VISALIA -- How do you address a shortage of physicians in an underserved rural county in the Central Valley? If you have a thriving regional medical district that operates the main referral hospital and the only trauma emergency department between Bakersfield and Fresno, you establish a medical residency program.
That's just what Visalia's Kaweah Delta Health Care District is doing. It soon will have the only medical residency program in Tulare County, a role that likely will increase the number of doctors in the area in a matter of years.
"We were already recognized as a trauma medical center and as a center that offers advanced medical care to the region, so to add teaching institution is exciting," said Mark Garfield, Kaweah Delta's chief medical officer.
Five Specialties for Residents
Residents will train in one of five specialties. The district already has received accreditation in family medicine and expects to receive accreditation in emergency medicine soon. Those two residencies, each lasting three years, are slated to begin July 2013. Kaweah Delta will accept six students each year in each of those fields.
Residencies in psychiatric medicine and general surgery are expected to begin in 2014 and 2015 respectively. Each year, four psychiatry residents will begin a four-year program and three surgical residents will begin a five-year program.
A fifth residency program -- called "transitional year" -- will begin in 2015. The program is geared toward doctors who will train for one year at Kaweah Delta and then go to another teaching hospital for sub-specialty training in areas such as brain surgery, radiology or dermatology.
"We have the blessing of being involved in an institution that is very forward thinking," said Robert Allen, program director for the family medicine residency program. "We have a strong commitment to educating these physicians, we have a state-of-the-art institution and we have plenty of patients with all the needed medical problems."
For instance, Allen said, family medicine residents will train in a clinic operated by the Kaweah Delta rural health clinic system. "We're offering a robust education in family medicine in an area which is medically underserved," he added. "Patients are oftentimes ones who would not have a health care provider otherwise. [The program] will expand access for patients who would not otherwise receive care."
If You Build It, They Will Come ... and Maybe Stay
There are not enough residencies in California to meet the need of graduates seeking family medicine residencies, Allen said.
Kaweah Delta will accept applications from students attending medical schools all over the United States and even those from foreign medical schools, as long as they meet the requirements for U.S. medical residencies.
The district will participate in the National Resident Matching Program, Allen said. The matching program will provide Kaweah Delta with up to 700 applications from interested medical students and recent medical school graduates. Interviews will begin in October.
The district expects the residency program to increase the number of physicians working in Tulare County. "If you have needs in your community, if there are jobs available, the observation has been that half of your graduates stay in the local area," said Allen. He added that the number is sometimes as high as 80% depending on an aging workforce and job availability.
The district commissioned a comprehensive study last year by Amerimed that included an analysis of the area's health care provider needs. "We are probably down according to the size of our market anywhere from 12 to 15 primary care physicians," said Steven Jacobs, the district's physician recruiter. The market, which is essentially Tulare County and a few other areas, includes about 500,000 people.
In terms of psychiatry, the District has "done a miraculous job with in-patient psychiatry," said Jacobs. That means the residents will be able to work in a 61-bed freestanding mental health hospital. But the hard part, said Jacobs, is in the outpatient arena. "There are just not enough psychiatrists for the follow up and follow through," he said. "We want to grow the outpatient side of psychiatry."
He said he's also looking forward to retaining some of the residents in general surgery. "We have an aging workforce in that area," he said. "Three of our surgeons (out of eight) are over 60."
Because of California's temperate climate, most teaching hospitals in California typically retain a large percentage of their residents, said Jacobs. According to the California Medical Association, California has the second-highest retention rate for medical residents in the nation at 69%.
Medical Staff on Board
Allen said one of his initial concerns was whether the medical staff would be supportive of a teaching institution. "The vast majority of our staff are enthusiastically embracing it," said Allen. "And no one has said they are going to leave because of it."
In fact, more than 100 physicians affiliated with the district already have expressed an interest in teaching or mentoring the residents.
In preparation for its residents, Kaweah Delta will house a graduate medical education center in its Support Services Building. The center will include conference rooms, a resident lounge and the graduate medical education offices. The simulation center also will be expanded to include a control room and an additional simulation suite, where residents can train on patient simulators.
The district has worked extensively with UC-Irvine on establishing the residency program. "UC-Irvine has been an invaluable partner on this," said Allen.
"They've been mentoring us and helping us establish policies," said Amy Shaver, director of the Graduate Medical Education Department. Shaver has assisted the program directors for each specialty in putting together applications for accreditation.
Medical students who are curious about the Kaweah Delta residency can do a four-week student clerkship program, which will introduce them to the hospital, said Shaver. Students are not paid during clerkships.
"We see graduate education as raising the bar for Kaweah Delta," said Allen. "There's nothing like having a question asked of you to do more studying yourself."