Since 1971, the WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) program at the University of Washington School of Medicine has been working to bolster the rural physician workforce, both by recruiting medical students from these communities and providing them financial support to return to their communities as family physicians. The program also provides specialized education that prepares graduates to practice medicine in non-metropolitan areas of the northwestern U.S.
A recent donation to the UW School of Medicine will help to bolster this program, and fund students who want to practice family medicine in rural and indigenous communities.
Dr. Tim Dellit is the CEO of UW medicine, and Kenya Morales is a second year medical student who is currently taking part in the WWAMI program at the UW School of Medicine. We’ll hear from them about this education model, the shortage of primary care physicians in rural areas, and about what this funding could mean for students who aspire to pursue family care in these areas.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. The University of Washington School of Medicine does not just take place in Washington. Since 1971, it’s also had a program that serves students in and from Wyoming, Alaska, Montana and Idaho. It’s called the WWAMI program, and it’s intended to bolster the rural physician workforce in those states. A recent $25 million donation will help to bolster this program and fund students who want to practice family medicine in rural and Indigenous communities.
Tim Dellit is an infectious disease doctor, the CEO of UW Medicine, and the Dean of the Medical School. Kenya Morales is a second year medical student who’s currently taking part in the WWAMI Program and is in the TRUST Program (Targeted Rural and Underserved Track) at the University of Washington School of Medicine. They both join us now. It’s great to have both of you on Think Out Loud.
Tim Dellit: Well, thank you for having us.
Miller: Doctor Dellit, I mentioned this WWAMI Program stands for Washington, Wyoming, Alaska, Montana, Idaho. How does it work?
Dellit: WWAMI was created over 50 years ago in the early 1970s. The idea was how could we collectively increase the number of physicians going into primary care, [and] increase access to care and the number of physicians serving our rural communities across the vast northwest of the U.S. and Alaska, covering 27% of the land mass. The concept was that if we did this as a community-based education, building those relationships with the students and the communities that they serve, that they would be more likely to return and serve those communities after they trained.
That was really the crux of the creation of the WWAMI Program over 50 years ago. Unfortunately, many of those same needs are still present today, in terms of the lack of access to health care in many of our rural communities across the Pacific Northwest and Alaska.
Miller: I was going to ask you that. So this was identified in 1971 because of the acknowledgement of a shortage of rural doctors. And you’re saying that it hasn’t really gotten better in the intervening time?
Dellit: I would say that we have made progress, in the sense that if you look at our history, over 65% of our students return and practice within the WWAMI region. Yet despite those efforts, we still have a paucity of physicians. If you look across our states, we have the lowest number of physicians per capita of any part of the U.S.
I would say, if you look at the impact of the pandemic when we saw loss of individuals in health care, and then now, particularly as we face some of the impacts of H.R.1 and the Medicaid impacts for our rural communities, this continues to be a significant concern. How do we increase access to care for our rural communities, [and] particularly in the Northwest, our Indigenous communities?
Miller: Why was this seen in 1971 – or even today, to zoom forward to the institutions that you lead – as the responsibility of the University of Washington? I can imagine UW saying, we’ve got our hands full in the Seattle area or let’s even say for the state as a whole, as a statewide institution. But we don’t have the resources to also worry about Wyoming, Montana, Idaho and Alaska.
Dellit: This was really developed as a partnership. WWAMI is founded on partnerships and how we can deliver cost effective medical education. Back in the 1970s, it was recognized [that] it was cost prohibitive for many of these states to have their own medical school. There simply wasn’t enough population or resources to be able to support that. So it was really a creative pilot, if you will, that began as an experiment and then has lasted over 50 years. But it’s all based on partnerships.
