In a side room at Community Health Care’s Hilltop Regional Health Center, Tami Ford clutched a cane, awaiting her doctor.
It wouldn’t require much patience, she said.
“I get in right away, and I do recommend it to my friends who don’t have a doctor,” said the 53-year-old University Place resident.
The Hilltop clinic, she said, has a large enough staff to keep her doctor available when she needs treatment.
On the other side of the clinic door, its leaders say the 18 medical residents — not long out of school and still under a veteran physician’s watch — are a significant factor in why the clinic was able to treat a rising number of patients — more than 22,000 in 2016 alone.
The three-year residency program, which will graduate its first class this summer, is part of a considerable regional growth in residency programs for family medicine, which runs from delivering babies to seeing the elderly.
For patients across the South Sound, this often means a younger doctor than perhaps anticipated, in exchange for making more of those appointments available to a growing region, now and in the future.
“The economy of a residency is you give teaching and you get, in exchange, free labor,” said Jeff Smith, who supervises the residency program for Community Health Center, which operates the Hilltop clinic and four others in Pierce County.
Demand is high on the applicant side as well, administrators and medical experts said.
“It’s an attractive place for residents to consider putting in their time — whether it be in a military capacity at Madigan (Army Medical Center) or in a civilian capacity,” said Bruce Ehrle, executive director of the Pierce County Medical Society.
“With the Pacific Northwest being one of the hottest destination markets in the country, Pierce benefits from that.”
GETTING MORE RESIDENTS
As anyone who has had to wait weeks for an appointment might attest, the state wants for doctors.
A Kaiser Family Foundation report in January indicated that 1.3 million Washingtonians — nearly a fifth of the state’s total population — live in places with a shortage of primary care physicians, from underserved communities to prisons and mental hospitals. That group has just 45 percent of the approximately 400 primary care doctors it needs, according to federal guidelines.
The U.S. Dept. of Health and Human Services found Washington needs 231 more primary care physicians in those places alone.
“There’s no shortage of patients,” said Devin Sawyer, medical director of the residency program at Providence St. Peter Hospital in Olympia. “You could probably put a family doctor in any community in the state of Washington, and in a few years they’ll be closed to new patients because they fill up that quickly.”
Medical residency programs are an important element in fixing that.
The programs are not new to the state. In the South Sound, St. Peter and MultiCare’s Tacoma Family Medicine have trained residents for decades. So has Madigan, where scores of military doctors are trained each year at Joint Base Lewis-McChord.
But locally and statewide, the recent growth of residency programs has been dramatic as clinics and hospitals try to bring on doctors to address the demands of today and the future. Experienced doctors, several experts said, aren’t available to fill the gap.
At the Hilltop clinic, the program established in 2014 is set to graduate its first class of three-year residents June 23. By accepting six residents each year to a lineup of 14 staff doctors, the clinic has more than doubled the number of doctors under its roof.
The number of applicants still far surpasses the available positions across the region.
“We have over 900 applicants for these eight slots (at St. Peter annually), so I don’t think there’s adequate slots,” said Jill Cooper, Providence Health’s vice president of quality for southwestern Washington.
According to the Washington Family Medicine Residency Network, there were 78 openings statewide for first-year medical residents in civilian programs in July 2010.
In 2017, that number had nearly doubled, to 136 first-year residency positions. That came through expansions of existing programs and the creation of several new ones. Today, there are 389 three-year residency slots for family medicine in the state’s civilian hospitals.
In the South Sound, Community Health Clinic, East Pierce Family Medicine in Puyallup and the Puyallup Tribal Health Authority started programs during that time.
“The Tacoma area has had more growth than most anyplace else, and the growth is an interesting one,” Bill Kriegsman, residency program director for MultiCare, said of the range of expanding programs.
MultiCare has 72 residents in four Pierce County programs, and 72 more in three programs elsewhere in the state.
Medical officials said a change in Medicare and Medicaid payment structures in the Affordable Care Act was a factor in expanding medical residency programs, particularly in family medicine clinics such as Hilltop.
TRAINING ON THE JOB
What residents can and can’t do can be hard for patients and hospital staff to grasp at first, said Kelsey McFall who will finish her third year of residency at the Hilltop clinic in June.
