Training New Doctors Right Where They’re Needed

California teaching centers aim to train and retain doctors in medically underserved areas. But funding remains a question.

teaching-health-center-7 training doctors.jpgOlga Meave, MD, examines Veronica Ayon at Clinica Sierra Vista, in Bakersfield, California, in August. Ayon says she feels most comfortable with Meave because they share a cultural background and language. | Heidi de Marco/KHN

Olga Meave, MD, didn’t mind the dry, 105-degree heat that scorched the Central Valley city of Bakersfield, California, one afternoon during the summer of 2017.

Sweltering days remind her of home in Sonora, Mexico. So do the people of California’s Central Valley region — especially the Latino first-generation immigrants present in large numbers, toiling in the fields or piloting big rigs laden with fruits and vegetables.

Meave’s sense of familiarity with the region and its residents drew her to an ambitious program whose goal is to train and retain doctors in medically underserved areas. She was part of the Rio Bravo Family Medicine Residency Program, operated by Clinica Sierra Vista, a chain of more than 30 clinics in the region. Meave, 34, graduated from medical school in Mexico and has pursued additional education and training in the United States. After she completes her residency in 2018, she plans to practice in Bakersfield, about 100 miles north of Los Angeles.

“The goal is for [doctors in training] to come for three years and stay for 20,” said Carol Stewart, director of the program.

Rio Bravo is one of eight teaching health centers in California and 57 nationwide that were created by the Affordable Care Act in 2010 to serve areas with large unmet medical needs. During the 2017-18 academic year, 732 residents were in teaching health centers across 24 states.

Unlike the Affordable Care Act itself, these teaching centers enjoy bipartisan support among federal lawmakers, who say such hubs will alleviate the primary care doctor shortage. But long-term funding is still in question as Congress debates the future of health care.

A residency is a stage of graduate medical training that’s required after medical school and before doctors can set up their own practices. Most family practice residencies last three years. Traditional residency programs are generally based at large, urban hospitals in areas where there are typically a sufficient number of doctors to go around.

The first teaching health centers began training residents in 2011. They operate primarily out of clinics in rural communities and other areas where primary care physicians are in short supply.

training doctors map.jpgThe ideal ratio of primary care physicians to patients is about 1 for every 2,000, Stewart said. The ratio in east Bakersfield “is more like 1 to 6,000, so we have a lot of catching up to do.”

Though teaching health centers remain relatively new, experts say they’re already succeeding: Their residents generally stay in the regions where they trained, putting down roots in communities with a big demand for health care.

In June 2017, the Rio Bravo program graduated its first class of six doctors. Two joined the staff at a Clinica Sierra Vista clinic in east Bakersfield. The other four are practicing in clinics serving low-income communities in Sacramento, Riverside and Los Angeles counties.

Stewart estimates that the six recent graduates together saw nearly 10,000 patients during their three years of training.

“That’s a significant contribution,” she said.

Though not all teaching health centers have affiliations with medical schools, the Rio Bravo program has an academic partnership with the UCLA medical school, which helps develop its curriculum, Stewart said. It also coordinates with a local hospital, Kern Medical, where residents complete rotations in different specialties related to family medicine.

A 2015 survey by the American Association of Teaching Health Centers found that 82 percent of their graduates stay in primary care and 55 percent remain in underserved communities. By contrast, about a quarter of graduates from traditional residency programs remain in primary care and work in underserved areas, according to the same survey.

Many graduates of teaching health centers have an incentive to stay in these areas because they may qualify for other programs that offer perks, such as help with paying off medical school loans.

The centers take their patient populations into consideration when selecting applicants. For instance, Rio Bravo aims to train culturally sensitive doctors, given the large local immigrant population, Stewart said.

It looks for applicants with ties to the Central Valley or who come from the cultures — and speak the languages — that are familiar to patients they will serve.

Meave doesn’t have a personal connection to the Central Valley, but she worked with low-income patients in Mexico. She has found that the population in the Central Valley, and its needs, aren’t much different from those in her home country.

At Clinica Sierra Vista, she sees patients who haven’t been to a doctor in decades. “They’ve never had a physical exam, never had their eyes checked. … They just deal with their aches and pains,” she said. “I think they feel happy that I can understand them and excited that someone from the same background is providing them care.”

Teaching health centers are financed by federal grants administered by the Health Resources & Services Administration, part of the U.S. Department of Health and Human Services. Congress determines the amount and duration of the funding. In July 2017, U.S. Rep. Cathy McMorris Rodgers, a Republican from Washington, introduced legislation that would fund the program for three years at about $157,000 a year per student — a total of $116.5 million annually.

teaching-health-center-4 training doctors olga meave.jpg

Olga Meave is a third-year resident in the Rio Bravo Family Medicine Residency Program, operated by Clinica Sierra Vista in Bakersfield, California. The program operates primarily out of clinics in rural or underserved communities where primary care physicians are in  short supply. | Heidi de Marco/KHN

The amount proposed would be a 65 percent increase from the 2017-level funding of $95,000 a year per resident.

“We … must advance a long-term solution to provide certainty for our teaching health centers, their residents and their patients,” McMorris Rodgers said in a prepared statement. “Without a sustainable funding level … the program will unravel.”

In the Central Valley, there is no medical school, and new doctors often avoid the area in favor of richer urban centers, where they can make more money.

This year, lawmakers earmarked $465 million from the state’s new tobacco tax to boost payments for some Medi-Cal providers, which could help make poor areas like the Central Valley more attractive to doctors.

At Clinica Sierra Vista’s location in east Bakersfield, where Meave’s residency is based, 75 percent of patients are covered by Medi-Cal — the state’s version of the federal Medicaid program for low-income residents — and 15 percent are uninsured, Stewart said. Asthma, diabetes and other chronic conditions are major health problems.

Veronica Ayon, a former farmworker, is one of Meave’s patients. Like her doctor, she is a native of Sonora.

Ayon, 48, was treated for cervical cancer in 2010 and last year underwent surgery to remove a malignant brain tumor. She feels comfortable with Meave because of their similar backgrounds and language, she said.

“She is very special to me,” Ayon said, speaking in Spanish inside her home in the town of Shafter, about 20 miles north of Bakersfield. “She explains things at a level I can understand.”

This story originally was published on Oct. 9, 2017, by Kaiser Health News.

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