Washington needs doctors. Actually, the whole country does. The Association of American Medical Colleges estimates the country may be short between 46,000 and 90,000 doctors by 2025. In Washington, and indeed most states, the need is even more acute in rural areas. Everyone involved in medical education seems to agree that we need more doctors. How to get them is another story.
Washington State University (WSU) is hoping to start a new medical school to help alleviate the problem. But the University of Washington (UW), which until earlier this year had a monopoly on state medical schools, fears that the money needed to start that new school will hamper its own efforts to expand medical education in eastern Washington. Furthermore, some wonder if increasing the number of medical school students, without increasing the number of residencies, will actually solve the problem.
For nearly 100 years, the UW had been the only game in town as far as medical schools go. Just a couple of months before the United States entered World War I, the state Legislature divvied up some of the more technical courses of study between the UW and what would become WSU. In general, WSU got anything having to do with agriculture and animals, and the UW got medicine, law and architecture.
While the rule that only UW gets to educate doctors had been on the books since 1917, the state didn’t fund the med school until 1946. During this year’s legislative session, the state changed that law to allow WSU to open its own medical school, with an eye toward increasing the number of doctors practicing in rural areas. Where the money for that school will come from is an open question, and a large part of what concerns officials at the UW.
The UW’s medical school is top-notch, says Ken Roberts, acting dean of medical sciences for WSU. But the state needs more doctors than the 140 per year attending the UW’s medical school, especially in rural areas, and WSU is well positioned to educate them.
“At some point,” Roberts says. “Washington is going to need more physician education infrastructure.”
He points to the numbers in a study funded by WSU that indicate the state will need about 4,000 more doctors by 2030. At current enrollment levels, the UW would graduate about 2,100 in-state doctors. The WSU study also found that King County is home to 49 percent of the state’s doctors, but only 29 percent of the state’s population, an imbalance WSU hopes to address.
Roberts says WSU would actively recruit students who have a desire to practice in rural areas, and work with them to encourage that desire.
The UW already provides that option, counters Randy Hodgins, UW vice president for external affairs. Since the 1970s, the UW has operated a campus east of the Cascades, first in Pullman and now in Spokane. That location has openings for 40 Washington students (with a goal of getting that number up to 80) and 105 students from four other states (Wyoming, Alaska, Montana and Idaho) that don’t have the resources for their own schools. Those states fund the spots for their students in a program known by the acronym WWAMI, taken from the initials of the states that participate (and pronounced “whammy”).
“The whole idea was ‘Let’s get young people to practice medicine in rural and underserved areas,’” Hodgins says.
WSU was a partner in WWAMI and has helped contribute some funding toward the program through this June, when it will pull out as part of its efforts to start its own school. Roberts says WSU still supports the idea of WWAMI and believes it does important work, but he maintains that the school couldn’t be expanded enough to meet the future need for more doctors.
WSU is asking for $2.5 million to begin the accreditation process and otherwise get started. Once the WSU medical school is fully operational, WSU’s study estimates it would take about $30 million per year in state funding to operate it. WSU’s medical school would include two years of classroom-based learning at the health sciences facility WSU has already built in Spokane. Med students would spend their third and fourth years at clinical sites around the state that would be affiliated with WSU’s satellite campuses, Roberts says. WSU aims to launch the school with 40 students in 2017, according to its president, Elson Floyd.
Funding is shaping up to be a big part of the UW’s problem with the new school. The state has been providing $4.7 million toward WSU’s teaching the first-year med school curriculum for WWAMI, Hodgins says, money that would be taken from WWAMI to fund the WSU medical school. The UW, he says, is not opposed to WSU starting a medical school, but it is worried that the money WSU would take could come from WWAMI or other programs.
“We kind of wonder, well, gosh, is the state going to have money for that?” Hodgins says. “The primary concern is, don’t let a WSU medical school do harm to the school that’s already in Spokane.”
Ana Mari Cauce, the UW’s interim president, echoed those concerns. She fears that taking funding from one program to start another will only exacerbate the problem of getting doctors into rural areas.
“Even if all the tailwinds of accreditation, etc. are with WSU, they will not have a practicing doctor coming out of their school for a decade, because it takes time. Having the potential for that school [WWAMI] to close down—because we can’t operate on air—will have severe consequences for eastern Washington at precisely that time when, we are all agreed, we need more, not less,” she says.
Roberts agrees it’s a lot of money at a time when the Legislature is under the gun to find ways to better fund K–12 education, but he argues that opening a med school—one he says will be substantially less expensive to run than the UW’s—will be a net fiscal positive in the long run.
“You have economic development around research and development,” he says.
Faculty could be another sticking point. The professors teaching first-year students at WWAMI are WSU faculty, Roberts says.
Starting next year, it seems likely they won’t be teaching there anymore, and the UW will need to hire some of WSU’s faculty on a contract basis, or find new professors. Whether any given professor will have time to take on the additional class load is an open question. Second-year students are already taught by faculty hired by the UW.
Some observers, such as Dr. Brian Seppi, president of the Washington State Medical Association, say the focus on medical schools, while important, isn’t getting at the bigger problem: that of residencies.
Typically, a prospective doctor spends four years in medical school (after getting an undergraduate degree). Those years are designed to give the doctor a broad range of training in different types of medicines, along with some of the science they need to do their jobs. After that, doctors apply to a residency program, which typically lasts from three to six years, through which they get in-depth, on-the-job training in their specialty.
The residency phase is where the state should be focusing its efforts if we want to find ways to encourage more doctors in rural areas, Seppi says. He adds that the association supports the idea of adding more medical school students (while remaining neutral on which school should do it). But increasing the number of students may be fixing the wrong problem.
“I think we may be in more trouble with the residency shortage than with the medical school shortage,” Seppi says.
The residency issue is twofold. First, most doctors tend to settle in areas where they complete their residency program, says Seppi, a Spokane resident. So finding ways to increase the number of residents in rural areas may be a better solution to getting more docs there.
“If we could increase those residency programs, we would have a better chance of keeping [new doctors] in the state,” he says.
Second, Seppi says, medical schools may soon run out of residency spots on a nationwide level. “We’re going to get to a point where we’ve got more med school grads than residency positions,” he says.
If this happens, universities could be educating doctors at medical school to then ship them to a residency in another state. Or potentially worse, they don’t find a residency anywhere, and are unable to work as a doctor even after finishing med school.
There are no easy answers to that problem. Most residencies are attached to hospitals, and rural areas don’t typically have hospitals large enough to support them. Of 16 residency programs in the state, only four are in eastern Washington: two in Spokane and one each in Yakima and Richland. And, of course, there’s the money. The bulk of residency programs are funded by the federal government through Medicare to the tune of $100,000 per year per resident, and the number of programs has been frozen since a change in legislation in 1997, Seppi says. “We have to find a way of funding those residency programs.”