“It’s definitely not explained from ‘Grey’s Anatomy,’” said McFall, 33, who grew up in Everett.
Residents have finished medical school and can prescribe drugs, but they work under the supervision of doctors and get more independence only as they move through the program.
In their first year, residents almost constantly see patients alongside doctors. By their third year, the supervision is more hands-off.
Caroline Barrett, a first-year Community Health resident, said a supervising doctor had recently subtly prompted her about a forgotten treatment component for a respiratory patient.
“My attending (physician) kept saying, ‘Is there anything else you want to give? Is there anything else?’ and then I remembered,” said Barrett, 33. “I’ll probably never forget that again.”
Skepticism from patients about being treated by fresh-faced doctors happens, but only rarely, according to several of the clinic’s patients, residents and supervising doctors.
A significant factor of their acceptance is a broad public understanding that residents are around and active because of a longstanding need for doctors.
“If it’s my patient, I say, ‘If you like what you’ve been getting from the doctors here, then help me train more of them,’ ” said Smith, the residency program supervisor for Community Health.
In an examination room at the Hilltop clinic, Miranda Foster waited for help with her growing attention-deficit problem. She didn’t flinch when told her physician wouldn’t be a long-practicing expert.
Was that a concern?
“Not at all,” said Foster, 26, who works as a veterinary technician. “I could care less. I respect the process of learning a lot.”
The area’s patients were markedly more grateful than at a Kentucky clinic where she did student work, said Kerry Smith, a third-year resident at the Hilltop clinic. The Kentucky patients were openly skeptical of her ability to help, no matter her efforts, she said.
“Coming here, it was really nice to have patients give that back to you and saying, ‘I really appreciate everything that you’re doing,’” she said. “Even if you don’t have any answers, they’re usually grateful.”
TURNING RESIDENTS INTO DOCTORS
Bringing more residents in addresses this problem two ways, medical officials said.
First, a resident is an additional licensed doctor to help handle the patient load. Second, many residents tend to stick in the areas where they train.
This makes intuitive sense: young doctors start their residencies when they’re moving from years of college and graduate school into the professional world, at a stage when many are looking to buy property and start families. Once the roots of adult life are set down, moving can be less inviting.
Such an effect might keep Hilltop first-year resident Olga Lutsyk in the area after her three years at the clinic are done.
At 46, she is not a traditional new doctor; she went to medical school as a mother of six. She has two grandchildren and considers remaining close to family alongside her desire to be a family doctor in a rural area.
She enjoyed working in a Tennessee clinic as a student, but that’s a distant place.
“My kids like Washington,” Lutsyk said when asked about staying, “so it’s something we are thinking about.”
After her residency at Community Health, Barret said she’s likely to practice in Oregon, near her roots, with an eye toward pursuing international work once her loans are tamed.
Once McFall finishes her residency at the Hilltop clinic she’ll head a few blocks away to her new permanent job in women’s health at St. Joseph Medical Center, where she and other Community Health residents work emergency shifts as part of the program.
Medical officials throughout the region said that generally, about half of all doctors settle within 25 miles of where they worked as residents.
Consider the residency program that has operated since 1991 at St. Peter. In those 26 years, the program has turned out 52 doctors who practice in Olympia, Sawyer said. This number includes Sawyer, who finished his residency at the Olympia hospital in 1999.
KEEPING IT LOCAL
The administrators behind growing residency programs in the South Sound want the results to be intensely local.
Sawyer said St. Peter has started a six-resident program at its Chehalis hospital in hopes of planting doctors to help the doctor-sparse rural areas of Lewis County.
“It’s a great way for a community to promote and recruit and train their own family doctors,” Sawyer said.
The growth of such programs is not over.
CHI Franciscan is starting up a family medical residency program in 2018 with eight slots per year at Harrison Medical Center in Bremerton to create “the single largest collection of primary care physicians on the Peninsula,” according to a news release.
Michael Watson, the Bremerton program’s founding director, said the program will help meet meet changing demographic needs on the Kitsap Peninsula.
“The need is here,” Watson said. “Family physicians, we take care of kids, pregnant women and newborns, newborns. We are kind of the jacks of all trades.”