Graduate Medical Education in Alaska - Part 2 of 2

This is the second of two articles about graduate medical education (GME) in Alaska. GME is the structured training of medical school graduates.  This article summarizes issues other than funding and expands on recommendations to increase GME in Alaska.

Compared to all other states, Alaska has the fewest number of GME programs, the fewest number of GME trainees (medical residents), and the lowest GME trainee to state population ratio.1 Eighty-five percent (85%) of GME funding comes through Medicare and Medicaid.2 In 2021 Medicare GME was $13.4 billion.3 Medicare GME funding in Alaska was third from lowest per state population and third from lowest per state Medicare population.  In 2022, Medicaid GME was $7.3 billion.4 Alaska does not use Medicaid to support GME.4 The Department of Veterans Affairs (VA), the Health Resources and Services Administration (HRSA), and the Department of Defense (DOD) do not support GME in Alaska.^5,6

Distinguishing Graduate Medical Education (GME) from Undergraduate Medical Education (UME)
Undergraduate medical education (UME) occurs in medical school.  During the first two years medical students are primarily in the classroom.  During the second two years medical students are in hospitals and clinics applying to patient care what was learned in the classroom.  Medical students pay tuition, receive grants, or may have post-training service obligations.  Medical students receive a medical doctor (MD) or doctor of osteopathy (DO) degree when graduating.  New medical school graduates are not ready to provide patient care without supervision.  All states require two-three years of GME prior to medical licensure.7 Alaska requires two years of GME prior to medical licensure. ⁸

GME is commonly referred to as medical residency or fellowship.  Examples of primary care residencies are Family Medicine, Internal Medicine, and Pediatrics.  Examples of specialty care residencies are Anesthesiology, Emergency Medicine, General Surgery, Neurology, Obstetrics and Gynecology, and Psychiatry.  Examples of subspecialty residencies or fellowships are Cardiology, Cardiothoracic Surgery, Infectious Disease, Neonatology, and Child & Adolescent Psychiatry.  Medical residents and fellows are taking care of patients.  Medical residents and fellows are supervised by senior physicians.  The Accreditation Council for Graduate Medical Education sets and monitors GME education standards.

Medical Residents and Fellows Are Essential Health Care Workers
The primary goals of GME are training physicians and providing patient care.  Approximately one in seven US physicians is in a GME program (14.3%).9,10 Medical residents provide 20% of the care for hospitalized patients and 40% of the care for patients without insurance.¹¹ The Association of American Medical Colleges (AAMC) estimates medical residents provide $8.4 billion in patient care per year.¹¹ The patient care provided by medical residents may not be billed to Medicare or Medicaid if the hospital or clinic receives federal GME support.

Medical residents provide patient care on weekdays, weekends, nights, and holidays.  Medical residencies are required to manage medical resident duty hours to prevent impaired judgment due to resident fatigue.  Medical resident salaries depend on training program and resident year in training.  Alaska Family Medicine Residency (AFMR) salaries range from $68,000 (first year resident) to $74,000 (third year resident).12 From a staffing perspective, medical residents may be less expensive than employing non-physicians.¹³

GME and Physician Recruitment & Retention
Most medical residents are in their 20s and 30s.  This is an important period for personal, social, and professional development.  Life-long collegial and social networks are formed.  Spouses and partners begin careers.  Children begin school.  By the end of GME training, residents have usually developed strong community roots.

Medical residents usually remain in the communities where they train.  The AAMC reports fifty-seven percent (57.1%) of medical residents remain in the state where they completed training.14 The Alaska Family Medicine Residency (AFMR) has one of the highest retention rates of any individual residency.  Approximately seventy percent (70%) of AFMR trainees remain in Alaska after training.¹⁴ AFMR recruits medical school graduates who want to train in Alaska.  AFMR has more applicants than training positions.

Graduates of AFMR work in clinical settings across Alaska including rural and critical access sites.  More than twenty-seven percent (27.3%) of Alaska’s family medicine physicians completed their GME training at AFMR.¹⁵ Some AFMR graduates leave Alaska for subspecialty training.  Some AFMR graduates who have left Alaska return.

