TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION, VOL. 128, 2017
Expanding the Health-care Pipeline through Innovation: The MCW model JOHN R. RAYMOND, Sr., MD, and (by invitation) CHERYL A. MAURANA, PhD, and JOSEPH E. KERSCHNER, MD MILWAUKEE, WISCONSIN
ABSTRACT In 2016, the Association of American Medical Colleges projected a physician shortage in the United States of approximately 90,000; in the same year, the Wisconsin Hospital Association projected a shortage of 2,000 physicians in Wisconsin. The Medical College of Wisconsin has begun to address these shortages in three ways: 1) creation of immersive regional medical school campuses in Green Bay and Central Wisconsin, in p artnership with rural serving health systems; 2) creation of rural-based psychiatry and family medicine residency programs in Green Bay and central Wisconsin; and 3) expansion of the scope of practice of pharmacists through creation of a new School of Pharmacy in collaboration with the Medical College of Wisconsin School of Medicine. This article will discuss those approaches, history and progress to date, principles used, and future plans to address the impending physician shortages.
Introduction In late 2011, the Wisconsin Hospital Association published a workforce analysis that predicted a shortage of about 2,000 physicians by 2030 (1). This report showed concordance with the 2011 Association of American Medical Colleges (AAMC) workforce analysis that predicted a similar shortage in Wisconsin by 2025 (2). In early 2012, the joint Education Committee of the Wisconsin Senate asked the state’s two medical schools, the University of Wisconsin (UW) School of Medicine and Public Health, and The Medical College of Wisconsin (MCW), to find ways to expand the medical student pipeline by approximately 100 students per year. They were particularly concerned about a perceived primary care physician shortage, and also about the maldistribution of physicians within Wisconsin. The maldistribution was most apparent
Correspondence and reprint requests: John R. Raymond, Sr., MD, 8701 Watertown Plank Road, Milwaukee, Wisconsin 53226, Tel: 414-955-8225, Fax: 414-955-6560, E-mail: [email protected]. Potential Conflicts of Interest: None disclosed.
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in the northern regions of Wisconsin. The committee’s request was challenging in that the two medical schools were matriculating nearly 400 allopathic medical students per year. In other words, one might argue that we already were doing our part. Indeed, this sentiment was expressed by some of our faculty members, who observed that MCW (established in 1893) already was one of the largest private allopathic medical schools in the United States, with more than 200 matriculated students per class. The leadership team of MCW responded to the challenge by visiting most of the larger health systems in Wisconsin in late 2011 and 2012. During those visits, we verified that many of the rural-serving health systems in Wisconsin were experiencing difficulties in recruiting and retaining both primary care and specialty physicians, and that they were enthusiastic about the prospects of addressing those challenges by expanding the pipeline of Wisconsin medical students. We also quickly realized that the rural-serving health systems were highly capable and mission driven, delivering high-quality, sophisticated, and highly accessible health care. We discovered that those health systems had a strong base of competent physicians, many of whom had never been asked to teach medical students. Similarly, we visited about two dozen educational institutions to assess their willingness, competency, and capacity to partner with MCW for medical student and interprofessional healthcare education. We found many willing and capable partners who saw the benefit of collaborating with a well-established medical school.
Responding to the workforce needs of Wisconsin — regional medical school campuses In January 2012, the MCW Board of Trustees authorized administration to assess the feasibility of expanding the student body on our Milwaukee campus, and to investigate up to eight regions of the state as possible campus locations. We had a series of internal discussions with small groups of faculty and staff, and quickly concluded that we had the space and teaching capacity to expand our Milwaukee campus by approximately 25 to 50 students. However, we did not believe that expanding our Milwaukee campus would solve the problem of physician maldistribution. Thus, we pursued the option of regional medical school campuses (3). In assessing the eight possible locations, we considered a number of factors, including 1) presence of capable health system partners and educational institutions that were willing to work with us and to share clinicians and teachers with us, and which had
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a clear commitment to underserved regions of our state; 2) presence in the communities of key teaching and learning resources that could be shared with us, including anatomy laboratories, simulation centers, technologically advanced classrooms; 3) enthusiasm of the business, community and government leaders; 4) presence and participation of our alumni; 5) philanthropic potential; 6) high-quality cultural amenities and K-12 education; and 7) willingness among competing health-care institutions to work together with each other and with MCW. Further, we asked each of the health-care entities to contribute $1 million to the start-up costs of the regional campuses, and to work with us to develop “destination residencies” in their region of the state. After an accelerated period of assessment, the MCW Board approved central Wisconsin (Wausau, Wisconsin Rapids, Marshfield, and Stevens Point) and Green Bay as the preferred locations. Further, the MCW Board requested that the campuses matriculate students no later than 2016, and that MCW create at least 25 new residency positions in those regions so that the regional campus graduates would be able to continue training in the communities in which we hoped they would begin their medical careers. We matriculated our first class of 25 students at MCW–Green Bay in 2015, and a second class of 30 in 2016. We matriculated our first class of 26 students at MCW–Central Wisconsin in 2016. In this article, we describe three strategies to address the physician shortage in Wisconsin: the creation and early experiences with regional medical school campuses; the creation of rural-based psychiatry and family medicine residency programs in northeastern and central Wisconsin; and expansion of the scope of practice of pharmacists through creation of a new School of Pharmacy in collaboration with the MCW School of Medicine. Principles of the Regional Medical School Campus Model Community Immersion. We posited that complete immersion in the community would facilitate interactions with mentors and role models, and that the students and their families would be more likely to “grow roots” in those communities. We knew from the Wisconsin Hospital Association study that individuals who attended medical school or who obtained residency training in Wisconsin had 38% and 47% likelihoods of practicing in Wisconsin, whereas individuals who both attended medical school and obtained residency training in Wisconsin were 70% likely to practice in Wisconsin (1). We hoped that the immersive model would yield similar results for the specific communities in which our regional campuses would be located.
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Competing Health Systems Must Work Together. Although central Wisconsin and Green Bay have multiple sophisticated health systems that provide high-quality health care, none of the individual systems have the capacity to accommodate 25 to 30 new medical students per class in each location in terms of patient volumes or variety of experiences. This was especially apparent for pediatrics, obstetrics and gynecology, and certain surgical subspecialties. On the other hand, two or three health systems working together in each community could accommodate both the volume of learners and patients and the variety of patients necessary to provide support for core rotations for each of the regional medical school campuses. Four Green Bay and three central Wisconsin health systems participated in multiple planning sessions and agreed to provide members for our Community Advisory Boards. Ultimately, three systems in Green Bay (Bellin, Hospital Sisters Health System/Prevea Health, and the Huempfner VA) and two in central Wisconsin (Ascension Wisconsin and Aspirus) agreed to work with us and each other to provide clinical rotations and teachers for our regional campuses. The private health systems (two in each community) each agreed to commit $1 million to the start-up of the regional campuses. This amount was chosen to be sufficient to show a significant (and equivalent) commitment to the partnership, but not large enough to have a material impact on their operating margins. We also found that maintenance of good working relationships among the competing health-care systems requires significant face time, trust building, candor, and a true sense of c ommon purpose. Minimization of Student Debt Burden. We recognized that the staggering life-time debt burden, which now averages $190,000 for all US medical school graduates (4), would limit medical student career options, making them less likely to pursue primary care specialties, community-based practice, practice in underserved areas, or faculty appointments. We used two approaches to minimize the financial cost to students. The first was to abate the infrastructure costs of the startup, ramp-up, and operational phases of the campuses (described in the next section). The second strategy was to offer an accelerated 3-year curriculum, which could reduce debt burden by saving the students 1 year of tuition, and giving them the opportunity for 1 more year of working career. We calculated the net present value (5) of the shortened curriculum to be nearly $1 million dollars, assuming an annual tuition of approximately $52,000, a starting salary of $150,000, a 35-year career, and 4.5% inflation.
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Our regional campus curriculum provides for 135 weeks of formal instruction over a 3-year period. We achieved this by matriculating students in the summer of the first year, eliminating the long break between the first and second year of medical school, and truncating holiday breaks. We knew that the 3-year curriculum could be a viable option based on a literature review of experiences with accelerated curricula in US and Canadian medical schools. Our review showed that graduates of 3-year medical school programs and those of the traditional 4-year programs perform substantially the same at every career stage. On the other hand, our literature review also revealed that 3-year medical school curricula were arduous for both faculty and students (6). Therefore, our admissions process also needed to be adjusted to matriculate students who would be capable of excelling within the advanced pace of the curriculum. Parsimonious use of Resources. To minimize the start-up, rampup, and operational costs to the community, our institution and the students, we pledged to reduce the cost of infrastructure. Inasmuch as we could share critical services and support such as our library, financial aid, tutoring, and other student services with our Milwaukee campus, we built only teleconferencing and hotel space for those functions. Moreover, we shared anatomy laboratories, simulation centers, and auditoria with our local host institutions. Using those approaches, we were able to reduce the total teaching and office space needs to approximately 14,000 ft2 for each of our campuses. The spaces were secured through a combination of leases and condominium purchases at the host institutions. The dedicated spaces in each location were built out to our specifications at Aspirus Wausau Hospital in central Wisconsin, and at the Gehl-Mulva Science Center at St. Norbert College in DePere, Wisconsin (adjacent to Green Bay). Simulation centers were built out and shared with North Central Technical College in Wausau and at the Bellin College of Nursing and Radiological Sciences in Green Bay. We also created locally based faculties through a combination of strategic full-time hires, and purchasing faculty time/service from local universities (rather than individual faculty members). We contracted with the local universities so that the administrative and academic leaderships would be committed to the medical school. This worked well, and the universities pledged to use a small cadre of dedicated basic science teachers (rather than a larger group of part-time f aculty) so that we could grant the teachers meaningful secondary faculty appointments, they could build relationships with MCW’s broader faculty and with our regional campus students, and they could provide consistent teaching for our medical students.
