The need for more primary care physicians has received increased attention in recent years, particularly in the context of a managed care environment. The shortage of primary care physicians is not, however, a new problem. Rural populations have suffered from a shortage of primary care physicians for many years, and have felt the chronic shortage longer and more severely than have urban and suburban populations. This has been particularly true for the Northwest states of Washington, Wyoming, Alaska, Montana, and Idaho, which constitute one of the most rural settings in the United States. Encompassing 27% of the nation's landmass, the five states contain only 3.3% of the population (nine million of 268 million people). With historically low physician-to-population ratios, the region lost further ground in its supply of physicians after World War II as the number of generalists declined nationally. This situation worsened in the 1960s and 1970s. The problem was compounded by the fact that all of these states except Washington did not have their own medical schools. Thus, it was difficult to offer state residents the means to undertake medical careers that would encourage them to remain in their home states.
Medical education's historic focus on inpatient care exacerbated the primary care shortage in all settings. This focus did not provide a good portrait of what the practice of primary care entails and did not encourage students to consider primary care as a career. Students from predominantly rural states without medical schools who pursued physician training elsewhere received exposure to urban, hospital-based care, which provided little incentive to return to their rural states as generalists.
The WAMI program, a regional medical education program named after the first four participating states (Washington, Alaska, Montana, and Idaho) was initiated in 1970 at the University of Washington School of Medicine (UWSOM) to increase the number of generalist physicians in the region. As originally designed, the program met dual needs: it offered medical education for states that could not fund their own medical schools, and it encouraged physicians in training to practice in the region. It also moved medical education from the urban hospital into the community setting, and in doing so, provided community-based primary care experiences for medical students.
WWAMI (Wyoming joined the program in 1996) has become an outstanding academic model of a comprehensive regional medical education program devoted to the recruitment and retention of physicians in underserved areas through a multifaceted approach.1 Several early published articles discussed the program's inception and original goals.2–6 Now celebrating its 30th anniversary, the WWAMI program has expanded and evolved over time. Today, more than 3,000 physicians across five states at over 170 active community-based educational sites participate. In this article, we provide a review of the inception of the program and an overview of changes in directions and components that have occurred throughout its history.
In the early 1960s, at the same time that the shortage of primary care physicians was increasing in rural areas, the dean of UWSOM appointed a special subcommittee to consider the direction of medicine in the subsequent 20 years. The Hunter Report, submitted in 1965, visualized an expanded health care system beginning with the primary care physician and proceeding to more specialized health care personnel and facilities.7 The report emphasized the need for flexibility and diversity in training in order to encompass the needs of family physicians. As a result of this report, the dean initiated a number of moves toward primary care that laid the foundation for enhancing ambulatory care services and increasing primary care faculty, initiating a family medicine program, and considering the need for primary care providers regionally as well as locally.
Within the same time frame, the medical school undertook a comprehensive curriculum review. Completed in 1968, the review called for coursework in the first two years of medical school organized by interdisciplinary committees rather than departments. It also called for enhanced self-learning, flexibility, and earlier and increased exposure to patient care and social aspects of medicine. As a result of changes emanating from this review, students were able to plan their own educational programs to a greater degree than had been true in the past. Increased elective flexibility permitted the students to complete considerable work away from the urban-based medical school campus. These changes to the curriculum, in concert with the planned completion of new UWSOM facilities in 1972, made it possible to consider enrolling more students than originally planned. Recommendations from the Hunter Report and curriculum changes also led to plans for a family medicine program.
A core group of faculty and administrators undertook development of the experimental WAMI program in 1970 following informal discussions of the need for more teachers for primary care residents. Community physicians were involved in program development from the beginning. At a regional meeting, an informal discussion took place between members of the medical school and community physicians concerning logistic problems in setting up adequate generalist training within the university system. In the midst of this discussion, a physician from a small rural town in eastern Washington is credited with saying, “Send me the residents and I'll teach them.” This statement initiated a plan to develop a network of peripheral resident training centers in Washington, Alaska, Montana, and Idaho, using practicing physicians as preceptors. Because a source of funds for resident training could not be found at the time, the initial plan of training residents was modified to one for training medical students.
The WAMI program's primary objectives addressed a broad set of regional needs:
- Improve the health of citizens in WAMI states through decentralized medical education.
- Increase the number of publicly supported medical school positions without major capital construction and without the addition of significant numbers of faculty.
- Increase the number of primary care physicians in the WAMI states.
