For the record, I am not and never have been a supporter of the Patient Protection and Affordable Care Act (PPACA) for many reasons: too much big government; too much top down; and too many rules, regulations and business process all sandwiched between the Health Information Technology for Economic and Clinical Health (HITECH) Act and ICD-10. With that said, Section 5508 may be the proverbial diamond embedded in a lump of coal. Section 5508 establishes direct funding to physicians in community-based health centers for rural residency programs. This component of the ACA allows rural physicians a way to reach the underserved and at the same time gives doctors the power and control to educate their peers in an environment that fosters a genuine family medicine experience that in turn provides the means for the revitalization of the small-town doctor or in today’s lexicon, the comprehensivist.
Teaching Health Center Graduate Medical Education (THCGME) is focused residency training in a rural setting in which family medicine residents can receive comprehensive training and experience. To me, this concept was a bit confusing at first. How is this type of GME training different from traditional programs? Why would a physician want to get his or her training “out in the sticks” somewhere? A web search quickly turned up a recently implemented THCGME program – Cahaba Medical Care (CMC) – in Centreville, Ala., and that is where I went.
Cahaba Medical Care (CMC)/Cahaba Family Medicine Residency (CFMR)
CMC is a rural family medicine clinic that is certified as a patient centered medical home (PCMH) which also has its own fully qualified residency training program, the Cahaba Family Medicine Residency (CFMR). John Waits, MD, Founder, Lacy Smith, MD, Co-Founder and Brittany Shanks, Chief Operating Officer, spearhead the program. This is truly an amazing group of young people.
In 2009, CMC was designated by Blue Cross/Blue Shield as one of four family medicine PCMH pilot sites; in 2010, they received NCQA certification, and in May 2013 cleared the final hurdles necessary to establish their own rural residency training program. “Our program is not created as an extension of an existing residency program,” Dr. Waits explained. “We actually used the funding and accreditation pathways to start a residency program where one did not exist. This program is the result of almost a decade of planning that included a two-year journey through ACGME accreditation and funding through a $75,000 grant from HHS.”
A true, built-from-the-ground-up rural residency training program, “…[it] is neither university nor hospital governed in terms of accreditation and funding,” Dr. Waits said. “CFMR is an unopposed 4-4-4 ACGME-accredited program held to the exact same standards as a university or hospital program. Family medicine residents seeking to be rural physicians actually receive mentored rural family medicine training over the full three years of residency training. This is real rural family medicine training you just won’t get anywhere else. In a town of approximately 5000 people and a 30-bed hospital, it is one of the most rural, free standing residency training programs in the country.” Because this program provides a rural component that translates into comprehensive immersion into patient care, “A resident in this program gets to see and do it all,” Dr. Waits noted.
In addition to in-depth training, the CFMR program provides its residents with levels of specialty training they may not receive elsewhere. “There is very little competition with other residents; in particular with residents who specialize,” Dr. Smithsaid. “In hospital- or university-based programs, family medicine residents often don’t get experience because they come second to the residents who are training to be specialists. For example, in a hospital or university setting, pediatric-specific residents tend to get patients before a family medicine resident.”
Quality Rural Demands Comprehensivists
Despite its rural setting, CFMR is a high-quality training program, held to the same requirements and thresholds as a university or hospital program. In addition to its high standards for quality, CFMR places an emphasis on the value of comprehensivist training. “A comprehensivist is a family medicine physician who is trained to provide a broad range of services desperately needed in a rural setting” explained Dr. Waits. “This is not to be confused by care managers who may reside in a patient centered medical home (PCMH) setting. [They] are like the traditional family doctors doing what they have always done: endoscopy, obstetrics, delivering babies, ultrasound, hospital and office procedures. The comprehensivists actually train to do everything,” Dr. Waits said. He also noted another beneficial distinction held by the CFMR. “The great thing about our program, and other THCGMEs, is there are lots of good residency programs out there but they lean heavily on PCMH and light on the comprehensivist side,” he said. “This is why family medicine residents who train in rural setting get more out of the program. Conventional residency programs in urban, university, hospital settings just don’t provide the same experiences a rural residency does.”