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We reimbursed local universities such as St. Norbert College, UW Green Bay, UW Stevens Point, and UW Marathon County for time and effort of their science faculty in our pre-clinical teaching. We found a very strong group of doctoral basic science teachers at the local universities who were exceptional pedagogues. Many of them had received degrees or post-doctoral training at MCW. Their home universities benefited by having connections to the medical school campuses, and by generating salary offset for the contracted faculty. The faculty from the partner institutions benefited from making connections to the MCW faculty, expanding their teaching to professional students, and gaining access to the research enterprise at MCW. We also were successful in minimizing other start-up and ramp-up costs. Start-up costs included construction, renovation, curriculum development, and faculty and staff salaries before matriculating students. Ramp-up costs included all operating and capital expenses incurred before we had a complete tuition revenue stream from three full classes at each regional campus, which will be achieved in July 2018. Our initial pro forma suggested that the total start-up and ramp-up costs would be approximately $32 million, and that we would be able to cover operating costs with tuition revenues and philanthropy by 2018. Actual expenditures were tracking well with the pro forma through submission of this article. We have been able to offset most of the expenses associated with the regional campuses through an appropriation from the Wisconsin Building Commission ($7.4 million), through a grant from the Advancing a Healthier Wisconsin Endowment ($4.3 million), and philanthropy ($13 million to date). Our parsimonious model compares favorably to start-ups- costs of new medical schools that exceed $100 million to $125 million. Community Advisory Boards. Early in the process of creating the regional campuses, we created community advisory boards to foster a sense of ownership in the communities in which we would immerse our students. The boards also serve as ambassadors to the community and advocates for the regional campuses and students, and as advisors who could bring local wisdom to our curriculum, fundraising, and admissions processes. The boards are composed of approximately 20 members representing academic, health care, business, philanthropic, and governmental agencies. They meet regularly to communicate progress, to make suggestions about policies, and to help to define and achieve common goals. These boards also assisted us in identifying local leaders and interested citizens who could serve as local i nterviewers of prospective medical students, and as donors.
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Community-Informed Admissions Process. Our admissions process is designed to seek community input about the character of applicants and about their “fit” for the community. All potential regional campus students are evaluated by the main admissions committee for competitiveness as compared against the entire pool of applicants and against our recently matriculated students. Applicants are deemed competitive for admission to MCW based on pre-matriculation scholastic achievement, MCAT scores, personal statements, and reference letters. Then, applicants are granted interviews with a subcommittee of our admission committee comprised of local c ommunity volunteers, alumni, educators, and laypersons. That subcommittee then makes recommendations for admission or wait-listing of the interviewees. Members of the regional admissions subcommittee frequently mentioned desirable attributes such as caring, compassion, and collaborative spirit (7,8) as key factors in their assessments of potential students, as well as the commitment of the applicants to pursue medical practice in underserved rural communities. We believe that this process helps to identify students most likely to stay in the region after graduation from medical school. The process also fosters a sense of commitment and ownership from the communities, while also ensuring that our high admission standards are maintained. Enriched Curriculum. The pre-clinical curriculum was modified so that anatomy and physical diagnosis courses were taught in the first few months of the first year. The latter was done so that students could begin longitudinal half-day clinics early in their first year. The vast majority of the pre-clinical curriculum was streamed synchronously from Milwaukee, with lectures delivered by interactive video streaming. Lectures also were archived for asynchronous viewing. This was done so that we could establish substantial equivalency of the traditional 4-year curriculum in Milwaukee, and the 3-year curriculum at the regional campuses for Liaison Commission on Medical Education accreditation. Lectures at the regional campuses were enhanced by the presence of local faculty in the regional campus classrooms, and by small group discussions facilitated by basic scientists and clinical faculty in a manner identical to that used in Milwaukee. The 3-year curriculum was enriched by incorporation of aspects of public and community, prevention and wellness, professionalism (9), interprofessionalism (10,11), and the Institute for Health I mprovement triple aim (12,13). This was much easier to accomplish than it would have been for our traditional 4-year curriculum because the faculty were building a new curriculum rather than trying to squeeze more content into a firmly established curriculum. We also provided early
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clinical experiences for students who started longitudinal clinics within the first few months of their education. The purpose of early clinical exposure (14) is 2-fold: to provide clinical context for the s tudents about the pre-clinical content of the curriculum, and to help our community physician preceptors and their staffs to become comfortable with medical students in their patient care settings. Preferential Weighting for Students With Wisconsin Ties. Because our goal was to address the physician shortage and maldistribution in Wisconsin, we chose to give preferential consideration for offering interviews to students with Wisconsin ties. The rationale was that students from Wisconsin would be more likely than those from other states to choose a Wisconsin site to pursue their medical practices. Indeed, the 2011 Wisconsin Hospital Association study (1) showed that students were 56% likely to practice in Wisconsin if they were originally from Wisconsin and completed medical school in Wisconsin. If Wisconsin students completed both medical school and residency in Wisconsin, their likelihood of practicing in Wisconsin rose to 86%. Despite the logic of granting preferential consideration to Wisconsin residents, initially some of our faculty members were skeptical because MCW is a national medical school. Historically, we have matriculated 50% to 60% non-Wisconsin residents at our Milwaukee campus. Nevertheless, we were able to matriculate 85% Wisconsin residents in our first two Green Bay classes and first central Wisconsin class without deterioration of our mean matriculated MCAT scores and grade point averages. It is too early to determine whether our Wisconsin-resident preferential policy at our regional campuses will have a material impact on retention in Wisconsin. Robust Student Support and Faculty Development. To provide student experience at the regional campuses equivalent to that in Milwaukee, we used a variety of methods to connect our students from all three campuses through student affinity groups, shared community service activities, extracurricular activities, curricular interactions, and student government representation. Our local health system partners insisted on strong faculty support mechanisms to ensure quality and value added for faculty, and to mitigate competition between the systems. We focused considerable effort on faculty development at the regional campuses so that the entire faculty would feel equally valued by the organization. This was accomplished through committee and faculty council representation, shared community-engaged research projects and grants, team teaching, and other methods. Importantly, MCW created an Office of Educational Improvement, which provides support for all of our faculty
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in distance learning and digital teaching methods; faculty travel and professional development awards; weekly educator pearls (peer tips); learning resource and education technology support; and recognition for teaching excellence. Challenges to Overcome. In order for our regional medical school campus model to be successful we needed to overcome faculty skepticism about the 3-year curriculum; concerns about qualifications of community faculty; and doubts about capabilities of community health systems and physicians to provide outstanding teaching and learning opportunities for our students. Our faculty also needed to acquire new skills in team teaching and distance learning modalities. We needed to develop a financial model that could break even on tuition revenue and philanthropy. Five years after the MCW Board approved creation of regional campuses, and nearly 2 years into the inaugural class of students at MCW-Green Bay, it seems that those challenges have been addressed reasonably well, although continuing vigilance and assessment will be necessary. At the time of submission of this work, our students had not yet completed United States Medical Licensing Examination Step 1 testing. However, our students at MCW-Green Bay and MCW–Central Wisconsin have performed as well on in-house examinations as our students in the traditional 4-year curriculum in Milwaukee. Ultimately, the success of this program will be judged on United States Medical Licensing Examination Step 1 examination scores, competitiveness for residencies, and the percentage of graduates who practice ultimately in underserved rural communities. With regard to competitiveness for residency placements, we are working hard to prevent stigmatization of our regional campus students or the 3-year curriculum. We also are developing new rural residency programs in family medicine and psychiatry (next section) to provide the regional campus graduates with destination residencies based in the communities in which we hope they will practice medicine.