- Address the maldistribution of physicians in the WAMI region.
- Broaden the educational experience of future physicians through the use of clinical resources in communities.
- Improve and expand continuing education programs for physicians and other health care professionals throughout the WAMI region and integrate these programs into an overall plan that includes undergraduate and residency training.
From its inception, the program addressed the use of an educational continuum as a means of building and reinforcing regional practices, starting with the medical school experience, continuing into residency, and then providing continuing medical education throughout clinicians' careers. The program also addressed a severe bias in medical education: the centralization of medical education within the context of the university setting to the exclusion of the communities in which most physicians practice. Although the term was not coined for many years, the WAMI program pioneered the concept of a “medical school without walls.”
For training medical students from participating states, a plan was devised that encompassed training in several regional locations. That plan has changed little since its inception. In the first-year, or university, phase of the WWAMI program, students receive medical training in their states. During the first year, existing faculties and facilities are used at state universities through basic science programs and faculty. Students at WWAMI sites and many students at UWSOM in Seattle also complete clinical preceptorships one half-day each week with community physicians. During the second year, all students attend courses together at the UWSOM in Seattle to complete organ-systems classes that must be taught by both basic and clinical scientists. During the third and fourth years, which are devoted to clinical training, all students have the option of receiving some of their training in community-based sites throughout the WWAMI region. All of the required third-year clerkships are represented at the community clinical units (which are regional sites for third-year clerkships). In addition, a large number of elective clerkships are offered across the five-state region in diverse practice settings.
The program provided an opportunity for Northwest states that lacked medical schools to implement state-specific medical education without the major expenditure involved in building a medical school. The task of bringing stakeholders in participating states to agreement on goals and methods was daunting. Each state contained its own matrix of governmental and organizational components, and the cooperation of all components was essential. From each state, stakeholders included the state legislature, state and local medical associations, hospital associations, higher education boards, and colleges and universities. As a first step, faculty administrators traveled throughout the region and lobbied most of the legislators in the four states. Early on, dialogue and full partnership with each entity were emphasized. The investment and satisfaction of each stakeholder were seen as essential to the partnership. As a result of this early emphasis, partnership has become a centrally important component of the program.
In addition to the UWSOM, the state universities from the four states were invited and agreed to participate—the University of Alaska, Washington State University (WSU), the University of Idaho (UI), and Montana State University (MSU). In 1988, the UI and WSU programs were combined under a single directorship, with students from WSU program also studying at UI. The University of Wyoming joined in 1996 (modifying the acronym to WWAMI). Each university developed a contractual relationship with the UWSOM for the training of medical students.
Because new construction was not necessary and administrative and legislative agreement proceeded relatively smoothly, program implementation was rapid. A three-year unrestricted $1 million grant from the Commonwealth Fund of New York to test the concept of regionalizing medical education was crucial to the successful initiation of the program. The federal Bureau of Health Resources Development provided additional contract support beginning in 1972. Member states commenced contributions through contracts in 1974, and by 1979 the program was self-sustaining.
Methods of selecting students have changed little since the program's inception. Applications are accepted and students admitted to the UWSOM from all participating states. Representatives of each state serve on the admission committee. The program initially brought 50–60 additional medical students into each entering class. Currently, 78 students spend their first year outside Seattle (ten in Alaska, ten in Wyoming, 18 in Idaho, 20 in Montana, and 20 at Washington State University in eastern Washington).
WAMI IN THE 1970S
Development of Academic Units at WAMI Universities
Although existing faculty from the basic sciences were available at participating universities, preparation, supervision, and development of a common curriculum across all sites were necessary to ensure comparable experiences. The concept of “single courses taught at five sites by a single region-wide faculty” guided curriculum planning and implementation. A director was appointed at each participating state university. A region-wide committee, chaired by a faculty member from UWSOM, planned the curriculum, with representatives from each university. New courses were developed at WAMI sites as necessary, and some new faculty were recruited. When existing courses were used, special sessions were held to provide a medical orientation for subject matter, and faculty from the UWSOM made frequent visits.
The university portion of the program was phased in, with nine students going to the University of Alaska in 1971 for a single semester of study. The other three university sites were phased in over the subsequent two years, with students attending for only one semester away from Seattle. In 1974, the program at the University of Alaska expanded to a full academic year, and in 1975, the other sites expanded to a full academic year.
