Partnerships to Establish and Sustain Rural GME: Q and A with Rob Epstein, MD of the Swedish Cherry Hill Family Medicine Residency 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.
Swedish Cherry Hill Family Medicine Residency (SCHFMR) is a separately accredited 1 + 2 rural track program, where residents spend most of their R1 year in Seattle at SCHFMR doing rotations unavailable in the rural location. Toward the end of their R1 year, the residents move out to Port Angeles to complete the rest of their residency in a rural area about three hours west of Seattle. Rob Epstein, MD is the founding program director of the rural residency and has been practicing in Port Angeles since 2001 as a family physician. His practice has always included inpatient and outpatient care. In addition, he has had a large obstetrics practice and does endoscopy. As the residency has developed, Dr. Epstein has decreased his clinical panel, but still practices in the hospital and works with residents who now care for many of the patients for whom he has provided care for decades. They teach rural family medicine by treating and caring for the very families he himself has treated and cared for since the 1970s.
ACGME: What drew you to academic medicine and to rural GME specifically?
Dr. Epstein: I started working with the University of Washington School of Medicine and its medical students in 2005. We developed a longitudinal family medicine clerkship site in our rural clinic. Eventually, I felt our community would be a good place to educate and train rural physicians, so we started developing a rural residency around 2014. I have found it rewarding to watch our residents become family doctors in our community.
ACGME: Describe the rural GME experiences within your program (e.g., types of sites, structure, curriculum).
Epstein: Our program is a rural 1 + 2 program. Our residents start their residency by spending most of their first year in Seattle, Washington, completing a combination of adult, pediatric, and obstetrics rotations at inpatient urban locations. They move to Port Angeles just before the end of their first year and complete their residency there, about three hours west of Seattle. The second and third years of residency are done in Port Angeles between our Federally Qualified Health Clinic (FQHC), our community hospital, and many community sites around the Olympic Peninsula.
ACGME: How did your Sponsoring Institution and program become involved in establishing rural GME experiences?
Epstein: At the beginning of our rural residency development, I contacted several western Washington residencies to gauge their interest in developing a rural program in Port Angeles. SCHFMR and Swedish GME were very interested in working with us to create such a program. Our local community hospital also invested in residency development because of the opportunity for physician workforce development. Our clinic had recently converted into an FQHC, so we were well-positioned to develop a GME program.
ACGME: Describe the internal and external partnerships that have been important in establishing and sustaining these experiences.
Epstein: We created a three-way financial services agreement among our local community hospital, the FQHC, and Swedish GME early in the development process and received additional financial help from our state legislature. Our first classes consisted of two residents a year, but after three years, we increased our complement to three residents a year because we realized that we had the clinical volume to support more learners.
ACGME: Describe the challenges you have experienced in developing and sustaining rural GME partnerships and experiences; and explain how you have overcome them.
Epstein: One of the biggest challenges was convincing folks that having a residency in our community was worth the effort. Community engagement and patience were key to overcoming the resistance to change. In the hospital, it was getting staff members to buy into the idea that we would now consider our small hospital a teaching hospital. For example, while nursing was a group that took more effort to get on board, nursing has since become one of our strongest supporters. Now, almost eight years into the process, some of our residents have stayed, and folks realize that what we were trying to do can work.
ACGME: Describe some of your program’s outcomes since establishing rural GME experiences, including the impact to the surrounding community.
Epstein: We are seeing an increased physician workforce. Not only have residents stayed after finishing their residency, but we have recruited physicians here because they can be involved in medical education. Our medical student experience has also improved with residents in the community. I am likewise seeing an increase in local youth interested in medical education and training. Our FQHC, where the residency is housed, has become a place where local young people in undergraduate preparation for medical school can shadow our clinic, and many are getting into medical school.
ACGME: What advice do you have for those interested in establishing rural GME experiences?
Epstein: Reach out and ask questions. Making a rural GME program work involves getting buy-in from the local medical community and the rural area. If a local champion has already practiced in the community for some time, that person or people need to be recruited early in the development phase.
ACGME: Describe the resources that have helped your program to establish rural GME experiences.
Epstein: The RTT Collaborative (RTTC) organization is renaming itself the Rural Medical Training Collaborative. Its annual spring meeting brings together rural GME educators from across the country and can be a wealth of information concerning starting a rural GME program. The Rural Residency Planning and Development Program maintains the RuralGME.org website, which contains extensive information about rural GME planning and development.
Email muap@acgme.org if you want to get in touch with Dr. Epstein. 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.