Responding to the workforce needs of Wisconsin — rural immersed family medicine and psychiatry residencies We knew from national data (2) and from the 2011 Wisconsin Hospital Association study (1) that physicians are more likely to practice in the state from which they graduated from medical school if they also performed residency training in the same state. Therefore, we sought
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to create new residency programs in northeast and central Wisconsin so that our regional medical school graduates had local graduate medical education programs that could serve as local training destination. We believed that such local residency options would enhance the likelihood that the graduates would choose to practice in the underserved regions of Wisconsin. We also knew from our interviews with health-care leaders across the state of Wisconsin that there was a desire to create residency programs in northeastern and central Wisconsin, but that most of the health systems were not comfortable with the complexities of accrediting, financing, and operating residencies. The health systems expressed keen interest in creating new residency programs in Family Medicine, Psychiatry and Behavioral Health, and General Surgery, the three areas of the most critical workforce shortages in rural Wisconsin. With encouragement from the Wisconsin Hospital Association and Wisconsin Medical Society, MCW was successful in creating two new accredited Psychiatry residencies using a distributed model with multiple partners in northeastern and central Wisconsin, and a new Family Medicine residency in Menomonee Falls, Wisconsin. Those residency programs have received initial accreditation from the Accreditation Council for Graduate Medical Education. Our efforts were facilitated by technical assistance and/or grant support from the Wisconsin Rural Physicians Residency Assistance Program, which was created by the state legislature in 2009 through Act 190 of the state budget (15). Other efforts are underway to create new two Family Medicine residencies in Eau Claire (Mayo Clinic; and a collaborative of Hospital Sisters Health System/Prevea Health, the UW School of Medicine and Public Health, and MCW), and Family Medicine residencies in Wausau (Ascension Wisconsin and MCW) and Green Bay (Hospital Sisters Health System/Prevea Health and MCW). MCW recently received approval for a rural General Surgery residency track in Wausua in partnership with Aspirus Health. This was facilitated by a grant from the Wisconsin Rural Physicians Residency Assistance Program (15). We believe that creation of these rural residency programs will be essential to the success of our regional medical school campuses in terms of providing opportunities for the graduates to receive specialty training and to establish practices in the region. Indeed, the MCW Board of Trustees recognized the importance of new residency programs by charging MCW’s administration with creating 25 new rural residency positions when they approved creation of the regional medical school campuses in 2012. Moreover, interaction with residents is a key component of an enriched clinical learning environment for
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medical students, as recommended by the Liaison Committee for Medical Education (16). There were three major hurdles to overcome in creating these new residency programs. The first hurdle was funding. Many of our potential hospital partners already had very low resident “caps” for direct funding by the Centers for Medicare and Medicaid Services under 42 Code of Federal Regulations 413.79 (17). The low caps required that the health systems would be responsible for bearing the full cost of the residency program. We mitigated this concern by encouraging partnerships between competing health systems to spread out the costs. This approach also allowed the health systems with opportunities to base rotations at sites with higher caps, or to establish new caps at sites without previously established caps. In addition, MCW contributed start-up funds so that we could show a true commitment to addressing the workforce needs of the health systems. We also worked diligently with the health systems and our local congressional delegation to introduce legislation to remove the somewhat arbitrary caps established for the rural serving health systems. This approach is consistent with the recent AAMC recommendation to increase residencies by approximately 3,000 slots (18), which supported the Resident Physician Shortage Reduction Act of 2015. Although those legislative efforts have not succeeded to date, they established ties between and a common purpose among the partners. The second hurdle was finding ways to encourage educational collaboration among health systems that were clinical competitors. This required significant trust-building, face-time, and creating a sense of common purpose. In terms of building trust and partnership, it helped that the same concepts already appeared to be working well for undergraduate medical education at our regional campuses. The third hurdle was the health systems’ lack of technical expertise in creating and operating graduate medical education programs. This was addressed through technical assistance from MCW and the Wisconsin Rural Physicians Residency Assistance Program (15), and a grant from the Advancing a Healthier Wisconsin Endowment.
Responding to the workforce needs of Wisconsin — creation of a new MCW School of Pharmacy During our deliberations about addressing the physician shortage and maldistribution in Wisconsin, we also considered the possibility of
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expanding the pipeline of non-physician providers. This solution is not new, as there are shortages of all types of health-care providers. The World Health Organization estimated that the worldwide shortage of health-care providers would grow from 7.2 million to 12.9 million by 2035 (19). In response, many have called for an increase in physician assistants, advanced practice nurses or nurse practitioners, and other types of health-care providers to fill in for the shortage of primary care physicians (20). Because of a large number of existing or planned nursing and physician assistant programs in Wisconsin, we considered the possibility of creating a pharmacy school as a complement to our other workforce initiatives. The MCW Board of Trustees approved creation of a Pharmacy School in May 2015. They also encouraged administration to create opportunities for the pharmacy students to learn side-by-side with medical students and to create a new kind of pharmacy curriculum to educate the pharmacist of the future. We were intrigued by permissive pharmacy practice legislation in Wisconsin, which allows that “a pharmacist may perform any patient care service delegated to the pharmacist by a physician…” (21). Our faculty viewed this legislation as an opportunity for the medical and pharmacy professions to collaborate to define the scope of competencies required both to delegate and be delegated to perform tasks. As an initial step, our pharmacy school has decided to incorporate physical examination and diagnosis into their curriculum. This will occur as a key interprofessional component of the curriculum, with pharmacy and medical students learning physical examination skills in the same classrooms, simulation, and clinical settings. Our purpose is not to create a class of health-care professionals who will compete with physician assistants and advanced practice nurses. Rather, we envision that our pharmacy school graduates will be able to perform triage in retail pharmacy settings, or to provide chronic disease management in retail pharmacy or clinic settings. Inarguably, pharmacists are experts in medication management, and this aspect of their training will be valuable in chronic disease management inasmuch as 80% of chronic disease management involves medications (22). Pharmacists also have long-recognized expertise in medication reconciliation, adherence, and side-effect profiling. Recently, pharmacists have begun to render point-of-care preventive services such as vaccinations; and Clinical Laboratory Improvement Amendments waived tests such as hemoglobin A1C and cholesterol. Finally, because there are more than 50,000 pharmacies in the United States, the pharmacy could be an ideal setting for preventive
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services such as diabetic foot examinations and retinal screens via tele-ophthalmology. These latter services will require that the pharmacist is capable of and comfortable with the laying of hands and stethoscopes on patients. Although we are optimistic that our pharmacy graduates will help to alleviate some aspects of the projected physician shortage through expanded scope of practice and competencies, our goal of educating the pharmacist of the future remains to be proven. We hope to matriculate our first pharmacy students into MCW in late 2017, pending approval of pre-candidate status from the American College of Pharmacy Education.
Summary and conclusions MCW has used a three-part strategy to address the physician shortage and maldistribution in Wisconsin: 1) creation of immersive regional medical school campuses in Green Bay and central Wisconsin, in partnership with rural serving health systems; 2) creation of rural-based psychiatry and family medicine residency programs in Green Bay and central Wisconsin; and 3) expansion of the scope of practice of pharmacists through creation of a new School of Pharmacy in collaboration with the MCW School of Medicine. We summarized our experiences in creating regional campuses in central Wisconsin and Green Bay, and progress of the first classes of students at those campuses. We also described initial steps toward creating new Family Medicine and Psychiatry residencies in underserved, rural Wisconsin communities. Finally, we discussed an aspirational initiative to create a School of Pharmacy that will expand the scope of practice and competencies for pharmacists. Recent studies have confirmed that the United States still suffers from a significant projected shortage of physicians (23,24). Therefore, we remain committed to addressing the physician workforce shortage and maldistribution through multiple innovative approaches.
ACKNOWLEDGMENTS Parts of this work were supported by grants to the authors from the Advancing a Healthier Wisconsin Endowment and the Kern Family Foundation. The authors thank the faculty and staff of the Medical College of Wisconsin, and our colleagues and collaborators in the initiatives described herein.
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Report. Geneva: World Health Organization; 2014. Available at: http://www.who.int/ workforcealliance/knowledge/resources/hrhreport2013/en/#.WKySKLL_TN4.mailto. Accessed September 2, 2016. 20. Bodenheimer TS, Smith MD. Primary care: Proposed solutions to the physician shortage without training more physicians. Health Affairs 2013;32:1881–6. 21. Wisconsin Statutes, Chapter 450.033. Available at: https://docs.legis.wisconsin.gov/ statutes/statutes/450/033. Accessed May 30, 2016. 22. McInnis T, Webb E, Strand L. The Patient-centered medical home: Integrating comprehensive medication management to optimize patient outcomes, Patient-Centered Primary Care Collaborative, June 2012. Available at: https://www.pcpcc.org/guide/ patient-health-through-medication-management. Accessed September 2, 2017. 23. Association of American Medical Colleges. New research confirms looming physician shortage. Available at: https://www.aamc.org/newsroom/newsreleases/458074/2016_ workforce_projections_04052016.html. Accessed September 2, 2016. 24. Association of American Medical Colleges Center for Workforce Studies. 2016 State Physician Workforce Data Book. Available at: https://www.aamc.org/download/263512/data/statedata2011.pdf. Accessed November 13, 2016.