So the way this works is that our students spend the first 18 months, essentially their classroom time, with our partner institution. Then their third and fourth year when they do their clinical training, they can rotate anywhere across the five states. So as an example, we have 30 students a year in Alaska. They start at the University of Alaska in Anchorage. We have 40 students at the University of Idaho, 30 at Montana State University, 20 at the University of Wyoming, 60 at Gonzaga University in Eastern Washington and then 100 here in Seattle. So it’s really all about partnerships and how we can collectively provide this education in a cost effective way across this large rural region.
Miller: Kenya Morales is with us, as I mentioned. Am I right that you’re finishing your second year right now?
Kenya Morales: Hi, thank you for having us. I am finishing my first year, so I am a brand new second year student.
Miller: Brand new second year, OK. Did you always know that you wanted to be a doctor?
Morales: I knew at a very young age after many times of interpreting for my parents, who were only Spanish speaking, at free clinics and seeing the need for Spanish speaking providers serving them and others in my community.
In addition, [I was] seeing the need for physicians at these free clinics and at clinics that were able to see patients who were low income and uninsured. I was interpreting for them ever since I was a child into high school. That led me on my path where I am today.
Miller: So you were a kid helping your parents and being an interpreter, going back and forth, English and Spanish in free clinics, and there was a part of you that said, I want to be on the other side. I want to be a doctor at clinics like this?
Morales: Exactly. As I got older, I saw that this was a bigger problem, not just of the lack of Spanish speaking physicians, but the need for just physicians serving in Idaho, and serving rural and underserved communities. So that’s something I later discovered with my experiences.
Miller: What role have you seen that community health workers or rural physicians play in communities?
Morales: Oh my gosh. Well, I was a community health worker for two years before starting med school, and I can speak so highly of the work that community health workers do. Because, as we know, the social determinants of health on a patient really impacts their ability to heal and to be able to afford the medications that the doctor needs them to take. So without resources, patients can’t get better health.
So community health workers are really a backbone into helping physicians and the clinic goal team help patients. Rural doctors who are aware of resources in their community also serve a big part because they’re able to refer patients to services that they know are needed and would be helpful.
Miller: Doctor Dellit, how do you recruit students from rural parts of these five states? How do you find your students?
Dellit: That is a great question. It first starts with allowing these students to actually see medicine as a possibility for them. That’s why this gift is so critical, because it decreases that financial barrier for them even considering the possibility of medicine. We have a number of programs around that ecosystem ... How do we reach out to students in middle school, high school, undergraduate students, encourage them not just in medicine, but health care in general? And [we] think about what those opportunities may be for them.
So it starts at a very early age. I think, again, there’s an opportunity for us to do more here, in terms of how we engage the communities? How [do] we help support individuals from our rural communities really to see medicine as an opportunity? What’s wonderful about our students is they want to give back. They love these communities. They want to be able to give back to these communities. We want to allow them a pathway to be able to do that.
Miller: Kenya, as we were talking about at the beginning, you saw the role that these clinics played for your own family and you wanted to do that yourself. You wanted a career as a rural physician. Did you see a path, as a kid, a teenager or even a young adult, to make that happen?
Morales: The pathway was always set by my parents who, even though we weren’t financially well, always told me that we would figure it out. So I guess their confidence in me led me to say, I’ll find ways or I’ll find help. The University of Washington, now that I’m in med school, the scholarships are a big part of my ability to continue in this path and my ability to feel well of pursuing this path, when I was applying to med schools. Yeah, it’s been through the help of scholarships that I was able to go to college and pursue med school.
Miller: Kenya, what are the financial burdens of pursuing this path?
Morales: Well, it’s definitely the over $100,000 in loan debt that you have after going through your medical school education, and specifically wanting to pursue rural medicine, where you are a family medicine doctor in a rural community. You’re not in a high paying specialty, like doing cardiology in a big city. So that’s kind of a barrier some students face when wanting to pursue rural medicine.
Miller: This gets us, Doctor Dellit, to the ways that this $25 million is actually gonna be put to use. Can you give us a better understanding of the different buckets of money that you now will have access to, going forward? How will they make it easier for future students to pursue this career?