Development of Community Clinical Units
The community phase of the WWAMI program covers the final two years of medical school during which students undertake clinical rotations. Beginning in 1971, clinical units were established in a number of communities to provide community-based clinical experiences and encourage more students to consider practicing in non-urban areas. The establishment of community clinical units was predicated on the knowledge that, over the previous ten years, an increasing number of well-trained specialists and generalists had migrated to moderate-sized towns in the region. These clinicians had considerable teaching experience from their postdoctoral training that was applicable to teaching medical students. The community clinical units were designed as teaching sites where groups of physicians who applied and were accepted as teachers would work in their practices with third- and fourth-year medical students. Thus, the units contracted with individual physicians rather than with hospitals. These physicians received clinical appointments to the faculty.
The opening of the first community clinical units went hand-in-hand with the development of a new Department of Family Medicine at the UWSOM. A family medicine division was established in 1970, and was converted one year later to a department. The department maintained a focus on rural medicine, and as the department developed, there was a strong sense that the teaching of rural medicine could not be accomplished in metropolitan Seattle. The first WAMI rural clerkship units were family medicine units established in 1971 at Grandview and Omak, Washington. This early use of regional locales set the stage for a family medicine program strongly oriented toward community training.
As the WAMI program developed, other academic departments became involved in the clinical portion, and a number of clerkship sites opened in the mid-1970s. The Department of Obstetrics and Gynecology conducted programs in Idaho, Alaska, and Washington; the Department of Pediatrics developed units in Washington, Idaho, and Montana; the Department of Psychiatry and Behavioral Sciences established programs in Alaska and Idaho; and the Department of Medicine initiated programs in Montana, Idaho, and Washington. Within each participating department, community clinical site coordinators were designated to oversee the program and maintain close contact with the departmental student coordinator at the Seattle campus.
The community clinical units came to serve as “hubs,” or centers, from which a number of activities emanated. In addition to serving as sites for training medical students, the sites were used to train residents, who spent periods of six weeks to six months at the sites and who participated fully as members of health-care teams. The community clinical units also served as centers for continuing medical education and the training of other health-care professionals. Faculty made frequent trips to check on clerkship activities, and in the process, provided lectures and clinical consultations for community physicians. For example, between 1977 and 1978, UWSOM faculty made 325 visits to peripheral sites throughout the four states.
Ensuring educational equivalency—that is, ensuring that the learning of students at WWAMI sites is equivalent to that of students remaining in Seattle—was a fundamental and necessary part of the program's design. An enormous amount of effort went into ensuring equivalency from the inception of the program. To achieve this goal, regional faculty members were carefully selected, common learning objectives were established, common performance assessment methods were instituted, and communication between faculty of UWSOM and teaching faculty at WAMI sites was made a priority. Common examinations were instituted for all courses across sites, and faculty, both from the UWSOM and from the participating universities, designed these tests. Annual retreats were held for course and clerkship coordinators to plan teaching activities and to ensure common course offerings. In addition, quarterly meetings were begun for site coordinators from each of the first-year university settings. These meetings brought course faculty from community sites and the university together for student performance review, curricular discussion, and administrative matters. The standard for educational equivalency was determined to be the standard achieved by the entire system rather than invoking Seattle as the “gold standard” against which all other sites were to be judged. This approach to educational equivalency and the associated retreats and regular meetings continue to the present.
The Office of Research in Medical Education, established in the late 1960s and later to become the Department of Medical Education, was assigned the role of providing statistical support for tracking graduates and developing and monitoring test-giving and evaluations to ensure equivalency. Comparisons of performances across all sites began immediately with the inception of the program.8–10 Students' performances have been assessed annually. There has not been a pattern of significant differences between the performances of students from the different campuses and types of clinical sites on national examinations. Although there have been performance differences between sites on common course examinations for some courses, these have not been large and have tended to cancel out over the years.11
Initial discussions leading to the WAMI program focused on regional residency training programs. Although funding circumstances redirected these initial efforts to undergraduate medical education, enhancing regional residency training remained a basic program goal. In the 1970s, the UW Affiliated Family Practice Residency Network started a regional network of family practice residency programs in urban and rural locales. In the same year the network began, Family Medicine Spokane (FMS), a community-based family practice residency program, was established. The first regional affiliated site outside Washington, the Family Practice Residency of Idaho in Boise, opened in 1975. Two years later, the Boise VA Medical Center affiliated with the UWSOM, and a primary care pathway for internists was established in which residents would spend their second year at the Boise VA center.