DISCUSSION Griner, Weston: One of your slides early on showed the areas of the state that are underrepresented in terms of health professionals not just physicians and so as you have demonstrated the innovations in preparation of medical students and residents, what’s going on with regard to nursing and other health professionals and the extent to which professional learning is taking place. Raymond, Milwaukee: Great question. As a freestanding medical school, it’s a real challenge for us. We have started an anesthesia assistant program and a CRNA program in the last year and we are partnering with the UW system and their PA and nursing programs to provide interprofessional opportunities in the communities, but more needs to be done. That’s part of why we started the pharmacy school. Thank you. Branch, Atlanta: I want to thank you. That is a wonderful vision that you have. My question is that the problem is the maldistribution of the health-care professionals and the unwillingness of people that graduate, go into the fields that are needed like primary care. There have been lots of efforts around the country for a while to put schools in communities to build primary care, medical schools — to build family medicine, residencies in communities to solve these problems. I am sure you have looked at all of the results and outcomes of these. How have the outcomes been? I mean is this a good solution? And do we have some data to show that we are solving this problem? Raymond, Milwaukee: Yes, the data are pretty mixed. I believe this is the largest community immersive model and it’s fully immersed. And of these other models aren’t. So, we are pleased to be doing the experiment and obviously I am a believer. I’m hoping that we will prove that it will work. We don’t know yet. Baum, New York City: I’d like to congratulate you on this initiative which has obviously been successful up to this point and we’ve all heard about bucket lists. And it’s my very strong impression as a Dean of students that the bucket runneth over and that we have now created some 25 or 26 new medical schools in the United States without creating more than a handful new residencies. I think that the original concept, and I hope I am not insulting anybody in the audience who was on that committee, but the original assumption was that we could create these new medical schools and of course
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American medical graduates would displace the international medical graduates and we would have no problem at all. The issue is that the hospitals that got used to having number one from a foreign medical school are not willing to replace those people with number 183 from the Albert Einstein College of Medicine. So we have a real problem, a funnel with lots more medical students being dropped in the top of the funnel and no place for them to go and after that. And I think that every school is experiencing an increase in unmatched students who previously would have matched. And these are now people with $200,000 worth of debt who don’t have a job. Can you comment on your thoughts about what’s going to happen? Raymond, Milwaukee: You’re absolutely right. In Wisconsin, we’ve created 32 residency positions so half of the students that graduate, if they choose to, have places to go in their community for residency training, and we didn’t wait for CMS to help. We put our own money on the table and asked the health system to do the same. They actually see this as a good recruitment tool and they are diverting some of the funds that they would put into recruitment of their physicians and they are trying to invest in these medical students. Again, early in the experiment, we hope it will work. Feldman, Philadelphia: So, we are about 10 years ahead of you and I can tell you a couple of cautions — issues that we ran into. The first is that I found that having 20 or 25 students is not big enough to have a community of scholars and as a result if you get one student or two students who just can’t find their mix in that group you have some very serious problems. The second problem we had is we could not demonstrate comparability. It’s very hard to do because you’ve got people that are in a very different culture and of course the LCME demands that. The third problem we had is that in one of our three schools, the partnering hospital was bought by a for-profit; that was the end of that program. The second decided they wanted to have their own medical school and so they bought a medical school and we were suddenly pushed out. And the last and I think the most important caution is that these students really do not have the exposure to research and to academic clinicians, and as a result our students have done very poorly at getting into the competitive residencies such as orthopedics, dermatology, ophthalmology. Obviously, that might not be the mission of the school, but when students are spending this much money if they decide somewhere along their education program that they want to go into one of these: It is harder to get into these specialties. It’s virtually impossible. Raymond, Milwaukee: You made a lot of great points. What I would say is that technology now enables us to have community with the Milwaukee campus and for the other two, we put in a lot of face time and we have people go back and forth, and there is an expectation that the students will produce scholarship. It probably won’t be bench science but they will be doing database work and clinical trials. So, we hope that we will be able to enrich their research environment. But again we are in the early phases, and you made excellent points. Olds, Grenada: John, I want to applaud the work that you are doing, you know I feel strongly about what you are doing. And particularly you have developed graduate medical education since half the decision of where doctors practice is when they finish their training. Interestingly, doctors do not practice where they go to med school. My comments are really two other ideas: about 40% of the decision is where you come from. I think you will have a much greater yield if you explicitly recruit students from rural Wisconsin. Look carefully at the admission requirements because that is the big yield. Recruiting someone from a rural area is much more likely, no matter what else you do, that they will end up practicing there. The other is the scholarship aspect on what I call mission based scholarships — linking potentially free medical school in return for 5 years of service in those areas. And the military has done this very successfully and
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that is a very successful model: to basically implant practicing physicians in these geographically disbursed areas in the United States. Raymond, Milwaukee: Fantastic points: One of our health system partners put $20 million dollars into a grant to scholarship fund so that if the students stay in the region when they are done with residency training, their loan will turn into a scholarship. Eighty-five percent of the students in these campuses are from Wisconsin and most of them are from within the five-county area around the regional campuses. So your first point is absolutely right. Thanks, Dick. Hochberg, Baltimore: So, when the legislature discussed this and your school stepped up to the plate to do this, what was the discussion about nurse practitioners who are licensed independent professionals and practice primary care and even mental health. And then physician assistants, physician extenders as opposed to implanting more physicians who may not necessarily go into those areas or stay in those areas. And then a second question which came to me during your presentation, and I may have paraphrased or understood it incorrectly: is the second interview when the local institution determines whether the student is “fit for the community” — What does that mean? Raymond, Milwaukee: It’s really not the local institution [that determines community fit] — it’s a community advisory board of 30 individuals that have been trained to interview medical students, and they bring the local perspective; they are business leaders, some of the elected officials, and a very few official representatives of the health-care education institutions. Our main admissions committee has already decided that these students are capable of making it through our medical school, so we are really looking for fit. I’d love to develop a tool kit through which one could actually measure the attributes of the student who would be successful in those environments and that’s actually one of our goals. What was your first question? Hochberg, Baltimore: First part was about nurse practitioner and physician’s assistant in the form of being licensed, independent practitioners. Raymond, Milwaukee: Right, we have a shortage of all primary care providers in the state of Wisconsin and in our discussion with our legislature we admitted that what we would do in the medical domain would only be part of the answer. Thibault, New York City: John, congratulations on a wonderful innovation. I want to make a couple of comments to put it in context. Your schools are part of at least 10 schools in this country now that are developing tracks for a 3-year plan to an MD degree. You’re the only schools that are actually doing it exclusively. With others it’s a subset and part of it a sponsored consortium to try to learn from this experience, both in the selection criteria in the assessment of competency, and in the outcomes. So, we will have more data from this consortium schools that you are participating in. The second comment is that we have just completed six regional conferences on GME innovations and we’ve heard exciting initiatives just as you described, of developing new GME slots funded by states, funded by systems, funded by consortiums to meet specific local and regional needs. So, I applaud you on both part of these national trends and I would say the positive part of this, acknowledging the problems that have been raised by other questioners — appropriate issues to raise, and cautions. But I think that the important positive part of this is that medical schools and GME programs are beginning to be developed and oriented towards this sense of social mission. They are they meeting the needs of the communities they serve and I think that is a very important health trend and I applaud you for being a part of that trend. Raymond, Milwaukee: Thank you. Zeidel, Boston: I have to act as a slight counterpoint to my friend and mentor Dr. Thibault. To what degree does a physician need to understand basic science? To what
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degree or what are we losing, by cutting the curriculum, moving people away from any contact with anyone who has ever done an experiment. While I think it’s very important that we fulfill our social mission the people we train need to have some understanding of science, how it advances, and they need to have that part of being a physician as well. And I am concerned that as we create more and more of these settings, that we are losing that as part of our profession. And I think it’s very important and I think that the patient who comes to see that physician has a certain expectation of that kind of expertise and perspective, which maybe is no longer justified. Raymond, Milwaukee: Well since you and I came from the same career background, I certainly started with the same biases that we all have as physician scientists. A couple of points to make: First of all about our 3-year curriculum; 90% of it is the same as our 4-year curriculum — it’s delivered electronically in real time by the same faculty. The lectures also are available asynchronously for students from all three campuses. There is a faculty member in the room whether the lecture is being delivered from Milwaukee or one of the regional campuses, and those faculty members are trained as basic scientists. I think what I am trying to get across to the students and our faculty is it that there won’t be a lack of scholarship. There may be fewer opportunities to do basic science research but we really didn’t cut any of the pre-clinical curriculum. It’s the same preclinical curriculum in Milwaukee. It’s enriched and enhanced with longitudinal clinical exposures. The real challenge for our students is that they don’t do the five core rotations before they have to choose where to interview for residencies and that’s a logistical challenge that we are still struggling with. But I understand your points entirely. Thank you. Wolliscoft, Ann Harbor: We all know that projections of workforce are highly, highly variable. Some of us remember COGME, “will cath for food,” etc...So that’s an issue. But what too frequently happens, and I have testified to the Michigan legislature, we have areas of physician and other health-care professionals shortages as well. Just like Wisconsin, but when you look at it the solution is always just produce more docs. However, the root cause analysis too frequently is inadequate economic base. Little in the way of cultural enrichment in these communities. No intellectual community, inadequate education for children of physicians and other health-care professionals. And so, it really is not incumbent solely upon medical schools or nursing schools to solve the maldistribution problem. How has the legislature and others really embraced this whole array of issues that have essentially kept physicians from going to these areas previously? Raymond, Milwaukee: Well Jim, you raised some outstanding and critical points. Our legislature is trying to address the issues of economics for the individual in a pretty rigorous way. And they are allowing us and experts from the UW School of Medicine and Public Health to advise them. The legislature is extremely receptive. I did say one of the factors that we would take into consideration in the communities was the enthusiasm of the community. What I have learned is that we have some very capable physicians and that health-care systems are doing great work in the rural communities. So, I am not so sure the quality of the local faculty or health systems is an issue. Almost a third of the students in these regional campuses are sons and daughters of physicians that practice in the region. But that point you make is absolutely correct. I am not sure this model could work in a community that didn’t have 200,000 people in it and three good health systems [like Green Bay], and that is something that we are going to have to explore later. Wolliscoft, Ann Harbor: And, unfortunately, a lot of those areas that I think that were underserved on the map areas that don’t have communities like that, so going forward that will be an issue.
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Expanding the Health-care Pipeline through Innovation: The MCW model JOHN R. RAYMOND, Sr., MD, and (by invitation) CHERYL A. MAURANA, PhD, and JOSEPH E. KERSCHNER, MD MILWAUKEE, WISCONSIN
ABSTRACT In 2016, the Association of American Medical Colleges projected a physician shortage in the United States of approximately 90,000; in the same year, the Wisconsin Hospital Association projected a shortage of 2,000 physicians in Wisconsin. The Medical College of Wisconsin has begun to address these shortages in three ways: 1) creation of immersive regional medical school campuses in Green Bay and Central Wisconsin, in p artnership with rural serving health systems; 2) creation of rural-based psychiatry and family medicine residency programs in Green Bay and central Wisconsin; and 3) expansion of the scope of practice of pharmacists through creation of a new School of Pharmacy in collaboration with the Medical College of Wisconsin School of Medicine. This article will discuss those approaches, history and progress to date, principles used, and future plans to address the impending physician shortages.
Introduction In late 2011, the Wisconsin Hospital Association published a workforce analysis that predicted a shortage of about 2,000 physicians by 2030 (1). This report showed concordance with the 2011 Association of American Medical Colleges (AAMC) workforce analysis that predicted a similar shortage in Wisconsin by 2025 (2). In early 2012, the joint Education Committee of the Wisconsin Senate asked the state’s two medical schools, the University of Wisconsin (UW) School of Medicine and Public Health, and The Medical College of Wisconsin (MCW), to find ways to expand the medical student pipeline by approximately 100 students per year. They were particularly concerned about a perceived primary care physician shortage, and also about the maldistribution of physicians within Wisconsin. The maldistribution was most apparent
Correspondence and reprint requests: John R. Raymond, Sr., MD, 8701 Watertown Plank Road, Milwaukee, Wisconsin 53226, Tel: 414-955-8225, Fax: 414-955-6560, E-mail: [email protected]. Potential Conflicts of Interest: None disclosed.