Alaska and Health Professional Shortage Areas (HPSAs)
Alaska has a well-documented shortage of medical doctors.^{16,17,18,19,20,21} HRSA is a federal agency trying to improve access to health care to people who are geographically isolated or underserved.  HRSA tracks Health Professional Shortage Areas (HPSAs) by geographic area, population group, and health care facility.  To determine HPSAs, HRSA uses population to provider ratios for primary care physicians, dentists, psychiatrists, and other health professions.  Last month HRSA reported that only 47.55% primary medical, only 32.36% dental, and only 27.11% mental health needs were being met nationally.22 Ideally, 100% of needs would be met, not less than half.

The state-by-state table below summarizes the percent of primary care, dental, and mental health needs being met by state.²² Alaska ranked 48th for primary medical needs being met (21.85%), 22nd for dental needs being met (34.98%), and 48th for mental health needs being met (11.90%).²²



Alaska Physician Recruitment
Health care organizations in Alaska compete with health care organizations in other states and with other Alaska health care organizations.  Between 2003 and 2006, the Alaska Department of Health and Social Services comprehensively analyzed Alaska health care workforce vacancies and recruiting.16,17 The analysis confirmed that Alaska health care worker turnover and recruiting were expensive.  Barriers to successfully recruiting physicians were identifying qualified candidates and spousal job availability/compatibility.  Alaska physician vacancy durations were often months to a year or longer depending on location and medical specialty.  GME in Alaska is a high yield physician recruiting strategy.  Increasing GME in Alaska will recruit more medical school graduates, more physicians-in-training, and more early career physicians.

Alaska and Non-Physician Alternatives
Since 1993, I have worked with, consulted with, and referred patients to non-physician health professionals. I have great respect for physician assistants, nurse practitioners, naturopaths, pharmacists, and other non-physician health care professionals.  Each brings something unique and valuable to patient care.  All are necessary and vital to a well-functioning health care system.

Some advocate for expanding the scope of practice of non-physicians to solve Alaska’s shortage of physicians.  But physician and non-physician training is different – different knowledge base, different skill mastery, and different clinical judgement.²⁶ For example, only physicians are required to complete structured clinical training after graduate school.  In general, a physician has 7-11 years of training with 12,000-16,000 hours of supervised patient care prior to independent practice.  A physician assistant has 2-3 years of training with 2,000 hours of supervised patient care prior to licensure eligibility.  A nurse practitioner has 2-4 years of training with 500-750 hours of supervised patient care prior to independent practice.  A naturopath has 4 years of training with 720-1,200 hours of supervised clinical care prior to licensure eligibility.  How could trainees with 12,000, 2,000, 1,200, or 750 hours of supervised patient care experience have the same knowledge, skill, and judgement when transitioning to independent practice?  Alaska needs more non-physicians but non-physicians do not replace physicians.



Telemedicine
Telemedicine was used by Alaska health care organizations to increase access to care long before the COVID pandemic.  Telemedicine became a necessity during the pandemic.  Now, some Alaska health care organizations rely on telemedicine by physicians and non-physicians who have no first-hand knowledge or experience with Alaska’s geography, climate, and systems of care.  Is there research examining telemedicine delivered by physicians and non-physicians who do not understand or consider Alaska’s uniqueness?  Are there differences in patient care quality, outcomes, or total cost?

Alaska has a history of well-intended out of state physicians and non-physicians who increase access to care but who do not provide follow up care, continuity of care, or coordination of care with patients’ Alaska physicians and non-physicians.  Is this high-quality care?

In general, I am an advocate for telemedicine but since the pandemic I have seen more telemedicine care that does not meet a reasonable standard of care.  Telemedicine must be more than increasing access to care.  Poor quality telemedicine care is poor quality medical care.

The ideal way to train physicians how to provide high quality telemedicine care for Alaskans is during training in Alaska.  

Washington, Wyoming, Alaska, Montana, & Idaho (WWAMI)
The University of Washington (UW) is the hub medical school for the WWAMI region.  WWAMI Alaska began in 1971 with nine medical students in Fairbanks.²⁷ Currently, there are approximately 85 Alaska medical students and 1,000 WWAMI medical students in the five-state region.

There are two additional medical schools in the Pacific Northwest; Pacific Northwest University of Health Sciences College of Osteopathic Medicine (PNWU) in Yakima Washington, and Washington State University Elson S. Floyd College of Medicine (WSU) in Spokane Washington.  PNWU opened in 2005 and WSU opened in 2015.  UW, PNWU, and WSU provide undergraduate medical education (UME).

