Partnerships to Establish and Sustain Rural GME: Q and A with Robert Gobbo, MD of the Providence Hood River Family Medicine Residency Rural Training Program
This interview is part of a series featuring Sponsoring Institutions and programs providing rural graduate medical education (GME) experiences. The series was initiated following the 2022 ACGME Annual Educational Conference presentation on Medically Underserved Areas/Populations: Partnerships to Establish and Sustain Rural GME, available in the ACGME’s digital learning portal, Learn at ACGME. Note: an account (free to create) is required to access most content in Learn at ACGME.
The Providence Hood River Family Medicine Residency Rural Training Program is sponsored by Providence Oregon, part of a long-standing, non-profit, Catholic health care organization that manages hospitals, physician practices, health plans, and other services in the Pacific Northwest. The residency is a collaboration between Providence Hood River Memorial Hospital, a 25-bed critical access hospital serving the rural communities of the Columbia River Gorge, and One Community Health in Hood River, a Federally Qualified Health Center (FQHC) serving as the primary clinical site for the program’s continuity clinic and employing many of the faculty members. Dr. Robert Gobbo has been the residency program director since 2012. He has been involved in GME in many roles, including as a volunteer, core faculty member, associate program director, and program director, since 1993.
ACGME: What drew you to academic medicine and to rural GME specifically?
Dr. Gobbo: I completed my family medicine residency in 1987 and an obstetrics fellowship in 1988, and moved to Hood River, Oregon as a full-spectrum family physician in 1988 to work at La Clinica Del Carino Family Health Center. I was always drawn to GME, and one of my mentors advised me to practice for five years before becoming a residency faculty member. So, I listened to him, and in 1993 moved to become a faculty member in Merced, California, where I was immersed in that program’s obstetrical and hospital care as an attending physician in a program with 18 residents. Besides my clinical work and teaching, I began writing for the Advanced Life in Obstetrics and Family Centered Maternity Conferences of the American Academy of Family Physicians (AAFP). I loved my work there as a teacher, clinician, and community advocate. In 2004, my family and I decided to move back to Oregon, and I joined the residency at Providence Oregon Milwaukie; and in 2011, I was asked to develop the necessary skills, knowledge, and relationship to start a rural program in Hood River. I completed the very valuable National Institute for Program Director Development fellowship in 2012, and we were accredited by the ACGME in early 2013 when we started our first class of two residents in Hood River.
ACGME: Describe the rural GME experiences within your program (e.g., types of sites, structure, curriculum, etc.).
Gobbo: Our program is located in the rural community of Hood River, a town of about 8,000 residents 62 miles east of Portland that serves the agricultural regions that produces some of the best pears, apples, cherries, and blueberries in the country! Our residents practice alongside other rural primary care and specialty physicians in the 25-bed critical access hospital and see their continuity patients at One Community Health (formerly La Clinica del Carino), which serves a large population of farmworkers whose primary language is Spanish. The education and training are structured to provide them with a full-spectrum experience, which includes obstetrical care and delivery, inpatient medicine, emergency, geriatric, and long-term care at the local nursing home. Their education and training also include seeing farmworkers in the orchards, packing houses, warming shelters, and fishing sites of the Native American tribes in the Gorge with our community health workers in a mobile medical clinic named La Clinica. Residents also staff the ski clinic at Mt. Hood Meadows in the winter, do electives in private rural physician offices learning procedures and ultrasound, and have opportunities for wilderness medicine experiences.
ACGME: How did your Sponsoring Institution and program become involved in establishing rural GME experiences?
Gobbo: Providence Oregon has a long history of sponsoring GME and one of its programs in Colville, Washington is one of the oldest family medicine rural GME programs in the country. The community of Hood River was interested in establishing a rural program after several years of having residents from Providence Milwaukie’s family medicine program spend one month with La Clinica and Columbia Gorge’s family medicine physicians. Due to shortages of primary care physicians in our area, as well as a critical access problem for primary care, leadership of Providence and then La Clinica agreed to form an affiliation to establish a rural residency program. We took the model in Colville and incorporated many of its strategies but also adapted our program to the uniqueness of our Columbia Gorge communities.