Dellit: I want to first start by thanking Bill and Carolyn Franke for their vision and partnership in really supporting our students and lifting them up. This is a $25 million gift. $20 million will be set up for endowed scholarships. So those scholarships will go directly to help support students who are interested in pursuing a career in rural medicine, serving our Indigenous communities across the WWAMI region.
Another $5 million will actually be used to help support some of that outreach, the recruitment. How do we identify and allow students to think about medicine as a possibility? How do we support students along their journey? Unfortunately, some of our students face housing insecurity, food insecurity. So we often need to help support them and ensure that they are successful, even after they get accepted into medical school. As well as academic support and other support that they need to be successful. So when we look at this, it’s really transformational to be able to provide scholarships.
What we’re anticipating is that ultimately, this will support about 30 to 35 students a year for half of their tuition, to decrease that financial burden that Kenya mentioned. [This] allows them to pursue their dreams and not their debt, especially going to serve rural communities, whether it’s as a family medicine physician or other physicians within our rural communities. So for us, this is just transformational to support our students and ultimately, to increase access to care for our rural communities.
Miller: Part of the national context for this is changes in federal loan limits for things like medical school. What does that mean in particular?
Dellit: Yeah, I think that’s a real significant barrier. When you look at the average debt for our students once they complete undergrad, their medical school training, it’s about $220,000 of debt. The new caps are going to be at $200,000. That is a real barrier for our students. We have got to lower that. So this is a prime focus for our school. This gift, again, $20 million going straight to support student scholarships, is an incredible gift which we are so grateful for. It’s that financial burden that we’ve got to be able to decrease to allow students both to see themselves coming to medical school and then to be successful as they go on throughout their career, and again, to be able to serve these smaller communities.
Miller: So we’ve been focusing a lot on the geographic piece of this, rural and Indigenous communities. But I want to turn to the medical practice side of this because we’re really talking, if I understand correctly, about the practice of family medicine. So, Dean Dellit, first – why is family medicine such a focus of this program?
Dellit: Well, family medicine physicians, particularly in small rural communities, do everything. They take care of individuals who may be pregnant. They help deliver the babies. They take care of the children, the adults. They help with the end of life. They care for the full cycle of life. We were talking a little bit about the importance of these physicians within their community. It’s not just taking care of the individual patient. They really are part of the fabric of that community and help the overall health of that community. So family medicine physicians are absolutely critical across our rural communities.
I’ll also just say that we need more specialists in our rural communities. It’s just hard because of the number of patients who may need their care. So we’re constantly thinking about how we extend our specialists out into our rural communities as well, or allow at least special tracks. For instance, we even have some of our surgical residents, who go out and train in rural areas for that experience, to understand what does it mean to be a rural surgeon? It’s very different when you are the only person there and the community relies on you to do everything related to their health care.
Miller: I want to hear more about the efforts to increase the availability of specialty care. But just to stick with the family medicine piece for a second, Kenya, how much are you attracted to this version of the practice of medicine as opposed to your desire to practice in a particular kind of place, in a rural area?
Morales: Family medicine is the specialty I’m interested in currently. I love that we’re able to take care of the whole family unit and we’re members of the community ourselves, that really know how to best treat our patients. I would like to pursue a fellowship in OB and also be able to provide obstetric care in the community that I’m in, deliver babies, really be a present physician in my community and be able to practice full spectrum rural medicine. Which means do a little bit of everything and more.
Miller: Where have you been based for your first year of your medical education?
Morales: I am currently in Moscow, Idaho.
Miller: As we heard from Tim Dellit, the first two years of medical education classically are more classroom-based. Have you had any clinical pieces though so far?
Morales: Yes, definitely. The University of Washington School of Medicine is so great at getting their students into clinical practice early on, which I think is unique about our program. We began school in July and by September, October, we were already practicing clinical skills. We were able to get into our critical access hospital nearby or just the hospitals, to see patients in a group setting, and do some primary care clinical work with doctors in our communities.
