband has a job offer in this town. What do you know about this place?" And he goes, "You need to go look at that place." Okay. And I came in here and I remember thinking, this is where I'm supposed to be. These people are learning a ton. They are smart. They've got a ton of good opportunities. They treat each other well. And that's what it was like for me that whole time.

I mean, did we work hard? We did. We worked really hard, but to be able to get that training and do it with people that cared for you and you cared for them, it matters because this is kind of your second family. And it frankly is your first family, because you work a lot. So you get to see your other family some, but to have that kind of support, I think is critical.

That is really cool. And Dr. Wadland now has an endowment that he put in the name of our program and-

Isn't that crazy.

Come full circle. That's so cool.

I know, it's so fun when that... You're like, "Hey, I know you, how did this happen that I ended up here." So yeah. I think he got a big kick out of that when I showed up at one of the first MSU meetings. Like, "Oh, there's a student that I had when I was at Vermont." It's like us seeing our residents places or them coming back and finding their picture on the wall with all the photos of the graduates. And that part is so much fun. And to have them come in and smile about the experience that they had here. That's been a newer idea of mine in the last few years when I've interviewed, I've said to people, "I think sometimes we look at residency, you're kind of towards the end of your training, you've been in school for a really long time. And you're like, okay, I need to, I need to survive this three years, but you really don't. You need to thrive in those years." You get to do this one time and it needs to be one of these life experiences that is challenging, but so good. And when you have people around you and it's a happy place, even though it's a challenging place and you work hard, it makes all the difference in your ability to thrive and not just survive.

I think I've had residents say to me over the years, "I had no idea. I thought I was going to come here and see kind of regular stuff. I'd see some pneumonias and some heart failure and broken legs. I can't believe all the variety, all the pathology and strange things." And so I said, "Really wherever there's patients, there are all those things." There are a lot of patients who come a long way to see us. And I think when they get out of town or have a day off and drive, realize how far it is to go to Gladwin or how far it is... And some people have been patients here and then moved and then still come back to see us. But it's challenging to say, "Hey, I want you to come back," Well I don't have a car or I live 30 miles away and we don't have a working car or can't they take dial-a-ride, not there, because it's not within the city limits or you can't take County Connection because it's not in the county.

So there's a lot of eye opening experiences for residents about that, for sure. I think some of them have had different experiences, poverty at a different level, in an inner city that we don't see necessarily those things, but we see different things. I know that residents don't realize how invested we are in them and this job. For those of us who do it, I mean, you care about the residents, you care about their learning, you care about their experience here.

So what's the goal of all of this. Well, Jerry has put it pretty simply-

You know, it's not one dimensional. It provides I think, significant value. And then of course the value to the community, you're building a physician base that would not have developed otherwise. Training residents in the UP, and [inaudible 00:24:19], in Traverse City for training family medicine residents, in Alpena where they've never trained before. And so now you're also building a faculty in those communities who can be utilized for undergraduate medical education. And it's a win, win, win. I think from the standpoint of the medical school, the standpoint of the resident, they benefit in terms of their training, being a rural site, or a underserved site, which is what they were interested in, they get a stipend or a loan forgiveness. And in quite frankly, if they do well in their residency, they've got a job coming out of the residency.

Thank you, Dr. Westfall, Dr. Hill, Jerry Kooiman, and Denise Sheldon for speaking with all of us today. I'm so grateful that you provided all of your stories, but more importantly, I'm grateful for all of the hard work that you've put in over these last few years. Thank you so much for making the rural workforce a priority and not just talking the talk, but working every day to make a difference. Thank you to Dr. [inaudible 00:25:40] for devoting all of her time and energy and talents to this and for empowering students to go into rural primary care. We are so grateful to you. Thank you for listening to this episode. We can't wait to send more your way and help you learn how you can make rural your mission.