WAMI IN THE 1980S AND 1990S
Because of the challenges inherent in incorporating medical students into ambulatory care settings in smaller communities, the WAMI founders had anticipated that the average clinical training site would remain active for about five years. They expected that periodic recruitment of new clinical training sites would be required. Contrary to this anticipated turnover, the program's structure remained stable during the early 1980s, as programs within the umbrella WAMI program underwent a period of consolidation and maturation. The satisfaction of community physicians involved in teaching medical students in their practices helped sustain the sites over time, resulting in minimal turnover. As a result, although a few new clinical sites were added, plans carefully made in the 1970s to actively recruit new sites to replace those dropping out were not put into place.
Several administrative changes occurred in the mid- to late 1980s in the first-year programs. In 1985, the Alaska site was moved from Fairbanks to Anchorage. In 1988–89, the UWSOM associate dean for academic affairs was given the title of WAMI director to unify the education of medical students regardless of the states in which students began their education. Shortly thereafter, the first-year directors in Alaska, Montana, and Idaho were given the title of assistant dean, and they reported to the associate dean for academic affairs in Seattle.
In the mid-1980s, a number of school task force reports identified lack of diversity in the entering classes as a major problem. While the balance between men and women entering medical school was reaching the 50–50 balance at that time, there were relatively few matriculants from underrepresented minority backgrounds and few from rural backgrounds. In 1987, the UWSOM moved from a stance of actively recruiting these missing applicants to working at the college and high school levels throughout the region to increase the applicant pool. Called “working the pipeline,” this effort began in earnest in 1989 with funding from The Robert Wood Johnson Foundation for a six-week summer enrichment program for minority students, described below.
Concurrent with this new direction, broader educational and regional focuses were initiated. One such focus was providing medical students earlier introductions to rural medicine. Another was continuing the development of rural and geographically diverse residency programs. A third focus was bolstering community health care infrastructures to increase positive health outcomes for rural inhabitants and to enhance working conditions for rural practitioners. And a fourth focus was providing more services that would reduce professional isolation and enhance retention of rural physicians, such as fostering continuing medical education and making telemedicine resources available.
Although many of these approaches had been visualized—and implemented—from the beginning of the WAMI program, an increased focus on interdependence among the components and the need for a comprehensive approach developed. Increased administrative decentralization supported these efforts, with individual states assuming more responsibility for enhancing health care services and initiating programs in their own states. Some advances in telecommunications facilitated the broadened program offerings. Chart 1 shows the programs, from K-12 through medical school training and residency and into the practice setting, that comprise the current educational continuum of WWAMI.
The following sections describe many of the key programs that developed to address the needs in the various areas of the educational continuum. Although some of the programs do not fall under the contractual WWAMI arrangement with participating states, they nonetheless have resulted from and contribute to the program's regional mission.
Throughout the 1980s and 1990s, programs were developed to encourage rural K-12 and undergraduate students to consider careers in the health sciences. In 1989, The Robert Wood Johnson Foundation funded a six-week enrichment program, the Minority Medical Education Program, for underrepresented minority college students each summer. Students come to the University of Washington campus for science courses, MCAT preparation, health care lectures, mentorship experiences, and information about medical school applications and admission. In 1990, the Medical Scholars Program began outreach work from the University of Idaho and Washington State University with rural K-12 and undergraduate students. In this program, promising high school students from rural schools and from underrepresented minority backgrounds are exposed to health care careers in a week-long “immersion in medicine.” The Ambassadors Program, established in 1993 in eastern Washington, encourages K-12 students and mid-career adults to pursue health careers in rural areas. The program links health care professionals with students interested in health careers. Idaho is currently developing an Ambassadors Program as well. The Rural Observation Experience, begun in 1996, gives students accepted to medical school the opportunity to work with rural physicians.
Adding to these efforts, federal grant funds and matching University of Washington money were used to develop six-week high school enrichment programs, known as U-DOC, throughout the region starting in 1994. Through U-DOC, promising high school students from minority, disadvantaged, or rural backgrounds participate in summer enrichment programs in Anchorage, Alaska; Seattle, Washington; Moscow, Idaho; Bozeman, Montana; and Laramie, Wyoming. The students attend classes designed to maximize their preparation for college through sessions in science and writing and involvement with mentors from medical fields. In 1992, recognizing the special needs of Native Americans and Alaska Natives (14% of the U.S. Native American and Alaska Native populations live in the WWAMI region), the UWSOM was designated a Center of Excellence for Native Americans, based on its success in matriculating these students into medical school. The Native American Center of Excellence recruits Native American students into health care careers, facilitates research in Native American health care issues, and provides faculty development for Native American physicians.