Miller: Two years before the classic clinical rotations where you’ll get a taste of all the different pieces of the potential future practice of medicine for yourself?
Morales: Yes. As part of the TRUST Program, I was able to begin my clinical experiences even before I started medical school as well. So they definitely take us into the community right away, which is great.
Miller: Do you think that you’ve already been learning things that you could only learn in a rural setting?
Morales: Yeah, I believe so. From what I’ve seen, the physicians that I’ve worked with so far are so knowledgeable and are experts in many different areas. In urban settings, I’ve heard physicians say to go back to your family medicine doctor to learn more. But here, it seems like they have the answers and they’re able to do procedures because they’ve gotten extra training, because they know there’s a need.
Miller: Tim Dellit, it seems like Kenya is in this for the long haul as a family medicine doctor, maybe with an OB addition, in a rural setting. Is that a requirement? When students go through this program with the idea that they will become family practice physicians in rural or Indigenous settings, do they have to? Could they then do a cardiology rotation in their third or fourth year and say, “you know what, I want to be a cardiologist in LA or Seattle?”
Dellit: Yeah, they’re not absolutely required. We try to identify students who show a strong interest. And as Kenya did, students in our TRUST program apply for that program as they’re applying for medical school. So that program selects out individuals who have said they want to practice rural medicine. If you look at the graduates of that program, a much higher proportion, but not 100%, end up practicing rural medicine.
One of the beauties of medicine is that there are so many opportunities. So if a student starts on that path and then later on they find they really love a different area, we want to support that as well. But I would say the vast majority of students who participate in the TRUST program will end up serving rural communities, but absolutely not a requirement.
Miller: I want to go back to the piece that we paused on before. Family medicine, these docs really seem like almost the decathletes of the medical profession, being able to do so many different things for so many different ages of patients. But as you noted, there is a really serious shortage of specialists in rural areas, and the economics make it really hard to change that. So what options do you see for more provision of specialty care in places where it’s highly unlikely that specialists are going to move to?
Dellit: Yeah, so [there’s] a couple of ways we’re approaching this. We’ve, to date, focused our discussion on medical education within our medical students. But we also are trying to grow what we refer to as graduate medical education, meaning that once our students graduate from medical school, they go and do a residency program, for an additional three-plus years depending on what they go into. We need more residency programs across these five states, because again, if you do your residency in one of these communities, you’re more likely to stay there and practice after you complete your training. So we’re working with all five of our states to continue to grow that.
One of the ways we do this [is with] a family medicine residency network. We have over 30 residency programs that are members of that network. The network is coordinated through the University of Washington, and we do things like helping them set up a residency program. How do we do faculty development and continuing medical education? They have access to our library and other resources through the university.
Another way we’re trying to do this is really taking advantage of this amazing time that we’re in, when we see advances in AI, technology, engineering, and how that combines with medicine. How can we extend, for instance, telemedicine or digital health out into our rural communities? How can we leverage technology so that our patients don’t always have to drive six to eight hours to see a physician, but can we do things with remote monitoring or other technology to bring care closer to them?
How can we leverage our specialists and connect them to the family medicine physicians practicing in these smaller communities for additional advice when needed, right? We’re always trying to think about, especially now, how we can leverage technology to extend specialty care. But fundamentally the backbone of care in our rural communities, it’s the family medicine physicians.
Miller: Tim Dellit and Kenya Morales, thanks very much.
Morales: Thank you.
Dellit: Thank you. It’s been a pleasure being with you.
Miller: Tim Dellit is an infectious disease specialist who is the CEO of UW Medicine and the Dean of the UW School of Medicine. Kenya Morales is now in her second year of medical school. She is in the Targeted Rural and Underserved Track [TRUST program].
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