ACGME: Describe the internal and external partnerships that have been important in establishing and sustaining these experiences.
Gobbo: Internal partnerships that have been important to establishing and sustaining these experiences start with our institutional partner, Providence Oregon, and our urban sister program, Providence Milwaukie, which provides the bulk of the first-year experiences in the Portland Metro region. Providence welcomed our small rural program into the GME family that includes other residencies in family medicine, internal medicine, and other specialties in Oregon and the Pacific Northwest region. Our local hospital CEO and her leadership team and foundation have been generous and steadfast in their support of our program. Our relationship with One Community Health FQHC is collaborative and central to our program’s identity. This partnership is vital for ensuring our residents receive education and training from role models in full-spectrum family medicine, including obstetrics with a faculty member who practices in this community and understands the importance of providing culturally and linguistically excellent health care.
Other external partnerships include the national organization, the Rural Medical Training Collaborative (formerly the RTT Collaborative), which has been a mainstay of support, mentorship, and community with other rural family medicine educators. Locally, important partnerships include the specialty and primary care volunteer physicians and other educators who support the program by providing clinical opportunities and teaching throughout the years.
ACGME: Describe the challenges you have experienced in developing and sustaining rural GME partnerships and experiences; and explain how you have overcome them.
Gobbo: The first challenge was to help the community understand what a residency program is and what value it would bring to the community. At first, some patients and even staff members were unsure if they wanted to have a program and expressed concerns about student doctors practicing on their vulnerable community. By communicating early on, staff members and patients were able to see the incredible benefit the residency brought in terms of providing access, improving faculty member job satisfaction and retention, and residents staying in the community as medical practitioners after completing the program -- and the value of the program became clear. Being a small rural program does have its challenges and one that we share with other programs is that of confidentiality and the effect of conflict within our residency and town. We have instituted many strategies to improve this, but it remains a challenge in a “town this size,” in some years more than others, due to personalities and difficulties of individual residents.
ACGME: Describe some of your program’s outcomes since establishing rural GME experiences, including the impact to the surrounding community.
Gobbo: As a small rural program, we have had eight graduating classes since 2016, have a 100 percent American Board of Family Medicine (ABFM) Board pass rate, and have had over 50 percent of our graduates stay locally to practice. Over 50 percent of our graduates have fulfilled the requirements to practice obstetrics as well.
ACGME: What advice do you have for those interested in establishing rural GME experiences?
Gobbo: My advice to others interested in establishing a rural GME experience is to make sure you have a local champion who knows the community well and already has relationships with key leaders in the community. Understand what the community’s needs are and model your program to be of service and take advantage of the unique opportunities and strong clinician leadership to serve as role models.
ACGME: Describe the resources that have helped your program to establish rural GME experiences.
Gobbo: Besides our local Providence network, the ACGME, the RMTC, the AAFP, and the ABFM, as well as local networks, particularly the Providence Hood River Hospital Foundation, were instrumental resources for our program.
ACGME: Is there anything else you would like to add we haven’t asked about?
Gobbo: The most important role in our residency is that of our program coordinator, who I have been privileged to work with for 10 years. Her skill set and professionalism is unparalleled, and without her contributions, the residency could not run smoothly. Since we use a longitudinal and personalized curriculum, she is amazing at keeping tabs on our residents and making sure they get to their required and elective experiences.
Email muap@acgme.org if you want to get in touch with Dr. Gobbo. Is your Sponsoring Institution/program already providing rural GME experiences and would you like to be featured in a future post in this ACGME Blog series? Email muap@acgme.org to share what you’re doing. Visit the MUA/P web page to learn more about the ACGME’s efforts.