Medical School Programs
The Rural/Underserved Opportunities Program (R/UOP), begun in 1989, offers medical students an elective summer fellowship between their first and second years to work in rural or underserved urban areas within the WWAMI region. The program gives students early exposure to primary care medicine in underserved settings. Each student is matched with a preceptor, and receives a stipend and housing for the four-week fellowship. In the first year of the program, 23 students were placed with rural preceptors. In recent years, about 80–100 students have been placed each summer (a third to half of each medical school class). By 2000, a total of 800 students and over 300 primary preceptors had participated.
Since 1994, third-year Idaho medical students have been able to choose to complete all of their third-year training requirements and selected fourth-year elective opportunities in Idaho. This track program stemmed from student interest and the Idaho legislature's desire to see more students return to Idaho to practice. Besides the third-year required clerkships, approximately 25 electives are available for fourth-year students. In 1997, both Alaska and eastern Washington began track programs as well.
One of the unanticipated developments associated with strong regional training sites that have functioned for 20 to 30 years has been that once-small towns housing these sites have grown, leaving fewer training sites in truly rural areas. This change was a contributing factor in the development of the WWAMI Rural Integrated Training Experience (WRITE), a program initiated in 1996 that trains medical students in towns much smaller than those at the mature clerkship sites. This experimental program, which gives some third-year medical students six months of extended education in rural community practices, provides sustained exposure to rural medicine and a rural lifestyle. Exemplary teaching sites are selected to host students, and community physicians and clinical faculty serve as teachers. Each student completes a substantial portion of the third-year clerkship requirements at a WRITE site. Prior to the WRITE experience, the student completes six weeks of obstetrics—gynecology, eight weeks of inpatient internal medicine, six weeks of surgery, three weeks of pediatrics, and three weeks of psychiatry. For a January-through-June WRITE rotation, students earn credit for six weeks of family medicine, four weeks of ambulatory internal medicine, three weeks of pediatrics, three weeks of psychiatry, and four weeks of an elective. Using activity logs certified by the preceptor and departmental knowledge of the practice location, each department determines whether the experience fulfilled the hospital-based and ambulatory care components of the basic clerkships. The program has been phased in slowly in order to ensure appropriate progress and evaluation. There are currently ten active WRITE sites throughout the WWAMI region.
The UW-affiliated Family Practice Residency Network has expanded since its inception, with the opening of new residency training programs throughout the 1980s and 1990s. Among regional sites, the Idaho State University Family Practice Residency Program, based in Pocatello, opened in 1992, with the mission of training physicians for rural practice in Idaho. Central Washington Family Medicine in Yakima, accredited since 1993, serves an underserved and ethnically diverse population. Family Medicine of Southwest Washington in Vancouver was established in 1995. The first residents were accepted to Montana Family Medicine Residency in Billings in 1996, and Anchorage Family Practice Residency accepted its first residents in 1997. In the Anchorage program, one six-week block in the second year of residency is spent in Bethel, Alaska, at the Yukon-Kuskokwim Delta Regional Hospital, the hub for health care for the Yup'ik Eskimo population. By 1999, there were 16 affiliated family medicine sites throughout the WWAMI region in rural and urban areas. It is anticipated that further affiliations will emerge as a result of Wyoming's entry into the WWAMI program.
Three programs in the Family Practice Residency Network have rural training tracks. Family Medicine Spokane, a 27-resident community-based family practice residency program established in 1972, has a rural training track with sites in Colville and Goldendale, Washington. Started in 1986, the Spokane rural training track was the first rural track in the nation. Of the 17 graduates through 1999, 14 (82%) are practicing in rural areas. Family Practice Residency of Idaho in Boise is a 27-resident program established in 1974 to train health care providers for rural and underserved areas. Its rural training track in Caldwell, Idaho, was initiated in 1995 and has two graduates through 1999, both now in rural practices. Montana Family Practice Residency in Billings has a rural training track in Glasgow, Montana, with one resident per year matched to the track. Four of the track's five graduates as of 1999 joined rural practices in underserved areas and the fifth works with the Indian Health Service.