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in the northern regions of Wisconsin. The committee’s request was challenging in that the two medical schools were matriculating nearly 400 allopathic medical students per year. In other words, one might argue that we already were doing our part. Indeed, this sentiment was expressed by some of our faculty members, who observed that MCW (established in 1893) already was one of the largest private allopathic medical schools in the United States, with more than 200 matriculated students per class. The leadership team of MCW responded to the challenge by visiting most of the larger health systems in Wisconsin in late 2011 and 2012. During those visits, we verified that many of the rural-serving health systems in Wisconsin were experiencing difficulties in recruiting and retaining both primary care and specialty physicians, and that they were enthusiastic about the prospects of addressing those challenges by expanding the pipeline of Wisconsin medical students. We also quickly realized that the rural-serving health systems were highly capable and mission driven, delivering high-quality, sophisticated, and highly accessible health care. We discovered that those health systems had a strong base of competent physicians, many of whom had never been asked to teach medical students. Similarly, we visited about two dozen educational institutions to assess their willingness, competency, and capacity to partner with MCW for medical student and interprofessional healthcare education. We found many willing and capable partners who saw the benefit of collaborating with a well-established medical school.
Responding to the workforce needs of Wisconsin — regional medical school campuses In January 2012, the MCW Board of Trustees authorized administration to assess the feasibility of expanding the student body on our Milwaukee campus, and to investigate up to eight regions of the state as possible campus locations. We had a series of internal discussions with small groups of faculty and staff, and quickly concluded that we had the space and teaching capacity to expand our Milwaukee campus by approximately 25 to 50 students. However, we did not believe that expanding our Milwaukee campus would solve the problem of physician maldistribution. Thus, we pursued the option of regional medical school campuses (3). In assessing the eight possible locations, we considered a number of factors, including 1) presence of capable health system partners and educational institutions that were willing to work with us and to share clinicians and teachers with us, and which had
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a clear commitment to underserved regions of our state; 2) presence in the communities of key teaching and learning resources that could be shared with us, including anatomy laboratories, simulation centers, technologically advanced classrooms; 3) enthusiasm of the business, community and government leaders; 4) presence and participation of our alumni; 5) philanthropic potential; 6) high-quality cultural amenities and K-12 education; and 7) willingness among competing health-care institutions to work together with each other and with MCW. Further, we asked each of the health-care entities to contribute $1 million to the start-up costs of the regional campuses, and to work with us to develop “destination residencies” in their region of the state. After an accelerated period of assessment, the MCW Board approved central Wisconsin (Wausau, Wisconsin Rapids, Marshfield, and Stevens Point) and Green Bay as the preferred locations. Further, the MCW Board requested that the campuses matriculate students no later than 2016, and that MCW create at least 25 new residency positions in those regions so that the regional campus graduates would be able to continue training in the communities in which we hoped they would begin their medical careers. We matriculated our first class of 25 students at MCW–Green Bay in 2015, and a second class of 30 in 2016. We matriculated our first class of 26 students at MCW–Central Wisconsin in 2016. In this article, we describe three strategies to address the physician shortage in Wisconsin: the creation and early experiences with regional medical school campuses; the creation of rural-based psychiatry and family medicine residency programs in northeastern and central Wisconsin; and expansion of the scope of practice of pharmacists through creation of a new School of Pharmacy in collaboration with the MCW School of Medicine. Principles of the Regional Medical School Campus Model Community Immersion. We posited that complete immersion in the community would facilitate interactions with mentors and role models, and that the students and their families would be more likely to “grow roots” in those communities. We knew from the Wisconsin Hospital Association study that individuals who attended medical school or who obtained residency training in Wisconsin had 38% and 47% likelihoods of practicing in Wisconsin, whereas individuals who both attended medical school and obtained residency training in Wisconsin were 70% likely to practice in Wisconsin (1). We hoped that the immersive model would yield similar results for the specific communities in which our regional campuses would be located.
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Competing Health Systems Must Work Together. Although central Wisconsin and Green Bay have multiple sophisticated health systems that provide high-quality health care, none of the individual systems have the capacity to accommodate 25 to 30 new medical students per class in each location in terms of patient volumes or variety of experiences. This was especially apparent for pediatrics, obstetrics and gynecology, and certain surgical subspecialties. On the other hand, two or three health systems working together in each community could accommodate both the volume of learners and patients and the variety of patients necessary to provide support for core rotations for each of the regional medical school campuses. Four Green Bay and three central Wisconsin health systems participated in multiple planning sessions and agreed to provide members for our Community Advisory Boards. Ultimately, three systems in Green Bay (Bellin, Hospital Sisters Health System/Prevea Health, and the Huempfner VA) and two in central Wisconsin (Ascension Wisconsin and Aspirus) agreed to work with us and each other to provide clinical rotations and teachers for our regional campuses. The private health systems (two in each community) each agreed to commit $1 million to the start-up of the regional campuses. This amount was chosen to be sufficient to show a significant (and equivalent) commitment to the partnership, but not large enough to have a material impact on their operating margins. We also found that maintenance of good working relationships among the competing health-care systems requires significant face time, trust building, candor, and a true sense of c ommon purpose. Minimization of Student Debt Burden. We recognized that the staggering life-time debt burden, which now averages $190,000 for all US medical school graduates (4), would limit medical student career options, making them less likely to pursue primary care specialties, community-based practice, practice in underserved areas, or faculty appointments. We used two approaches to minimize the financial cost to students. The first was to abate the infrastructure costs of the startup, ramp-up, and operational phases of the campuses (described in the next section). The second strategy was to offer an accelerated 3-year curriculum, which could reduce debt burden by saving the students 1 year of tuition, and giving them the opportunity for 1 more year of working career. We calculated the net present value (5) of the shortened curriculum to be nearly $1 million dollars, assuming an annual tuition of approximately $52,000, a starting salary of $150,000, a 35-year career, and 4.5% inflation.
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Our regional campus curriculum provides for 135 weeks of formal instruction over a 3-year period. We achieved this by matriculating students in the summer of the first year, eliminating the long break between the first and second year of medical school, and truncating holiday breaks. We knew that the 3-year curriculum could be a viable option based on a literature review of experiences with accelerated curricula in US and Canadian medical schools. Our review showed that graduates of 3-year medical school programs and those of the traditional 4-year programs perform substantially the same at every career stage. On the other hand, our literature review also revealed that 3-year medical school curricula were arduous for both faculty and students (6). Therefore, our admissions process also needed to be adjusted to matriculate students who would be capable of excelling within the advanced pace of the curriculum. Parsimonious use of Resources. To minimize the start-up, rampup, and operational costs to the community, our institution and the students, we pledged to reduce the cost of infrastructure. Inasmuch as we could share critical services and support such as our library, financial aid, tutoring, and other student services with our Milwaukee campus, we built only teleconferencing and hotel space for those functions. Moreover, we shared anatomy laboratories, simulation centers, and auditoria with our local host institutions. Using those approaches, we were able to reduce the total teaching and office space needs to approximately 14,000 ft2 for each of our campuses. The spaces were secured through a combination of leases and condominium purchases at the host institutions. The dedicated spaces in each location were built out to our specifications at Aspirus Wausau Hospital in central Wisconsin, and at the Gehl-Mulva Science Center at St. Norbert College in DePere, Wisconsin (adjacent to Green Bay). Simulation centers were built out and shared with North Central Technical College in Wausau and at the Bellin College of Nursing and Radiological Sciences in Green Bay. We also created locally based faculties through a combination of strategic full-time hires, and purchasing faculty time/service from local universities (rather than individual faculty members). We contracted with the local universities so that the administrative and academic leaderships would be committed to the medical school. This worked well, and the universities pledged to use a small cadre of dedicated basic science teachers (rather than a larger group of part-time f aculty) so that we could grant the teachers meaningful secondary faculty appointments, they could build relationships with MCW’s broader faculty and with our regional campus students, and they could provide consistent teaching for our medical students.
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We reimbursed local universities such as St. Norbert College, UW Green Bay, UW Stevens Point, and UW Marathon County for time and effort of their science faculty in our pre-clinical teaching. We found a very strong group of doctoral basic science teachers at the local universities who were exceptional pedagogues. Many of them had received degrees or post-doctoral training at MCW. Their home universities benefited by having connections to the medical school campuses, and by generating salary offset for the contracted faculty. The faculty from the partner institutions benefited from making connections to the MCW faculty, expanding their teaching to professional students, and gaining access to the research enterprise at MCW. We also were successful in minimizing other start-up and ramp-up costs. Start-up costs included construction, renovation, curriculum development, and faculty and staff salaries before matriculating students. Ramp-up costs included all operating and capital expenses incurred before we had a complete tuition revenue stream from three full classes at each regional campus, which will be achieved in July 2018. Our initial pro forma suggested that the total start-up and ramp-up costs would be approximately $32 million, and that we would be able to cover operating costs with tuition revenues and philanthropy by 2018. Actual expenditures were tracking well with the pro forma through submission of this article. We have been able to offset most of the expenses associated with the regional campuses through an appropriation from the Wisconsin Building Commission ($7.4 million), through a grant from the Advancing a Healthier Wisconsin Endowment ($4.3 million), and philanthropy ($13 million to date). Our parsimonious model compares favorably to start-ups- costs of new medical schools that exceed $100 million to $125 million. Community Advisory Boards. Early in the process of creating the regional campuses, we created community advisory boards to foster a sense of ownership in the communities in which we would immerse our students. The boards also serve as ambassadors to the community and advocates for the regional campuses and students, and as advisors who could bring local wisdom to our curriculum, fundraising, and admissions processes. The boards are composed of approximately 20 members representing academic, health care, business, philanthropic, and governmental agencies. They meet regularly to communicate progress, to make suggestions about policies, and to help to define and achieve common goals. These boards also assisted us in identifying local leaders and interested citizens who could serve as local i nterviewers of prospective medical students, and as donors.
