Omar Guzman entered the world in 1980 in a delivery room at Kaweah Delta Medical Center, a county hospital in Visalia, in rural San Joaquin Valley. Forty years later, he’s back at the hospital where he was born, working as an emergency medicine physician and serving a Latinx population that is largely low income.
He’s also a teacher, helping shape and train young doctors by mentoring them and sharing his passion for being a healer in a community that badly needs them. “Growing up here in the valley, I was aware of all the health disparities,” Guzman said. “I always wanted to return and give back to the community.”
Transitional Program Office Created to Expand GME in California
Mathematica, a research and policy consultancy, has created a Transitional Program Office with CHCF support to promote the creation of new hospital Graduate Medical Education (GME) programs in underserved communities. “We have identified more than a hundred ‘GME-naive’ hospitals across California that could take on this work,” said the office’s leader, Mathematica Senior Fellow Diane Rittenhouse, MD, MPH. “Our job is to support their efforts by providing resources and knowledge sharing.”
The transitional program office has produced multiple resources to aid this effort and will be releasing a request for proposals for feasibility grants this month. The office hopes to establish a permanent public-private GME Governance Council for California to continue to support establishment of new residency programs over the next decade.
The shortage of doctors and other medical professionals in California is large and growing, particularly for psychiatrists and primary care physicians, and for rural communities like Visalia. By 2028, California will face a shortfall of 2,683 psychiatrists (PDF) and 4,334 primary care clinicians, according to data supplied by Janet Coffman, a health services researcher and professor at the UCSF School of Medicine’s Institute for Health Policy Studies. Her work helped inform the California Future Health Workforce Commission, a blue-ribbon panel supported by CHCF that studied the workforce shortage and last year issued findings and recommendations (PDF). The Commission projected significant misalignments between the supply of and demand for other types of physicians as well.
Call for More Medical Residents in California
One key recommendation was to increase the number of residency programs in California, formally known as graduate medical education (GME) programs, as a way to train and retain more doctors in those communities. Medical residents are physicians who have recently graduated from medical school and are working as salaried trainees in their chosen specialty. Training new residents is labor-intensive and expensive, costing anywhere from $100,000 to $180,000 per year. Most residencies last three or four years and are based at large academic medical centers such as those affiliated with the University of California. The cost of training is largely paid by Medicare, an obligation dating to the 1965 creation of that federal health care program for people over 65. This payment mechanism for GME was not intended to be permanent, experts say.
But federal Medicare funding to train residents at existing teaching institutions has been frozen for years, which makes it difficult for hospitals with established programs to increase the number of residents they train. That restricts the pipeline of future local doctors. Now, a new strategy that emerged from the Commission’s work is being pursued: recruiting hospitals that have never offered GME programs and encouraging them to launch new residency programs using available Medicare dollars.
Under federal rules these so-called “GME-naive” hospitals are eligible to start new residency programs with Medicare subsidies, said Diane Rittenhouse, MD, MPH, a family physician and senior fellow with Mathematica, a research and policy consultancy. Rittenhouse is heading up the two-year transitional GME program office, funded by CHCF, that is leading the effort to increase the number of residents trained in California.
The program office is seeking hospitals that don’t now have residency programs, encouraging them to start one, and providing resources including small “feasibility grants” that enable hospitals to explore their options.
“If hospitals decide that it is feasible to launch a new GME program, they will need to make an investment over the first two or three years while they get accredited and build the program,” Rittenhouse said. They must create libraries, lounges, and “call rooms” — rest areas for residents who work around the clock. They must recruit residency directors and identify members of their medical staff who would make good teachers.
“Once residents begin their training, Medicare will provide the hospital with substantial subsidies,” Rittenhouse said. The hospital has five years to expand and stabilize its program at peak enrollment, and Medicare will continue to pay at that level indefinitely.
Overcoming Resistance to Becoming a Teaching Hospital
When Lori Winston, an emergency medicine physician, was recruited in 2011 to help Kaweah Delta set up its residency program, it was a GME-naive hospital with some staff members who were resistant to it becoming a training institution. “It’s been a huge culture shift,” Winston said. “You’ve got a hospital full of busy doctors that are working clinically. And they don’t always think that taking on learners is that appealing. At first, a lot of people were saying, ‘This is going to slow me down’ or ‘I don’t really want to teach.’ It took a while to find the people that wanted to do it and effect change in a positive way.”