In addition to rural rotations and tracks through the Family Practice Residency Network, other University of Washington residency programs offer rotations at community clinical units. Since 1973, all residents in the Department of Pediatrics have completed a two-month rotation at Yakima/Toppenish, Washington, Port Angeles, Washington, Pocatello, Idaho, Great Falls, Montana, several sites in Alaska, or other rural sites. In the Department of Medicine, 20 residents complete clinical rotations each year in eastern Washington, Wyoming, Alaska, or Montana. In addition, ten residents in the Seattle/Boise Primary Care Internist Program each year spend their second residency year at the Boise VA Medical Center in Idaho. The Department of Psychiatry and Behavioral Sciences established a separate track in Spokane in 1991. The ten residents in the Spokane track divide their time equally between Seattle and Spokane, with elective opportunities in rural psychiatry in Montana, Wyoming, or Alaska.
Area Health Education Centers. Several programs started in the 1980s focus on enhancing the practices of health care professionals in rural areas. In 1985, the University of Washington initiated sponsorship of the region's federally funded Area Health Education Center (AHEC) program. Five AHEC centers were phased into operation beginning in 1985. A sixth center was added in Wyoming in 1994. In addition, the Rural Alaska AHEC and the AHEC at Washington State University Spokane received funds in the 1990s through the new federal Health Education and Training Center. This program was designed to address health personnel shortages and health systems needs of communities with special needs that could not be met through traditional or existing programs.
AHEC Centers and Offices of Rural Health in individual states serve as personnel clearing houses, link communities with health care professionals seeking new locations, and advise towns on recruitment. For practicing physicians and health care personnel, AHECs arrange continuing medical education courses, maintain learning resource centers, and work with Programs for Healthy Communities to strengthen local health care systems. To encourage careers in underserved areas, the six interdisciplinary centers, in cooperation with the region's health professions training programs, place students in all disciplines in rural and underserved areas for parts of their training. The program office also assists in placement of medical students in the Rural/Underserved Opportunities Program.
WWAMI Research Centers. The WWAMI Rural Health Research Center, established in 1985, is one of five federally funded policy-oriented rural health research centers in the nation. Based in the UWSOM's Department of Family Medicine, the Center performs research on rural and underserved health care issues. The Center has published and distributed 56 working papers based on its research. Over 100 articles have been published in peer-reviewed journals. Topics focus on areas that may enhance knowledge about rural practices, such as rural hospital utilization, access to obstetric care in rural areas, and rural hospital closure.
The WWAMI Center for Health Workforce Studies was established in 1998 with funding from the Bureau of Health Profession's (BHP's) National Center for Health Workforce Information and Analysis. One of four regional centers funded, its goals are: to conduct high-quality and policy-relevant health research in collaboration with the BHP and WWAMI state agencies; to provide expert guidance to local, state, regional, and national policymakers on health work-force issues; to build an accessible knowledge base on work-force methodology, issues, and findings; and to disseminate results to facilitate appropriate state and federal workforce policies. The widely interdisciplinary Center has collaborators from medicine, nursing, dentistry, public health, the allied health professions, pharmacy, and social work. The Center emphasizes research on state workforce issues in underserved rural and urban areas of the WWAMI region.
Programs for Healthy Communities. Programs for Healthy Communities began in 1989 to help rural communities stabilize their health systems through a variety of approaches. The program grew out of the Rural Hospital Project, a research program funded by the Kellogg Foundation in 1983. Programs for Healthy Communities, located in the dean's office of the UWSOM, has ties to the region through long-standing partnerships with WWAMI-affiliated universities and the regional AHECs. The core effort of Programs for Healthy Communities is the Community Health Systems Development program. This program's team, based in the Department of Family Medicine, conducts community assessments, market surveys, management and financial studies, and other analyses to assist local community leaders in developing long-range plans for improvements of health systems. In addition, technical assistance is offered in such areas as governance, planning, marketing, administration, and financial management. The Community Health Systems Development program has applied this community-based approach in over 70 settings in the WWAMI region. Programs for Healthy Communities also serves as home to the WWAMI Rural Telemedicine Network, begun in 1995, which links six rural communities to rural consultants at the University of Washington with two-way interactive compressed video transmissions.
