RTT program problems, funding and recruitment and competition

AMA News http://www.ama-assn.org/sci-pubs/msjama/articles/vol_282/no_13/stunted.htm

Hi Bob---Since I have seen some of the recent National Rural Health Association work, your work, and Tom Rosenthal’s work, I thought this may interest you.

We just found out that both of our R1s will be leaving next year. One had decided to switch to an ER residency and another decided to transfer to be with family to help them take care of their 3 children. This will leave the program with no residents for next year. For financial reasons, we have decided to look for 2 R2s to replace them. We are interviewing nearby residents, but are concerned about taking residents from other programs and leaving them shorthanded. At this point, we don't see any other option.

R1 funding is inadequate for the RTT. All Medicare passthroughs for our R1s goes to the home program. We currently receive no state funding and no AHEC funding. Other programs have some funds from these sources. Consequently, the only income received for training R1s in the RTT is the income generated by the R1s' clinic practice. Since we allow only up to 6 patients per half day in clinic for the R1s, they don't generate much income. Certainly, it doesn't begin to cover residency expenses.

The biggest expense is the loss of faculty physician productivity when we are cutting back or not seeing patients due to staffing guidelines. The financial picture brightens when we have R2 or R3 residents. We then start receiving Medicare passthrough dollars. The residents see more clinic patients and generate better income in the FP clinic.

I am contacting you to see what can be done to improve our R1 funding. At this juncture, our clinic administration doesn't have a lot of interest in recruiting R1s. It doesn't help that we will have carried the expense of training 2 R1s this year only to have them not complete their more profitable 2nd and 3rd years.

I would like to know if there has been any progress made in garnering state funding for RTTs. I also would like to know if you have any other suggestions as to how we can improve R1 finances.

Thanks,

Response:

The questions I see involve:

1. Funding sources
2. Recruitment issues
3. Competition issues

Funding sources: I certainly hope that you are able to convince the state or the AHEC of the value of support. Oklahoma was able to work out a community match program that matched state and local dollars to give the resident more salary as soon as he or she signed with the community. Such legislation could work to share funds back to the program of origin. The Office of Rural Health could be helpful in this area or with similar proposals. You might be able to convince the home program to fund you based on your value to the state (worth a try). Perhaps also the medical school needs to find a way to give up GME slots to a better cause. Obviously you want to keep up the GME funding for the positions to keep from decreases in GME funding over time. Support for rural programs is included below in the closing statements as well.

Regarding funding and recruitment:

Is it possible to connect the RTT program with the medical center and bridge the match. This would involve some GME funds, trade of PGY-1 salary for tuition deferment, and spread of resources to minimize first year costs. At Nebraska we do have traditional RTT programs, but we have two other innovative programs that start at the M-4 level. M-3s nearing the end of their first clinical year have a choice between a combined internal medicine-family practice program and our accelerated rural fp residency. Each program has 4 or 5 positions. The combined IM-FP program involves an internship year as an M-4, then the match in either FP or IM. Most have chosen FP and most of these have chosen an RTT. The Accelerated RTP starts with a combined M-4 and FP PGY-1 year, then two FP years in Omaha in residency, then a rural fellowship year in Omaha and surrounding locations doing procedural rotations (neonatal, ob, anesthesia, scopes, etc.) Candidates for each program give at least a verbal commitment to rural practice. So far about 75% of all of our rural types of programs have chosen rural - a surprise to me since the Accel RTP folks were so long in Omaha (7 years). It seems perhaps that the love of procedures and the ability to do them drives them out of urban areas. The Accel program solidified an often troubled match, and the in-service scores of the residents soared.

To me the best of all worlds would be 3 yrs med school, 3 yrs rural training, 4th year fellowship in procedures, hopefully at a rural or hi volume location as much as possible. Adding a few months of internation rotations would not be a bad idea to get more procedures, decision-making, and the right kind of residents.

All areas of the nation need to do better to admit the right types of students that will virtually demand RTT and other rural training. This is the most neglected area of all of rural medical education. Do what you can in this area please.

Competition between programs:

This has been an issue since the first RTT in Spokane. It takes constant education of folks in the home program so that they understand why RTTs are important. Given adequate time, the home program is usually able to recruit a replacement far better than an RTT, especially in some parts of the nation. Our community-based programs have taken some hits as residents that would have gone to Lincoln have chosen RTT or ARTT programs. Lincoln has managed to recruit well from other Nebraska students as well as Iowa and other states. The net benefit has been to get more students into Nebraska who are more likely to choose rural practice in Nebraska. Obviously this is a take home point to the legislature, the medical school, and the office of rural health. It all fits together, just make them see it.

Recruiting to Rural Programs