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Community-Informed Admissions Process. Our admissions process is designed to seek community input about the character of applicants and about their “fit” for the community. All potential regional campus students are evaluated by the main admissions committee for competitiveness as compared against the entire pool of applicants and against our recently matriculated students. Applicants are deemed competitive for admission to MCW based on pre-matriculation scholastic achievement, MCAT scores, personal statements, and reference letters. Then, applicants are granted interviews with a subcommittee of our admission committee comprised of local c ommunity volunteers, alumni, educators, and laypersons. That subcommittee then makes recommendations for admission or wait-listing of the interviewees. Members of the regional admissions subcommittee frequently mentioned desirable attributes such as caring, compassion, and collaborative spirit (7,8) as key factors in their assessments of potential students, as well as the commitment of the applicants to pursue medical practice in underserved rural communities. We believe that this process helps to identify students most likely to stay in the region after graduation from medical school. The process also fosters a sense of commitment and ownership from the communities, while also ensuring that our high admission standards are maintained. Enriched Curriculum. The pre-clinical curriculum was modified so that anatomy and physical diagnosis courses were taught in the first few months of the first year. The latter was done so that students could begin longitudinal half-day clinics early in their first year. The vast majority of the pre-clinical curriculum was streamed synchronously from Milwaukee, with lectures delivered by interactive video streaming. Lectures also were archived for asynchronous viewing. This was done so that we could establish substantial equivalency of the traditional 4-year curriculum in Milwaukee, and the 3-year curriculum at the regional campuses for Liaison Commission on Medical Education accreditation. Lectures at the regional campuses were enhanced by the presence of local faculty in the regional campus classrooms, and by small group discussions facilitated by basic scientists and clinical faculty in a manner identical to that used in Milwaukee. The 3-year curriculum was enriched by incorporation of aspects of public and community, prevention and wellness, professionalism (9), interprofessionalism (10,11), and the Institute for Health I mprovement triple aim (12,13). This was much easier to accomplish than it would have been for our traditional 4-year curriculum because the faculty were building a new curriculum rather than trying to squeeze more content into a firmly established curriculum. We also provided early
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clinical experiences for students who started longitudinal clinics within the first few months of their education. The purpose of early clinical exposure (14) is 2-fold: to provide clinical context for the s tudents about the pre-clinical content of the curriculum, and to help our community physician preceptors and their staffs to become comfortable with medical students in their patient care settings. Preferential Weighting for Students With Wisconsin Ties. Because our goal was to address the physician shortage and maldistribution in Wisconsin, we chose to give preferential consideration for offering interviews to students with Wisconsin ties. The rationale was that students from Wisconsin would be more likely than those from other states to choose a Wisconsin site to pursue their medical practices. Indeed, the 2011 Wisconsin Hospital Association study (1) showed that students were 56% likely to practice in Wisconsin if they were originally from Wisconsin and completed medical school in Wisconsin. If Wisconsin students completed both medical school and residency in Wisconsin, their likelihood of practicing in Wisconsin rose to 86%. Despite the logic of granting preferential consideration to Wisconsin residents, initially some of our faculty members were skeptical because MCW is a national medical school. Historically, we have matriculated 50% to 60% non-Wisconsin residents at our Milwaukee campus. Nevertheless, we were able to matriculate 85% Wisconsin residents in our first two Green Bay classes and first central Wisconsin class without deterioration of our mean matriculated MCAT scores and grade point averages. It is too early to determine whether our Wisconsin-resident preferential policy at our regional campuses will have a material impact on retention in Wisconsin. Robust Student Support and Faculty Development. To provide student experience at the regional campuses equivalent to that in Milwaukee, we used a variety of methods to connect our students from all three campuses through student affinity groups, shared community service activities, extracurricular activities, curricular interactions, and student government representation. Our local health system partners insisted on strong faculty support mechanisms to ensure quality and value added for faculty, and to mitigate competition between the systems. We focused considerable effort on faculty development at the regional campuses so that the entire faculty would feel equally valued by the organization. This was accomplished through committee and faculty council representation, shared community-engaged research projects and grants, team teaching, and other methods. Importantly, MCW created an Office of Educational Improvement, which provides support for all of our faculty
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in distance learning and digital teaching methods; faculty travel and professional development awards; weekly educator pearls (peer tips); learning resource and education technology support; and recognition for teaching excellence. Challenges to Overcome. In order for our regional medical school campus model to be successful we needed to overcome faculty skepticism about the 3-year curriculum; concerns about qualifications of community faculty; and doubts about capabilities of community health systems and physicians to provide outstanding teaching and learning opportunities for our students. Our faculty also needed to acquire new skills in team teaching and distance learning modalities. We needed to develop a financial model that could break even on tuition revenue and philanthropy. Five years after the MCW Board approved creation of regional campuses, and nearly 2 years into the inaugural class of students at MCW-Green Bay, it seems that those challenges have been addressed reasonably well, although continuing vigilance and assessment will be necessary. At the time of submission of this work, our students had not yet completed United States Medical Licensing Examination Step 1 testing. However, our students at MCW-Green Bay and MCW–Central Wisconsin have performed as well on in-house examinations as our students in the traditional 4-year curriculum in Milwaukee. Ultimately, the success of this program will be judged on United States Medical Licensing Examination Step 1 examination scores, competitiveness for residencies, and the percentage of graduates who practice ultimately in underserved rural communities. With regard to competitiveness for residency placements, we are working hard to prevent stigmatization of our regional campus students or the 3-year curriculum. We also are developing new rural residency programs in family medicine and psychiatry (next section) to provide the regional campus graduates with destination residencies based in the communities in which we hope they will practice medicine.
Responding to the workforce needs of Wisconsin — rural immersed family medicine and psychiatry residencies We knew from national data (2) and from the 2011 Wisconsin Hospital Association study (1) that physicians are more likely to practice in the state from which they graduated from medical school if they also performed residency training in the same state. Therefore, we sought
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to create new residency programs in northeast and central Wisconsin so that our regional medical school graduates had local graduate medical education programs that could serve as local training destination. We believed that such local residency options would enhance the likelihood that the graduates would choose to practice in the underserved regions of Wisconsin. We also knew from our interviews with health-care leaders across the state of Wisconsin that there was a desire to create residency programs in northeastern and central Wisconsin, but that most of the health systems were not comfortable with the complexities of accrediting, financing, and operating residencies. The health systems expressed keen interest in creating new residency programs in Family Medicine, Psychiatry and Behavioral Health, and General Surgery, the three areas of the most critical workforce shortages in rural Wisconsin. With encouragement from the Wisconsin Hospital Association and Wisconsin Medical Society, MCW was successful in creating two new accredited Psychiatry residencies using a distributed model with multiple partners in northeastern and central Wisconsin, and a new Family Medicine residency in Menomonee Falls, Wisconsin. Those residency programs have received initial accreditation from the Accreditation Council for Graduate Medical Education. Our efforts were facilitated by technical assistance and/or grant support from the Wisconsin Rural Physicians Residency Assistance Program, which was created by the state legislature in 2009 through Act 190 of the state budget (15). Other efforts are underway to create new two Family Medicine residencies in Eau Claire (Mayo Clinic; and a collaborative of Hospital Sisters Health System/Prevea Health, the UW School of Medicine and Public Health, and MCW), and Family Medicine residencies in Wausau (Ascension Wisconsin and MCW) and Green Bay (Hospital Sisters Health System/Prevea Health and MCW). MCW recently received approval for a rural General Surgery residency track in Wausua in partnership with Aspirus Health. This was facilitated by a grant from the Wisconsin Rural Physicians Residency Assistance Program (15). We believe that creation of these rural residency programs will be essential to the success of our regional medical school campuses in terms of providing opportunities for the graduates to receive specialty training and to establish practices in the region. Indeed, the MCW Board of Trustees recognized the importance of new residency programs by charging MCW’s administration with creating 25 new rural residency positions when they approved creation of the regional medical school campuses in 2012. Moreover, interaction with residents is a key component of an enriched clinical learning environment for
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medical students, as recommended by the Liaison Committee for Medical Education (16). There were three major hurdles to overcome in creating these new residency programs. The first hurdle was funding. Many of our potential hospital partners already had very low resident “caps” for direct funding by the Centers for Medicare and Medicaid Services under 42 Code of Federal Regulations 413.79 (17). The low caps required that the health systems would be responsible for bearing the full cost of the residency program. We mitigated this concern by encouraging partnerships between competing health systems to spread out the costs. This approach also allowed the health systems with opportunities to base rotations at sites with higher caps, or to establish new caps at sites without previously established caps. In addition, MCW contributed start-up funds so that we could show a true commitment to addressing the workforce needs of the health systems. We also worked diligently with the health systems and our local congressional delegation to introduce legislation to remove the somewhat arbitrary caps established for the rural serving health systems. This approach is consistent with the recent AAMC recommendation to increase residencies by approximately 3,000 slots (18), which supported the Resident Physician Shortage Reduction Act of 2015. Although those legislative efforts have not succeeded to date, they established ties between and a common purpose among the partners. The second hurdle was finding ways to encourage educational collaboration among health systems that were clinical competitors. This required significant trust-building, face-time, and creating a sense of common purpose. In terms of building trust and partnership, it helped that the same concepts already appeared to be working well for undergraduate medical education at our regional campuses. The third hurdle was the health systems’ lack of technical expertise in creating and operating graduate medical education programs. This was addressed through technical assistance from MCW and the Wisconsin Rural Physicians Residency Assistance Program (15), and a grant from the Advancing a Healthier Wisconsin Endowment.