RETURN RATES AND SATISFACTION WITH THE PROGRAM
Large numbers of students and residents have participated in the WWAMI program since its inception. As shown in Table 1, a total of 6,732 medical student clerkships were completed at WWAMI sites between 1970 and 1999. Compared with the average national “return rate” for state medical schools of 41.5%, students who attend UWSOM from Idaho, Montana, and Alaska have high practice return rates to their states, as shown in Table 2. (Wyoming joined the WWAMI program only recently; return rates are not yet available.) When considering the number of UW graduates who have gone on to practice in those states, the percentages are even higher. The WWAMI program, along with other influencing factors, has resulted in a strong commitment among UW graduates to primary care fields. Of the 1999 graduating class, 55% entered primary-care training, indicating a strong likelihood of pursuing a career in primary care.
Among all UWSOM and affiliated residency programs, 2,581 residents completed portions of their training at WWAMI regional sites between 1970 and 1999. A total of 1,465 residents graduated from the UW Affiliated Family Practice Residency Network between 1973 and 1999. According to a 1997 alumni survey, approximately 21% practiced in rural communities of less than 10,000 population and 31% practiced in communities of less than 25,00012 A total of 21% of Network graduates in this same graduate follow-up survey were practicing in designated underserved practices (including urban and rural underserved areas). Seventy-four percent were practicing in Washington, Alaska, Montana, Idaho, or Wyoming. Among the 24 graduates to date from rural training tracks, 20 (83%) were in rural practices.
Satisfaction of Medical Students and Clinical Faculty
In the graduation survey completed annually by medical school graduates for the Association of American Medical Colleges, results are available for UWSOM graduates between 1994 and 1998. In response to the question, “Please comment on what you perceive to be the strengths of your medical school,” UWSOM graduates most frequently cited the WWAMI program. The strength cited second most frequently by UWSOM graduates was the emphasis on and high proportion of graduates in primary care; the strength cited third most frequently was the wide variety of clinical patient populations and variety of hospitals.
In 1995, a one-time survey was mailed to 386 WAMI faculty who had working relationships with the UWSOM to determine their attitudes toward the evolution of the WAMI curriculum and program and satisfaction with their working relationships with the UWSOM. A total of 184 clinicians (approximately 50%) responded. Faculty were asked to rate their satisfaction with their experiences as WAMI participants, using a 1–4 Likert scale (1 = very satisfied, 2 = generally satisfied, 3 = generally dissatisfied, and 4 = very dissatisfied). Ninety-five percent of the respondents were “very” or “generally” satisfied with their experiences. When asked to rate general teaching issues on a four-point scale rating from 1 (agree strongly) to 4 (disagree strongly), 62% responded “agree strongly,” or “agree” to a statement that the overall core course content was well defined; 71% to a statement that they were comfortable with the evaluation system used to grade students; and 87% to a statement that they had the flexibility to add something unique to the course/clerkship/preceptorship.
IMPLICATIONS OF THE WWAMI PROGRAM
In the 1960s, UWSOM undertook two reflective exercises, one directed outward toward the future of medicine and the other directed inward toward the adequacy of the curriculum. These two exercises had far-reaching results. The Hunter Report, the product of the first exercise, foresaw the renewed importance of primary care for the future of medicine. The report of the comprehensive curriculum review called for enhanced self-learning and flexibility, and earlier and increased exposure to patient care and social aspects of medicine. Taken together, these two documents set new directions for the school of medicine. One of the key results of this self-reflection was initiation of the WAMI program. The program addressed regional medical needs but simultaneously addressed the expansion of medical education into the community.
The program has provided opportunities for medical education for large numbers of residents of states without medical schools. The return rates of students to the WWAMI states indicate that the program has been successful. WWAMI students have returned to their home states at rates exceeding the national average for a state school, and most important, have returned often to pursue practice in underserved settings. Apart from what the program may have accomplished for the region, the WWAMI program has been a defining experience for UWSOM. The program has created excellent relations between academic and community physicians, providing them with joint and complementary functions. The result has been a close collegial relationship between academic and community clinicians that transcends the usual “town-gown” dichotomy. The program has permitted the UWSOM to fully develop an ethic of guided innovation—the willingness to try out new ideas and approaches while systematically and continuously testing their efficacy. The WWAMI program provided the school with an early example of the value of self-reflection; in fact, the school is currently in the third year of a comprehensive curriculum review that may once again redefine some of its directions. Earlier than most other medical schools, the WWAMI program set a tradition of focusing on primary care in addition to biomedical research, creating the opportunity to excel as a “bimodal school.”13 The program established a clear emphasis on community-based teaching and moved clinical education out of the hospital long before changes in the health care environment set the stage for all medical schools to make that move.
