Crisis Creates New Way To Train Family Physicians in Valley

When an arcane federal regulation shut down an established residency program serving impoverished patients in the San Joaquin Valley, it caused turmoil and frustrations that Peter Broderick would not wish upon anyone.

But he hopes the innovative program that improbably rose to take its place is widely replicated.

“We walked over hot coals. But, somehow, out of the ashes, we discovered the ability for a residency program to be owned by a community,” Broderick — CEO for the Valley Consortium of Medical Education and program director for the Valley Family Medicine Residency Program in Modesto – said. “It makes sense: we all benefit from family doctors in the area and now we’re all together and committed to residency education. It’s a robust model.”

Out of the Ashes

The idea is to move residencies away from hospitals in urban centers, which tend to produce high-paid specialists, and put the resources into community health centers training family doctors in small towns and little-served areas.

Primary care educators are looking to the Modesto program as a template.

Callie Langton, associate director of health care workforce policy at the California Academy of Family Physicians, said she’s been fielding many inquiries about the program.

“There are so many benefits to having medical education directly in communities: a population that needs serving gets top-notch care. Residents receive wide, hands-on training. Local economies are protected, secondary jobs created. And residents are more likely to stay in the communities where they trained,” Langton said.

“This is a model we want to be looking at. It’s just an incredible story. One of the main things Peter has accomplished is to make ‘change’ a positive word in the residency world.”

Dark Beginnings

The original residency program was a large part of the social safety net in an area where 22% of the residents rely on Medi-Cal, California’s Medicaid program. The residents and faculty treated about 70,000 patients a year, according to the California Academy of Family Physicians.

Founded in 1935, the program was, in the beginning, a general practice residency at the public county hospital. When the county hospital closed in 1997, the residency program continued through Doctors Medical Center, owned by Tenet Healthcare.

But in 2009, federal attorneys said the residency program had ceased to qualify for federal funding for medical education when the Tenet medical group took over the program a dozen years earlier. CMS officials not only cut off funding, but they also they ordered the program and Stanislaus County to repay $19.1 million in federal funds.

To just keep the program breathing until June 2010, Stanislaus County supervisors were forced to approve $11.1 million to begin to repay CMS. That year, 10 residents graduated and nine stayed in the area as family doctors.

There was a public outcry over the federal government’s shuttering of a family practice residency in an impoverished area during an economic downturn. U.S. lawmakers representing California, including Sen. Dianne Feinstein (D) and Rep. Dennis Cardoza (D), spoke out against the action. The California Medical Association and Stanislaus Medical Society begged CMS to reconsider. There was broad media coverage.

All to no avail.

The few options CMS offered — including turning the family practice residency into a residency for osteopathic specialists — all required closing down the program for one year and beginning again with new residents, faculty and director.

It seemed to be the end of the road.

“Everybody — the faculty and the residents – were saying, ‘Well, might as well look for new jobs.’ Most directors would have thrown in their hat,” Langton said. 

Instead, Broderick started over — completely over — with a new way to run a primary care residency. The old program closed; the new one opened the next day.

Bright Advantages

Doctors Medical Center, Memorial Medical Center and Stanislaus County Health Services, with its network of outpatient clinics, pooled their resources to start California’s first “teaching health center.”

The facilities have formed a not-for-profit consortium that owns the program. Their mission statement is “to train physicians through service to those in need.”

There have been no difficulties in drawing interested residents.

“We don’t have to struggle to recruit residents. We’re a key destination in residency education. Our residents all have these incredible personal stories. They’re idealistic, and they survived many obstacles to get here. Many are from communities like this and that’s where they want to practice,” Broderick said.

The consortium plans to add other residency programs, including emergency medicine and surgery.

More Hurdles

Industry experts say hospitals could be expected to push back at this type of model. Residency programs are money makers for hospitals and help provide financial stability. Programs in high-paying specialties bring in more revenue for hospitals than primary care, so organizations tend to favor those.

On the other hand, in California, six out of nine regions have a shortage of primary care physicians. Nearly 30% of primary care physicians are more than 60 years old. And national health care reform is expected to create a need for more family doctors as more people gain health insurance.

In January, the consortium’s residency program was one of 11 in the country —  and the only one in California — to be designated a Teaching Health Center and receive five years of federal funding through the Affordable Care Act.

The aim of the Teaching Health Center program is to increase the number of primary care medical and dental residents trained in community-based settings across the country. The consortium’s initial ACA award was $625,000 — the most in the country.

Ironically, the only reason the program was eligible for the federal funding is because it is new as of July 2010 as a result of its run-in with federal regulations. Only new residency programs can qualify for ACA funding.

In May, the House passed HR 1216, a bill that would strip the Teaching Health Center program of its five-year funding and make residency programs reapply each year. The bill now will move to the Senate.

The latest political hurdle has not fazed Broderick.

“After everything we’ve been through, this just seems like political posturing,” he said. “If they take this funding, we’ll find some other way.”

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