Partnerships to Establish and Sustain Rural GME: Q and A with J. Miguel Lee, MD of the Providence Chehalis Family Medicine 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.
Providence Medical Group is part of a not-for-profit health care system, founded in 1850, that integrates multiple specialties across the West Coast and Texas in the US. Providence has multiple GME sites among which are rural training programs, such as the St. Peter Family Medicine Chehalis Rural Training Program. Its continuity clinic is called Providence Chehalis Family Medicine (CFM). J. Miguel Lee, MD started working at CFM as a founding faculty member in 2014 and stepped into the role of Program Director much quicker than anticipated due to the structure of rural tracks at the time as separately accredited programs. At that time, the clinic also needed a Medical Director, so Dr. Lee also took on this role upon starting the residency. During the development of an associated rural program, Dr. Lee temporarily also served as Interim Program Director and handed over the duties of Medical Director to the Associate Program Director at CFM.
ACGME: What drew you to academic medicine and to rural GME specifically?
Dr. Lee: I always knew I wanted to work where the need is highest. I’ve always thought that everyone is entitled not only to health care, but to high-quality health care. Rural medicine allows us to work with a typically underserved population. I am drawn to academic medicine because I wanted to put my drop in the bucket to help the underserved population and I’ve always enjoyed teaching. I realized I could make a small difference seeing patients in underserved areas, but I could make a larger impact teaching other family physicians to practice excellence in medicine in these areas.
ACGME: Describe the rural GME experiences within your program (e.g., types of sites, structure, curriculum).
Lee: Most of our experiences across the three years are in rural Washington. Most of the first-year hospital rotations (obstetrics, inpatient medicine, and pediatrics) occur in Olympia, Washington in a larger community hospital. Second- and third-year hospital rotations (obstetrics, inpatient medicine, surgery, emergency medicine) take place in Centralia, Washington, which serves a largely rural demographic. All three years, residents care for patients in our rural continuity clinic in Chehalis. We have a longitudinal curriculum that resembles the practice of family medicine, and residents spend at least one full day of clinic each week in their continuity clinic. We have some excellent “specialty” clinics, which we hope will entice residents to work with these populations when they graduate, as the need is so great. These include, to name just a few, Procedure Clinic, Osteopathic Manipulation Clinic, Medication Assisted Therapy Clinic & Hepatitis C Clinic, and Primary Care Psychiatry Clinic. Residents get additional exposure to other specialists and can use elective time to further tailor their learning experience depending on their personal career goals.
ACGME: How did your Sponsoring Institution and program become involved in establishing rural GME experiences?
Lee: Providence has had GME for decades, and when rural training programs and tracks became a viable solution to the worsening rural physician shortage, we were early in the adoption of these models, with our program starting in 2014. The primary care physician to patient ratio is almost half of what it is in Washington State and the US as a country (County Health Rankings).
ACGME: Describe the internal and external partnerships that have been important in establishing and sustaining these experiences.
Lee: From early on, we knew that it takes a village to train residents. Our local partners in the community have been integral to our success. Internal partnerships within Providence Medicine Group with obstetrics and gynecology, hospital medicine, surgery, and palliative care were some of the first we developed. We also partnered with our local orthopaedic and pediatric clinics to enrich learning opportunities. We have developed community partnerships with the Lewis County Drug Court (for our MAT [medication-assisted therapy] clinic), as well as Gather Church, for which we assisted them to start a low-barrier medication-assisted therapy clinic where our residents and faculty members continue to care for patients. We are incredibly grateful to all our internal and external community partners and preceptors who help support our resident learners, and we work hard to maintain these relationships so these can be beneficial experiences for both parties.
ACGME: Describe the challenges you have experienced in developing and sustaining rural GME partnerships and experiences; and explain how you have overcome them.
Lee: The challenge in our experience has always been some hesitation with the unknown. Once a resident rotates with one of our partners, it doesn’t take long before these same partners ask when the next resident will rotate. Some concerns regarding productivity are usually resolved once residents show that they can be very helpful in return for the education they receive.
ACGME: Describe some of your program’s outcomes since establishing rural GME experiences, including the impact to the surrounding community.
Lee: Since our inception, we have had two graduates stay on as faculty members at CFM. Two graduates joined a practice in neighboring Mason County. Three graduates joined a practice in Grays Harbor County (including one pharmacy graduate from our clinic) and serve as faculty members for an associated rural program. Additionally, two graduates are practicing in Grant County and another graduate joined an outpatient rural practice in Oregon. Several of our graduates return to our clinic to serve as community preceptors. We also have had, for the first time in decades, graduates from urban programs join practices in Chehalis because of our presence. We continue to work hard to stabilize the physician shortage by creating a stable clinic in our area. Several other graduates are working in other rural areas outside of Washington and Oregon.
ACGME: What advice do you have for those interested in establishing rural GME experiences?
Lee: There are as many ways to run a rural residency as there are rural practices. Every site is going to have different challenges and advantages, it’s a matter of working with what you have, to create what you need. Being creative is important, and there are many ways that GME requirements can be met while serving a community and training the future of our rural primary care workforce. Make use of the proverbial village; we’re all happy to help other upcoming rural training programs figure things out.
ACGME: Describe the resources that have helped your program to establish rural GME experiences.
Lee: In developing our program, we utilized resources within the WWAMI [Washington, Wyoming, Alaska, Montana, and Idaho] network and the RTT Collaborative (now Rural Medical Training Collaborative). Additionally, we utilized our resources within Society of Teachers of Family Medicine and the American Academy of Family Physicians Residency Leadership Summit conferences.
ACGME: Is there anything else you would like to add we haven’t asked about?
Lee: Developing a residency program is challenging, but watching residents develop their skills over three years is incredibly gratifying and fulfilling. I’d like to mention a few people who made this possible. I’ve had the support of Dr. Rein Lambrecht, associate program director and founding faculty member, working tirelessly on every detail of creating and supporting a residency. I’d also like to call out Lisa-Ann Roura, our coordinator, for her tireless work in keeping us going. I’m also incredibly grateful to the faculty members who work so hard to make our residency excellent, and the current and former residents who have placed their trust in us and have done their part in putting us on the map, as well as our clinic staff members for their endless support, and the trust our patients put in us.
Email muap@acgme.org if you want to get in touch with Dr. Lee. 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.