Why has the program worked? A talented, energetic, and visionary initial group of faculty, both at the medical school and throughout the WAMI states, deserves the credit. By systematically canvassing the states and lobbying for the experiment, the WAMI founders provided firm ground upon which to build a program. The resulting degree of cooperation among participants that has characterized the 30-year history of the program has been maintained across a broad partnership of diverse stakeholders, including state legislatures, state government officials, medical societies, state higher education boards, community physicians, universities, and hospital associations. Strong esprit de corps among faculty, clinicians, administrators, and legislators and a strong focus on participation in and ownership of the program have characterized the WWAMI program from its inception. A talented and dedicated cadre of regional faculty has been the norm. The immediate and sustained attention to educational equivalency was also an important factor.
A concern among many early skeptics was that the clinical experience for medical students at rural WWAMI sites would not be comparable to that at the university-based clinical sites. Such concerns focused on the different type of clinical encounters in rural settings, with more ambulatory than inpatient exposure, and the inability to control the level of teaching when community practitioners are used. To ensure that educational equivalency was the norm, common examinations were instituted, course learning objectives were developed with universal applications, and performance was measured and monitored on an ongoing basis. Frequent contact between faculty, students, and community clinicians at WWAMI sites was also encouraged to assess the level of the learning experience. As a result, faculty visit WWAMI clinical sites on a regularly scheduled basis to evaluate the educational experience, confer with students and clinicians, and offer consultations and continuing medical education for the rural sites. In addition, WWAMI coordinators come to the Seattle campus quarterly for grading meetings, and regular retreats and conferences are held, as means to ensure educational equivalency. Ironically, the early concerns about potentially excessive ambulatory care experience in the rural setting have gone by the wayside with the decline in hospital care and increases in ambulatory care in all settings. Extensive testing performed annually has shown consistently comparable performances between Seattle-based and non-Seattle-based students on common UWSOM exams and National Board examinations.
The WAMI founders saw the value of an educational continuum, starting with medical school, continuing through residency training, and then progressing through the lifetime of the practitioner via continuing medical education. The concept of a continuum evolved further in the 1980s and 1990s. The program's educational continuum now focuses on developing health care resources regionally through maintaining a presence at all levels of education. This includes K-12 and undergraduate recruitment of students for possible rural medical careers, and programs that support rural practitioners and the facilities upon which they depend.
The concept of a continuum has expanded in other ways as well. A career continuum defines the importance of recruiting and training different kinds of practitioners—physicians, physician assistants, and others—to work in rural settings. The MEDEX program to train physician assistants developed simultaneously with the WAMI program and has a strong regional orientation.14 An academic continuum means that all aspects of the school of medicine mission are incorporated into the regional program: education, clinical work, research, and community service. In fact, the bimodal strength of the school has led to strong interest in and focus on research in some of the WWAMI sites, including especially well-regarded research programs at the Boise VA Medical Center, the University of Alaska, and the University of Idaho. A geographic continuum defines the region as ranging across five states and spanning inner city, urban, suburban, and rural environments, without a hierarchy defining one environment as of greater educational or service importance than any other. For example, in the R/UOP program, students can work with preceptors in either rural or inner-city settings, and other programs provide experiences in inner-city medicine as well. Finally, in the newest frontier, a communication continuum defines the extent to which technology has transformed the realm of communication regionally. Where mail, telephones, and periodic visits once provided the primary connections between urban and rural sites, electronic teaching-learning and telecommunications increasingly link the UWSOM campus in Seattle with sites throughout the region. The vast physical frontier that characterizes the WWAMI region is aptly symbolic of the frontier that will serve the region in upcoming years through critical telecommunication links that bring patients, students, residents, and clinicians in rural settings into the urban classroom and exam room, and vice versa. Just as the WAMI program in the 1970s broke down the traditional walls of medical schools and moved medical training out of the tertiary care center and into the regional community, so may information technology permit the WWAMI program and others like it to move even farther. Telecommunication links that will close distances give promise of adding the concept of “virtual WWAMI” to that of the “medical school without walls” that has come to play such an important part in the culture of the University of Washington School of Medicine.
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11. Jan D. Carline, PhD, Department of Medical Education, University of Washington. Personal communication, 2000.
12. 24th Annual Report of the University of Washington School of Medicine Affiliated Family Practice Residency Network. Seattle, WA: UWSOM, 1999.
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© 2001 Association of American Medical Colleges
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