Rural Training Outreach and Partnerships
While the CFMR program is not affiliated with a hospital or university, it works closely with academic institutions throughout Alabama. “CMC has a strong network of relationships with other programs,” said Dr. Lacy. “We have relationships with University of Alabama at Birmingham, the Tuscaloosa Family Medicine Residency program and the new Alabama College of Osteopathic Medicine in Dothan (ACOM) where they share rotations with their medical students.” She further explained that “…as a core site for ACOM, medical students come and spend their 3rd and 4th year with us doing their clinical rotations. “This is also a natural fit for UAB students who do their month long rotations here.” She continued. “In addition to these programs, CFMR also works closely with the University of Alabama in Tuscaloosa and their rural medical scholars program whose mission is to produce physicians for rural Alabama who are leaders in developing healthy communities. Dr. Lacy closed by saying, “Rural residency is a very different and extremely important quality component of a physician’s training program.
While the idea of rural training appears new, THCGME is not. “Although [THCGME] actually occurred as part of the ACA, it is a concept that has been around since the 1960s,” Dr. Waits said. “Prior to ACA legislation, the AAFP campaigned for decades not merely to increase GME slots, but also for GME reform that would provide a way to focus GME on the rural health setting where patient care is most needed.” Dr. Waits continued, “True GME reform has never occurred prior to the implementation of the ACA. Current GME funding follows the prototypical economic middle man concept by which it is allocated by Medicare to the hospital, then the university, then the dean’s office, then the program chair, then the program director, using what’s left for GME curricula.” Under the THCGME model, the program itself gets funding directly so it can develop the curriculum needed. If a hospital rotation is needed, the program purchases it and “…the THCGME cuts through the red tape providing community based health centers direct funding to develop the programs needed in each community with all reporting going directly back to the ACGME,” said Dr. Waits.
More Than the Right Thing to do
Providing care to rural communities that have little or no access to care should be reason enough to support rural training. THCGME programs are the solutions for rural patient care; physicians who train in rural areas usually practice in rural communities (Citation). THCGME programs provide the physicians on the front line with the direct funding they need to grow rural medicine in a state, therefore improving access to care and lessening congestion at the closest hospital which might be hours away. To this point, consider Alabama’s Coosa County. With a population of roughly 11,500, this area “…doesn’t have a single physician within its borders,” Dr. Waits explained. “The state of Alabama lost 25% of GME slots when programs in Anniston and Birmingham were closed.” According to the Healthy People 2020 report, Alabama will see a shortage of 3500 family practice physicians by 2020. He continued, “It’s important to address training issues now if we hope to mitigate this crisis looming in the near future”
If caring for patients in rural communities still isn’t enough, consider the positive economic impact of this training. Rural residency training brings with it traditional capitalistic economic stimulus. When residents move to a community to serve, they spend money. The same is true when these residents go into practice. “Physicians training in underserved areas are 2.5%-3.5% more likely to remain in rural areas,” Dr. Waits noted. In Centreville, the CFMR program has had an immediate positive economic impact on the community. CFMR residents have moved in and become part of the community – currently there are seven medical families and four teaching health center families living in the community purchasing goods and services.
Leaders Don’t Wait for Legislation
The healthcare team at CMC are what the todays’ healthcare leaders look like; not through word or title, but through action and service. Section 5508 of the ACA provides funding for THCGME, training for rural family medicine doctors who choose to go out to the far corners of the world to provide care for those who have need. This is a mission that is worthy of support from the medical and business communities. Funding programs like this should not require legal action from lawyers and politicians mandating them though healthcare policy and legislation, especially when the amount of money needed to fund these programs is relatively small.
Within a family of medicine, some are called to go. They move their families and their lives out into rural areas to give care; others have been blessed with financial resources to help support this mission. In either case, leaders find ways. They don’t wait for laws, they act. The survival of THCGMEs should not be contingent on the survival of the ACA; they should be funded by the family of medicine. This particular program, which has four residents, can survive on $75,000 per year per resident. Leave a legacy and support the health of patients by supporting these young physicians and their mission to make a difference.
Cahaba Family Medicine Residency
A rural residency training program with a heart for mission
405 Belcher Street, Centreville, AL 35042 • Phone: 205-926-2992 • Fax: 205-316-7675
Southern Medical Association
The Family of Medicine
SMA is a 501c3 regional multispecialty association providing physicians and healthcare professionals with education, service and support. Your tax deductible contributions support educational activities, scientific publications, and healthcare professional support services
Disclaimer: The views expressed here are solely those of the author in his private capacity and do not in any way represent the views of the Southern Medical Association or any of its Council members, officers, partners, vendors or subsidiaries. Furthermore, neither the Southern Medical Association nor any of its subsidiaries have approved, endorsed, or embraced anything associated with this post.