The program, now in its seventh year, has graduated more than 200 residents and enrolls 47 new residents each year, Winston said. Financially, it has worked out far better than she anticipated. She initially projected that the hospital would take a $10 million loss over 10 years, but now thinks the hospital will end up $5 million ahead.
Before the residents arrived, “the medical staff at Kaweah Delta was aging — the average age was 56 or 57 years old,” Winston said. The residents have brought to the hospital youthful energy and ideas, as well as greater racial and cultural diversity, she said. Just as important, almost half of the residents have stayed in the area after their training, easing the chronic shortage of physicians. The hospital has been especially successful with the two priority specialties, retaining as local practitioners 9 of 25 family medicine residents and three of six psychiatry residents, Winston said.
Rural communities are not the only ones lacking enough doctors and other vital health services. South Los Angeles, a low-income area of more than a million people in the nation’s most populous county, is largely Black and Latinx — and severely underserved by health care service providers.
“You drive around South LA, you don’t see doctors, you don’t see dentists, you don’t see pharmacies, and you certainly don’t see psychiatrists and psychologists,” said David Carlisle, MD, president and chief executive officer of Charles R. Drew University of Medicine and Sciences in the Willowbrook neighborhood of Los Angeles. “It’s not just a medical desert, it’s a medical Saharan desert.”
Overreliance on the Emergency Department
The only emergency department serving the area is at Martin Luther King Jr. Community Hospital. When it opened in 2015, it was designed to handle 30,000 patient visits a year. Instead it now serves more than 100,000, Carlisle said. The high volume is a result of the shortage of physician practices and clinics in the area, said Carlisle’s colleague Deborah Prothrow-Stith, dean of Drew’s college of medicine.
“It’s the wrong kind of care, and it’s a direct reflection of the right kind of care not being accessible and available,” Prothrow-Stith said. One result is that rates of amputation, end-stage renal disease, and dialysis are three times higher than in other communities, she said.
Another indication of the community’s shortfall of health care services came in April when the university opened a walk-up COVID-19 testing site on its campus. About 25,000 people were tested between April and June, and one-third of them said they had no regular place to receive medical care. Of those tested, 12% of Latinx people and 9.4% of people overall were infected, rates significantly higher than the 8% of positive tests nationally, according to the CDC.
The dearth of health professionals in South Los Angeles and the shortage of physicians of color are the key reasons Drew University opened in 1966, and why it is now working to create its own four-year medical school, independent of an existing joint program with UCLA. In its 54-year history, Drew has graduated more than 600 physicians and trained over 2,700 residents through the program with UCLA. The new effort, slated to begin in the fall of 2023 with a class of 60 entering students, will enable the school to increase enrollment from 28 to 88 medical students a year, boosting the pipeline that creates physicians and residents.
Drew’s GME programs abruptly ended in 2007, when the original MLK Jr. Hospital was closed due to performance problems. “For over 12 years, the area was pretty much without physicians-in-training,” said Prothrow-Stith. Three years ago, in collaboration with UCLA’s medical school, she reestablished residency training programs in family medicine and psychiatry, which today have 42 residents. The benefits to the community are substantial, she said.
What makes Drew’s new residency programs unique is not just the demographics of the GME enrollees, it’s the nature of their training, Prothrow-Stith said. “Our psychiatry and our family medicine residents spend the first month together in an experience that’s all about the social determinants of health,” she said. The residents do research, learn about community conditions, and reflect on the ways health and social justice intersect.
Visalia Residents Learning Street Medicine
Omar Guzman is taking a similar approach in his new emergency medicine residency program in Visalia. For three years, he has been leading the Street Medicine program, deploying teams of medical residents and students to provide direct services to people who are experiencing homelessness. The program helps a group with extensive medical and social needs while also connecting the medical residents to the community they’re serving.
This is exactly the kind of impact that Rittenhouse and the transitional office hope to see as more GME programs sprout in communities that have not had them and help to ensure that California has an adequate physician workforce that meets the needs of the entire population.
“What draws people to work in underserved areas is if they have roots there or they train there” and develop a “special connection with a place,” Guzman said. A community-based residency program like Street Medicine “allows residents to remember why they went into medicine in the first place. It rehumanizes the patient for them, and it makes that patient-doctor relationship come to life right in front of them.”