Responding to the workforce needs of Wisconsin — creation of a new MCW School of Pharmacy During our deliberations about addressing the physician shortage and maldistribution in Wisconsin, we also considered the possibility of
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expanding the pipeline of non-physician providers. This solution is not new, as there are shortages of all types of health-care providers. The World Health Organization estimated that the worldwide shortage of health-care providers would grow from 7.2 million to 12.9 million by 2035 (19). In response, many have called for an increase in physician assistants, advanced practice nurses or nurse practitioners, and other types of health-care providers to fill in for the shortage of primary care physicians (20). Because of a large number of existing or planned nursing and physician assistant programs in Wisconsin, we considered the possibility of creating a pharmacy school as a complement to our other workforce initiatives. The MCW Board of Trustees approved creation of a Pharmacy School in May 2015. They also encouraged administration to create opportunities for the pharmacy students to learn side-by-side with medical students and to create a new kind of pharmacy curriculum to educate the pharmacist of the future. We were intrigued by permissive pharmacy practice legislation in Wisconsin, which allows that “a pharmacist may perform any patient care service delegated to the pharmacist by a physician…” (21). Our faculty viewed this legislation as an opportunity for the medical and pharmacy professions to collaborate to define the scope of competencies required both to delegate and be delegated to perform tasks. As an initial step, our pharmacy school has decided to incorporate physical examination and diagnosis into their curriculum. This will occur as a key interprofessional component of the curriculum, with pharmacy and medical students learning physical examination skills in the same classrooms, simulation, and clinical settings. Our purpose is not to create a class of health-care professionals who will compete with physician assistants and advanced practice nurses. Rather, we envision that our pharmacy school graduates will be able to perform triage in retail pharmacy settings, or to provide chronic disease management in retail pharmacy or clinic settings. Inarguably, pharmacists are experts in medication management, and this aspect of their training will be valuable in chronic disease management inasmuch as 80% of chronic disease management involves medications (22). Pharmacists also have long-recognized expertise in medication reconciliation, adherence, and side-effect profiling. Recently, pharmacists have begun to render point-of-care preventive services such as vaccinations; and Clinical Laboratory Improvement Amendments waived tests such as hemoglobin A1C and cholesterol. Finally, because there are more than 50,000 pharmacies in the United States, the pharmacy could be an ideal setting for preventive
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services such as diabetic foot examinations and retinal screens via tele-ophthalmology. These latter services will require that the pharmacist is capable of and comfortable with the laying of hands and stethoscopes on patients. Although we are optimistic that our pharmacy graduates will help to alleviate some aspects of the projected physician shortage through expanded scope of practice and competencies, our goal of educating the pharmacist of the future remains to be proven. We hope to matriculate our first pharmacy students into MCW in late 2017, pending approval of pre-candidate status from the American College of Pharmacy Education.
Summary and conclusions MCW has used a three-part strategy to address the physician shortage and maldistribution in Wisconsin: 1) creation of immersive regional medical school campuses in Green Bay and central Wisconsin, in partnership with rural serving health systems; 2) creation of rural-based psychiatry and family medicine residency programs in Green Bay and central Wisconsin; and 3) expansion of the scope of practice of pharmacists through creation of a new School of Pharmacy in collaboration with the MCW School of Medicine. We summarized our experiences in creating regional campuses in central Wisconsin and Green Bay, and progress of the first classes of students at those campuses. We also described initial steps toward creating new Family Medicine and Psychiatry residencies in underserved, rural Wisconsin communities. Finally, we discussed an aspirational initiative to create a School of Pharmacy that will expand the scope of practice and competencies for pharmacists. Recent studies have confirmed that the United States still suffers from a significant projected shortage of physicians (23,24). Therefore, we remain committed to addressing the physician workforce shortage and maldistribution through multiple innovative approaches.
ACKNOWLEDGMENTS Parts of this work were supported by grants to the authors from the Advancing a Healthier Wisconsin Endowment and the Kern Family Foundation. The authors thank the faculty and staff of the Medical College of Wisconsin, and our colleagues and collaborators in the initiatives described herein.
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REFERENCES 1. Wisconsin Hospital Association. 100 New Physicians a Year: An Imperative for Wisconsin. Available at: http://www.wha.org/Data/Sites/1/pubarchive/reports/2011 physicianreport.pdf. Accessed May 30, 2016. 2. Association of American Medical Colleges Center for Workforce Studies. 2011 State Physician Workforce Data Book. Available at: https://www.aamc.org/download/263512/data/statedata2011.pdf. Accessed May 30, 2016. 3. Chiefetz, CE, McOwen, KS, Gagne, P, et al. Regional medical campuses: a new classification system. Acad Med 2014;89:1140–3. 4. Association of American Medical Colleges. The Complexities of Physician Supply and Demand: Projections from 2013-2025. Available at: https://www.aamc.org/ download/426248/data/thecomplexitiesofphysiciansupplyanddemandprojectionsfrom2013to2.pdf. Accessed May 30, 2016. 5. Available at: http://www.businessdictionary.com/definition/net-present-value-NPV. html. Accessed October 20, 2016. 6. Raymond, JR Sr, Kerschner JK, Hueston WJ, et al. The merits and challenges of three-year medical school curricula: time for an evidence-based discussion. Acad Med 2015;90:1318–23. 7. Lown BA, McIntosh S, Gaines ME, et al. Integrating compassionate, collaborative care (the “Triple C”) into health professional education to advance the triple aim of health care. Acad Med 2016;91:310–6. 8. Balmer DF, Hirsch DA, Monie D, et al. Caring to care: applying Noddings’ philosophy to medical education. Acad Med 2016;91:1618–21. 9. Irby DM, Hamstra SJ. Three professionalism frameworks for medical education. Acad Med 2016;91:1606–11. 10. Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: National Academy Press; 2003. 11. World Health Organization. Working Together for Health: The World Health Report 2006. Geneva, Switzerland: World Health Organization; 2006. 12. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health and cost. Health Affairs 2008;27:759–69. 13. Institute for Healthcare Improvement. IHI triple aim initiative. Available at: http:// www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx. Accessed May 30, 2016. 14. Ogrinc G, Mutha S, Irby DM. Evidence for longitudinal ambulatory care rotations: a review of the literature. Acad Med 2001;77:688–93. 15. Available at: https://docs.legis.wisconsin.gov/2009/related/acts/190.pdf. Accessed May 30, 2016. 16. Liaison Committee on Medical Education. Functions and structure of a medical school: Standards for accreditation of medical education programs leading to the MD degree. Standard 3. March 2016. Available at: http://lcme.org/publications. Accessed September 2, 2016. 17. 42 CFR 413.79 - Direct GME payments: Determination of the weighted number of FTE residents. Available at: https://www.law.cornell.edu/cfr/text/42/413.79. Accessed September 2, 2016. 18. Association of American Medical Colleges. GME Funding: how to fix the doctor shortage. AAMC News. September 27, 2016. Available at: https://news.aamc.org/for-themedia/article/gme-funding-doctor-shortage. Accessed September 28, 2016. 19. Global Health Workforce Alliance and World Health Organization. A universal truth: No Health Without a Workforce. Third Global Forum on Human Resources for Health
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Report. Geneva: World Health Organization; 2014. Available at: http://www.who.int/ workforcealliance/knowledge/resources/hrhreport2013/en/#.WKySKLL_TN4.mailto. Accessed September 2, 2016. 20. Bodenheimer TS, Smith MD. Primary care: Proposed solutions to the physician shortage without training more physicians. Health Affairs 2013;32:1881–6. 21. Wisconsin Statutes, Chapter 450.033. Available at: https://docs.legis.wisconsin.gov/ statutes/statutes/450/033. Accessed May 30, 2016. 22. McInnis T, Webb E, Strand L. The Patient-centered medical home: Integrating comprehensive medication management to optimize patient outcomes, Patient-Centered Primary Care Collaborative, June 2012. Available at: https://www.pcpcc.org/guide/ patient-health-through-medication-management. Accessed September 2, 2017. 23. Association of American Medical Colleges. New research confirms looming physician shortage. Available at: https://www.aamc.org/newsroom/newsreleases/458074/2016_ workforce_projections_04052016.html. Accessed September 2, 2016. 24. Association of American Medical Colleges Center for Workforce Studies. 2016 State Physician Workforce Data Book. Available at: https://www.aamc.org/download/263512/data/statedata2011.pdf. Accessed November 13, 2016.
