Family Medicine Residency Program Helps Address Need for Rural Physicians

Second-year medical student Kenley Unruh with pediatric patient and instructor Dr. Cicely White in Spokane.

September 18, 2019
Cindy Hval

According to UnitedHealth, rural areas are five times more likely to lack access to primary care physicians, and they predict a 49,000 primary care physician shortage by 2030.

When Dr. Molly Gilbert attended medical school at the University of Washington in Seattle, she knew she wanted to practice family medicine. Her residency in Spokane, confirmed she'd found her calling.

"You get to treat patients over a lifetime and offer the full spectrum of care," she said. "That’s the heart of it-- seeing families from birth to death."

Now, Gilbert heads the Family Medicine Residency Program Spokane (FMRS) and is passing her passion for family practice on to a new generation.

"It's such an important program for our community," Gilbert said. "So many residents stay where they trained."

Indeed. Currently, 240 University of Washington School of Medicine alumni, live in Spokane County.

Retention rates are especially important for rural communities like Colville, Washington. The Steven's County town with a population just under 5,000 is home to the first Rural Track Training (RTT) program in the nation.

Residents interested in rural practice do their first year of the Family Medicine core program in Spokane, and then can complete the next two years of their residency in Colville.

Gilbert said many residents are attracted to both FMRS and RTT Colville because of the obstetrics training they receive.

"I'm still delivering babies, in addition to teaching. We also have an OB fellowship here as well," she said."While not all family medicine residents pursue the rural training track, they are all well-prepared to step into a rural practice because of their full-spectrum training in Spokane." 

The RTT program accepts two residents per year, and is led by site director Dr. Caleb Holtzer, who graduated from the program.

He came to family medicine from the public health sector and was immediately drawn to rural practice.

"Access to care is one of the biggest disparities folks living in rural areas face," Holtzer said. "Addressing health disparity is something I care a lot about."

The shortage of primary care physicians create hardships in small communities where people must travel to seek medical care.

That's why Holtzer is proud of the RTT program's retention rate.

"Over 80% of residents who train in rural areas stay where they trained," said Holtzer. "Over the last five years in Colville, we've retained 100%."

Out of 31 graduates from the program, 11 have remained to work in Colville.

That's a boon for the community, and rural medicine is all about community.

"We work throughout Stevens County," Holtzer said. "It's rare to go to the grocery store without seeing someone you know."

This familiarity enables them to address community-wide issues, whether lack of fluoridation for kids or hepatitis C rates in adults.

Technology has augmented both patient care and resident training.

"We're integrated into the Providence Healthcare network and share their electronic health records,' said Holtzer."We also access UW's TelePsychiatry program."

Those connections are crucial when practicing in rural areas. There are no specialists to consult across the hall or even down the street.

That's why Dr. Pete Edminster, who just completed the RTT program, prefers a more low-tech connection. 

"I pick up the phone," he said. "Knowing which specialist to call when needed is so important. I learned to be acutely aware of my limitations."

The UWSOM graduate decided early on that rural medicine was what he wanted to pursue.

He was on the Targeted Rural and Underserved Track (TRUST), and did much of his training in Libby, Montana.

Though his father and brother are ER physicians, Edminster said the lure of family practice was compelling.

"No other specialty gives you the ability to meet people where they're at and solve problems," he said. "There's an added level of intimacy, not just in the clinic, but in the community."

He was thrilled when he opened his Match Day envelope to find he'd been invited to join the RTT program in Colville.

"There's no other place I could have gotten better training."

Edminster said that residency training in a rural community is much different than in an urban setting.

"The scope of practice is expanded," he said. "More things fall in your lap. It's more of a challenge, and for me it's more fulfilling."

On any given day, he could be performing a vasectomy, delivering a baby, doing a colonoscopy or monitoring a patient with a chronic health issue, like diabetes.

That kind of training stretches the intellect and skill set, and he relishes the challenge.

"Most of us are out of our comfort zone every single day," said Edminster.

The public health aspect was also a draw for him. Being part of a small community can lead to big picture thinking.

"You discover the needs of the community," he said."For example, my peers made fluoride varnish available in the clinic, and established a needle-exchange program. It's deeply humanistic. It's a privilege to do this kind of stuff."

Third-year RTT resident, Dr. Alana Jackson agreed.

"There's never a dull moment," she said. "I'm a farm kid from rural Minnesota. I knew from the get-go, I wanted to do rural medicine."

Jackson is delighted to be doing her residency in Colville.

"In traditional residency programs, residents spend one month doing a particular rotation. For example they may spend one month doing only OB, or only pediatrics," Jackson said. "My schedule is very different. I spend one week a month working in the hospital, seeing adult inpatient medicine. A 'typical' week may include OB/pediatrics clinic, my own continuity clinic, clinic with visiting specialists such as cardiology, nephrology, or overseeing our TelePsychiatry program. I am always multi-tasking."

And she can attest to the shortage of primary care physicians.

"I get calls from recruiters every week," she said.

Jackson feels her experience in Colville emulates what it’s like to be a practicing rural physician. 

"I'm always thinking at least five steps ahead," she said. "I'm recognizing what I can and cannot do in a rural setting."

The demands on her time and expertise come from a variety of areas.

"You have to learn to juggle a laboring a patient while also providing good care to either your hospital or clinic patients, which is hard to do," she said. "This is an art that I am certain it takes years to master. But it’s nice to get a jump start figuring out this balance during residency."

And for her and the other rural track training residents, that balancing act is a perfect fit.

"Finding something you love to do, in a setting that you love is amazing," said Jackson.