Health Care: The Washington Medical School Flap

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 medical 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) hopes 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 in Washington, fears that the money needed to start a new school will hamper its own effort to expand medical education in eastern Washington. Furthermore, some wonder if increasing the number of medical school students without increasing the number of medical residencies will actually solve the problem.

For nearly 100 years, the UW has 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 UW got medicine, law and architecture.

While the rule that only the UW gets to educate doctors had been on the books since 1917, the state didnt find money to fund the medical school until 1946, after the end of World War II. During this years 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 Medical School is top notch, says Ken Roberts, acting dean of medical science for WSU. But we need more doctors than the 140 per year attending the UW program, 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 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 Washington. Roberts also points to what he says is an imbalance in the distribution of doctors. The WSU-funded study found that King County is home to 29 percent of the states population and 49 percent of its doctors.

Roberts says WSU would actively recruit students who express a desire to

practice in rural areas, and would work with them to encourage that desire. You get diversification of the kind of education the student can have, he says.

The uw already provides that option, counters VP for External Affairs Randy Hodgins. Since the 1970s, the UW School of Medicine has operated a campus east of the Cascades, first in Omak and now in Spokane. That location has spots for 40 Washington students (with a goal of getting that number up to 80), plus 105 students from four other states (Wyoming, Alaska, Montana and Idaho) that dont necessarily 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 [of WWAMI] was, Lets get young people to practice medicine in rural and underserved areas, Hodgins says.

WSU was a partner in WWAMI and helped contribute funding toward the program until this year, when it withdrew as part of the effort to start its own medical school. Roberts says WSU still supports the idea of WWAMI and believes it does important work, but he maintains that the school couldnt be expanded enough to meet the future need for more doctors. States with populations similar to Washingtons, such as Virginia and New Jersey, have four and three publicly funded medical schools, respectively.

WSU is asking for about $2.3 million to begin the accreditation process and otherwise get started. Once a medical school is fully operational, WSUs study estimates it would take about $30 million a year in state funding to operate it. WSUS medical school would include two years of classroom-based learning at the health sciences facility WSU has already built in Spokane. The third and fourth years would be at clinical sites around the state that will be affiliated with WSUs 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 UWs problem with the new school. The state has been contributing about $4.7 million per year to WSUs 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 WSUs starting a medical school, but it is worried that the money it will 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 dont let a WSU medical school do harm to the school thats already in Spokane.

Ana Mari Cauce, the UWs interim president, echoes 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, etcetera, 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 cant operate on air will have severe consequences for eastern Washington at precisely that time when we are all agreed that we need more, not less, she says.

Roberts agrees its 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 UWs 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, they likely wont be teaching there anymore, and the UW would need to hire some of WSUs faculty on a contract basis. 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, like Dr. Brian Seppi, president of the Washington State Medical Association (WSMA), say the focus on medical school, while important, isnt getting at the bigger problem: 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 medicine, 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, where they get in-depth, on-the-job training in their specialties.

Seppi says the residency phase is where the state should be focusing its efforts if it wants to find ways to encourage more doctors in rural areas. He adds that the WSMA supports the idea of adding more medical school students, while remaining neutral on which school should do it. But adding to 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 notes.

The residency issue is twofold. First, most doctors tend to settle in areas where they complete their residency programs, 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 physicians there. If we could increase those residency programs, he notes, we would have a better chance of keeping them in the state.

Second, Seppi says we may soon run out of residency spots on a nationwide level. Were going to get to a point where weve got more med school grads than residency positions, he says.

If this happens, we could be educating doctors at medical school to then ship them to a residency in another state. Or potentially worse, they dont 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 typically dont 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, theres the money. Most residency programs are funded by the federal government through Medicare, to the tune of $100,000 per year per resident, and their number has been frozen since 1997.