DISCUSSION Griner, Weston: One of your slides early on showed the areas of the state that are underrepresented in terms of health professionals not just physicians and so as you have demonstrated the innovations in preparation of medical students and residents, what’s going on with regard to nursing and other health professionals and the extent to which professional learning is taking place. Raymond, Milwaukee: Great question. As a freestanding medical school, it’s a real challenge for us. We have started an anesthesia assistant program and a CRNA program in the last year and we are partnering with the UW system and their PA and nursing programs to provide interprofessional opportunities in the communities, but more needs to be done. That’s part of why we started the pharmacy school. Thank you. Branch, Atlanta: I want to thank you. That is a wonderful vision that you have. My question is that the problem is the maldistribution of the health-care professionals and the unwillingness of people that graduate, go into the fields that are needed like primary care. There have been lots of efforts around the country for a while to put schools in communities to build primary care, medical schools — to build family medicine, residencies in communities to solve these problems. I am sure you have looked at all of the results and outcomes of these. How have the outcomes been? I mean is this a good solution? And do we have some data to show that we are solving this problem? Raymond, Milwaukee: Yes, the data are pretty mixed. I believe this is the largest community immersive model and it’s fully immersed. And of these other models aren’t. So, we are pleased to be doing the experiment and obviously I am a believer. I’m hoping that we will prove that it will work. We don’t know yet. Baum, New York City: I’d like to congratulate you on this initiative which has obviously been successful up to this point and we’ve all heard about bucket lists. And it’s my very strong impression as a Dean of students that the bucket runneth over and that we have now created some 25 or 26 new medical schools in the United States without creating more than a handful new residencies. I think that the original concept, and I hope I am not insulting anybody in the audience who was on that committee, but the original assumption was that we could create these new medical schools and of course
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American medical graduates would displace the international medical graduates and we would have no problem at all. The issue is that the hospitals that got used to having number one from a foreign medical school are not willing to replace those people with number 183 from the Albert Einstein College of Medicine. So we have a real problem, a funnel with lots more medical students being dropped in the top of the funnel and no place for them to go and after that. And I think that every school is experiencing an increase in unmatched students who previously would have matched. And these are now people with $200,000 worth of debt who don’t have a job. Can you comment on your thoughts about what’s going to happen? Raymond, Milwaukee: You’re absolutely right. In Wisconsin, we’ve created 32 residency positions so half of the students that graduate, if they choose to, have places to go in their community for residency training, and we didn’t wait for CMS to help. We put our own money on the table and asked the health system to do the same. They actually see this as a good recruitment tool and they are diverting some of the funds that they would put into recruitment of their physicians and they are trying to invest in these medical students. Again, early in the experiment, we hope it will work. Feldman, Philadelphia: So, we are about 10 years ahead of you and I can tell you a couple of cautions — issues that we ran into. The first is that I found that having 20 or 25 students is not big enough to have a community of scholars and as a result if you get one student or two students who just can’t find their mix in that group you have some very serious problems. The second problem we had is we could not demonstrate comparability. It’s very hard to do because you’ve got people that are in a very different culture and of course the LCME demands that. The third problem we had is that in one of our three schools, the partnering hospital was bought by a for-profit; that was the end of that program. The second decided they wanted to have their own medical school and so they bought a medical school and we were suddenly pushed out. And the last and I think the most important caution is that these students really do not have the exposure to research and to academic clinicians, and as a result our students have done very poorly at getting into the competitive residencies such as orthopedics, dermatology, ophthalmology. Obviously, that might not be the mission of the school, but when students are spending this much money if they decide somewhere along their education program that they want to go into one of these: It is harder to get into these specialties. It’s virtually impossible. Raymond, Milwaukee: You made a lot of great points. What I would say is that technology now enables us to have community with the Milwaukee campus and for the other two, we put in a lot of face time and we have people go back and forth, and there is an expectation that the students will produce scholarship. It probably won’t be bench science but they will be doing database work and clinical trials. So, we hope that we will be able to enrich their research environment. But again we are in the early phases, and you made excellent points. Olds, Grenada: John, I want to applaud the work that you are doing, you know I feel strongly about what you are doing. And particularly you have developed graduate medical education since half the decision of where doctors practice is when they finish their training. Interestingly, doctors do not practice where they go to med school. My comments are really two other ideas: about 40% of the decision is where you come from. I think you will have a much greater yield if you explicitly recruit students from rural Wisconsin. Look carefully at the admission requirements because that is the big yield. Recruiting someone from a rural area is much more likely, no matter what else you do, that they will end up practicing there. The other is the scholarship aspect on what I call mission based scholarships — linking potentially free medical school in return for 5 years of service in those areas. And the military has done this very successfully and
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that is a very successful model: to basically implant practicing physicians in these geographically disbursed areas in the United States. Raymond, Milwaukee: Fantastic points: One of our health system partners put $20 million dollars into a grant to scholarship fund so that if the students stay in the region when they are done with residency training, their loan will turn into a scholarship. Eighty-five percent of the students in these campuses are from Wisconsin and most of them are from within the five-county area around the regional campuses. So your first point is absolutely right. Thanks, Dick. Hochberg, Baltimore: So, when the legislature discussed this and your school stepped up to the plate to do this, what was the discussion about nurse practitioners who are licensed independent professionals and practice primary care and even mental health. And then physician assistants, physician extenders as opposed to implanting more physicians who may not necessarily go into those areas or stay in those areas. And then a second question which came to me during your presentation, and I may have paraphrased or understood it incorrectly: is the second interview when the local institution determines whether the student is “fit for the community” — What does that mean? Raymond, Milwaukee: It’s really not the local institution [that determines community fit] — it’s a community advisory board of 30 individuals that have been trained to interview medical students, and they bring the local perspective; they are business leaders, some of the elected officials, and a very few official representatives of the health-care education institutions. Our main admissions committee has already decided that these students are capable of making it through our medical school, so we are really looking for fit. I’d love to develop a tool kit through which one could actually measure the attributes of the student who would be successful in those environments and that’s actually one of our goals. What was your first question? Hochberg, Baltimore: First part was about nurse practitioner and physician’s assistant in the form of being licensed, independent practitioners. Raymond, Milwaukee: Right, we have a shortage of all primary care providers in the state of Wisconsin and in our discussion with our legislature we admitted that what we would do in the medical domain would only be part of the answer. Thibault, New York City: John, congratulations on a wonderful innovation. I want to make a couple of comments to put it in context. Your schools are part of at least 10 schools in this country now that are developing tracks for a 3-year plan to an MD degree. You’re the only schools that are actually doing it exclusively. With others it’s a subset and part of it a sponsored consortium to try to learn from this experience, both in the selection criteria in the assessment of competency, and in the outcomes. So, we will have more data from this consortium schools that you are participating in. The second comment is that we have just completed six regional conferences on GME innovations and we’ve heard exciting initiatives just as you described, of developing new GME slots funded by states, funded by systems, funded by consortiums to meet specific local and regional needs. So, I applaud you on both part of these national trends and I would say the positive part of this, acknowledging the problems that have been raised by other questioners — appropriate issues to raise, and cautions. But I think that the important positive part of this is that medical schools and GME programs are beginning to be developed and oriented towards this sense of social mission. They are they meeting the needs of the communities they serve and I think that is a very important health trend and I applaud you for being a part of that trend. Raymond, Milwaukee: Thank you. Zeidel, Boston: I have to act as a slight counterpoint to my friend and mentor Dr. Thibault. To what degree does a physician need to understand basic science? To what
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degree or what are we losing, by cutting the curriculum, moving people away from any contact with anyone who has ever done an experiment. While I think it’s very important that we fulfill our social mission the people we train need to have some understanding of science, how it advances, and they need to have that part of being a physician as well. And I am concerned that as we create more and more of these settings, that we are losing that as part of our profession. And I think it’s very important and I think that the patient who comes to see that physician has a certain expectation of that kind of expertise and perspective, which maybe is no longer justified. Raymond, Milwaukee: Well since you and I came from the same career background, I certainly started with the same biases that we all have as physician scientists. A couple of points to make: First of all about our 3-year curriculum; 90% of it is the same as our 4-year curriculum — it’s delivered electronically in real time by the same faculty. The lectures also are available asynchronously for students from all three campuses. There is a faculty member in the room whether the lecture is being delivered from Milwaukee or one of the regional campuses, and those faculty members are trained as basic scientists. I think what I am trying to get across to the students and our faculty is it that there won’t be a lack of scholarship. There may be fewer opportunities to do basic science research but we really didn’t cut any of the pre-clinical curriculum. It’s the same preclinical curriculum in Milwaukee. It’s enriched and enhanced with longitudinal clinical exposures. The real challenge for our students is that they don’t do the five core rotations before they have to choose where to interview for residencies and that’s a logistical challenge that we are still struggling with. But I understand your points entirely. Thank you. Wolliscoft, Ann Harbor: We all know that projections of workforce are highly, highly variable. Some of us remember COGME, “will cath for food,” etc...So that’s an issue. But what too frequently happens, and I have testified to the Michigan legislature, we have areas of physician and other health-care professionals shortages as well. Just like Wisconsin, but when you look at it the solution is always just produce more docs. However, the root cause analysis too frequently is inadequate economic base. Little in the way of cultural enrichment in these communities. No intellectual community, inadequate education for children of physicians and other health-care professionals. And so, it really is not incumbent solely upon medical schools or nursing schools to solve the maldistribution problem. How has the legislature and others really embraced this whole array of issues that have essentially kept physicians from going to these areas previously? Raymond, Milwaukee: Well Jim, you raised some outstanding and critical points. Our legislature is trying to address the issues of economics for the individual in a pretty rigorous way. And they are allowing us and experts from the UW School of Medicine and Public Health to advise them. The legislature is extremely receptive. I did say one of the factors that we would take into consideration in the communities was the enthusiasm of the community. What I have learned is that we have some very capable physicians and that health-care systems are doing great work in the rural communities. So, I am not so sure the quality of the local faculty or health systems is an issue. Almost a third of the students in these regional campuses are sons and daughters of physicians that practice in the region. But that point you make is absolutely correct. I am not sure this model could work in a community that didn’t have 200,000 people in it and three good health systems [like Green Bay], and that is something that we are going to have to explore later. Wolliscoft, Ann Harbor: And, unfortunately, a lot of those areas that I think that were underserved on the map areas that don’t have communities like that, so going forward that will be an issue.
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