Zack Scrivner wasn't quite sure what to do.
The chair of the Kern County Board of Supervisors was presiding over a meeting in Bakersfield to determine the direction of the Kern Medical Center family practice residency program, and there were just too many people there who wanted to say something.
They were sitting on the steps, in the aisles, along the walls, out the doors. They were in the hallway outside the conference room.
"When we first walked in here and we saw everyone lined up here, I thought, well, this was a concern," Scrivner said. "Occupancy in this room is 59, and we're at least twice that here."
Scrivner was concerned because the people in the hallway couldn't hear, which might be a violation of the Brown Act that calls for open meetings in California. Another supervisor worried that blocking the aisles might be a fire hazard. Usually, the Kern County Board of Supervisors' meetings are quiet affairs, with few audience members.
But this wasn't "usually."
People from all over the county came to the meeting to express opposition to the cutback of the family practice residency program. The crowd of citizens included physicians, health care administrators -- and even Dolores Huerta, the cofounder (along with Cesar Chavez) of the United Farm Workers.
Officials of Kern Medical Center last month announced plans to suspend the Bakersfield program for a year to save money. It wasn't closing it down completely, but it was shutting out a year of residents from the program, and that signaled that the program was in big financial trouble.
According to Paul Hensler, CEO of Kern Medical Center, the family practice residency program was costing the hospital about $5.5 million every year, and the cash-strapped facility just couldn't afford to sustain it.
"Just about all hospitals are concerned about their residency programs," Hensler said. "With the new rules [governing residents' work hours], the number of service hours have decreased, and it has put most residencies into a squeeze. It's an exceptionally high cost."
Callie Langton, associate director of workforce policy for the California Academy of Family Physicians, said program costs cited by Kern Medical Center officials don't really make sense.
"While KMC is not doing super well financially, perhaps it's a little overstated, how much the residency program costs the hospital," Langton said.
According to Hensler, the program's 18 residents each draw a salary of about $50,000 annually. The bulk of the program's $5.5 million estimated cost is overhead expenses specific to the residency, such as the time and cost of physicians who supervise and train the residents.
The work put in by the residents, Langton said, has to be looked at in context -- the cost of replacing the often 80-hour work weeks put in by residents would be much higher than any training costs connected to the program. And, she pointed out, family practice residents care for a wide range of patients in the hospital.
"The county still has an obligation to care for those people," Langton said. "If KMC closes [or restricts] the family practice residency, they are going to feel the pinch in other departments -- in pediatrics, internal medicine, in the emergency room -- so there's no way closing the program would save all those millions of dollars."
Not only are residents a good labor investment, Langton said, but they also are a community resource, as many of the residents remain in the area to practice medicine. Because Bakersfield already has a dearth of primary care physicians, the loss of the KMC family practice residency would affect access and quality of care in the whole county, Langton said.
"Residents are a wonderful source of inexpensive labor," she said. "They work hard; they're eager to help the community. And if you put out just three of them into the community every year, that's such a valuable resource for the community. If they cut off that pipeline, they're going to feel it for years and years," Langton said.
'We Have A Jewel Here'
Hensler said the residency program itself was not in jeopardy of being cut, but the hospital needed to make a decision about whether it could support this year's incoming group of residents for the full three years of residency.
"If there was a doubt that we could do that, then the prudent choice was to hold off on [this year's] class," Hensler said.
"We are not eliminating the residency program. The question is, can the program be more fiscally responsible, and are there better models, such as collaborative programs within the community and with the rural hospitals and rural health centers."
That's the reason for the "hiatus," Hensler said. "Now we have six months to evaluate our program."
But the county supervisors and the public had a problem with that notion.
"I know this residency has been successful for many years," Dolores Huerta said. "It brings doctors into the Valley, it brings them in where we need them. We know the Affordable Care Act will kick in in 2014, so I don't think we should throw this baby out with the bath water." In 2014, she said, the need for primary care physicians will increase even further, and the Bakersfield area will end up needing the doctors who've graduated from the family practice residency program.
"We have a jewel here," Huerta said. "We don't want to throw it away."
Raymond Neufeld, a longtime family physician in Bakersfield, said eliminating one class out of the three-year residency program is not a compromise, it's a mistake.
"I believe this is a death blow to the program," Neufeld said. "This will have a devastating effect on the program, and I worry that damage may be irreparable. I am incensed that 36 years of work was done in by a 30-second decision."
Ryan Gates works at Kern Medical Center, running the pharmacy practice residency program. "I don't pretend to understand the fiscal difficulties we are under," Gates said. "But I believe this is a shot across the bow, not just for KMC, but for Kern County. The primary care physician shortage is here now. ... We have to keep KMC alive and well."
The supervisors agreed.
Supervisors Approve Motion To Save Program
"The residency program is the medical safety net for our community," Supervisor Jon McQuiston said. "I think this decision was a little premature, and we haven't had enough community involvement. I think we should keep this program going."
"My motion is to recruit six new students," Supervisor Mike Maggard said. "I suspect there are incredible physicians out there for us, if we are diligent about doing that, because they are stars that haven't yet been discovered."
He added, "I want to guarantee to the community a full-fledged, fully complemented residency program. My motion is to sustain the program, and to direct you to recruit six new residents."
Supervisors passed the motion unanimously to cheers and yelps of laughter and relief.
According to Carol Havens, president of the California Academy of Family Physicians, keeping the residency program on track is important for the region.
"It would be a tragic loss for Kern County," Havens said. "It would be a huge loss in the future, because of the lack of physicians in the community, and in the short term it would be a loss, as well. And it may be harder to recruit [residents] in the future."
According to an announcement last week from CAFP, all residency slots for the next academic term are filled in California -- including the spots in Kern County.
"The Kern program received thousands of phone calls and emails from across the nation in just a few hours and easily filled its six residency slots," Havens said in the release.