WSU sponsors three GME programs: Family Medicine, Internal Medicine, and Pediatrics.  UW sponsors more than 120 GME programs.

UW has a long history of partnering with hospitals and clinics in the WWAMI region to develop and operate residency tracks, such as the Alaska Pediatrics Track and the Alaska Internal Medicine Track.  UW helps recruit residents and trains residents in patient care the partners are unable to provide.  These tracks help states launch and operate GME programs to increase state physician workforces.

UW also fosters and coordinates GME networks.  For example, the WWAMI Family Medicine Network is a group of 33 Family Medicine residency programs and 10 rural training tracks.²⁸ The network collects and shares ideas, research, and provides mentorships.

Alaska GME Including Tracks
Alaska has one independent GME program, the Alaska Family Medicine Residency (AFMR).  AFMR is sponsored by Providence Alaska Medical Center.  AFMR has more applicants than training positions and has demonstrated GME in Alaska retains graduates for clinical practice in Alaska.  Approximately seventy percent (70.8%) of AFMR trainees remain in Alaska after training.¹⁴ Twenty seven percent (27.3%) of Alaska’s family medicine physicians completed AFMR training.¹⁵ Alaska has two UW Alaska tracks: the Pediatrics Track and the Internal Medicine Track.  The Pediatrics Track graduates three residents per year.  The Internal Medicine Track is currently recruiting its first cohort of three residents.

Alaska has two subspecialty fellowships, Hospice & Palliative Care Medicine, and Addiction Medicine.  Hospice & Palliative Care Medicine usually trains one fellow per year.  Addiction Medicine is training its first fellow this year.  Both fellowships are sponsored by Providence Alaska Medical Center.



Summary
Alaska has a shortage of physicians.  Alaska has only one independent GME program - AFMR.  AFMR has more applicants than training slots and trains physicians specifically for primary care practice in Alaska.  AFMR has one of the highest retention rates of any GME program – approximately seventy percent (70.8%) of graduates remain in Alaska.  More than 25% of Alaska’s family medicine physicians completed AFMR training.

The first article summarized GME funding and how Alaska is largely outside federal GME funding systems.  This article distinguishes WWAMI, UW, UME, GME and summarizes selected Alaska physician workforce issues.

Since 1997, there have been efforts to increase GME in Alaska.  Lack of understanding about GME and limited sustainable funding were obstacles.  Alaska policy leaders focused more on increasing the training of non-physicians, broadening the scope of practice of non-physicians, and expanding telemedicine.  Other states with similar challenges found pathways to meet these challenges.

Increasing GME in Alaska would increase the number of physicians in Alaska and would improve access to care, quality of care, and outcomes of care.29,30 What steps could Alaska policy leaders take to increase GME?

Recommendation 1:  Alaska GME Council
Idaho, Montana, and New Mexico created GME councils.  GME councils have been instrumental in developing GME in their respective states.  An Alaska GME council would be composed of Alaska physician workforce stakeholders and could report directly to the Alaska governor and legislature.  An Alaska GME council could measure, track, and recommend GME priorities to the Alaska governor and legislature.  The Alaska GME council mission, duties, and membership could be formalized in Alaska statutes like other boards, commissions, and advisory committees.  

Currently, there are multiple bills in the US Congress to increase and expand GME in high need communities and for high need medical specialties.  An Alaska GME council would be more effective than multiple individual GME stakeholder groups.  Alaska would benefit from a clear and unified GME vision and mission.

Recommendation 2:  Alaska Medicaid
Compared to other states, Alaska already has the fewest number of independent GME programs, fewest number of medical residents, and the lowest medical resident to population ratio in the US.  GME expansion in Alaska may be insurmountable given the current limited federal support for Alaska GME.  

Most states use Medicaid to support state-determined GME priorities.  In 2022, Medicaid GME totaled $7.34 billion.  Forty-three (43) states, the District of Columbia, and Puerto Rico used Medicaid to support GME.  If Alaska Medicaid supported GME at the national median per state resident amount ($10.60), Alaska would have invested $7.78 million with at least half being provided by the federal government.  There is a precedent for Alaska Medicaid supporting GME.  Alaska Medicaid supported GME in 2002, 2005, 2009, and 2012.

If Alaska Medicaid supported GME, it would signal to Alaska health care organizations, HRSA, the VA, and philanthropic organizations that the State of Alaska believes increasing GME in Alaska is a priority.  This would increase the likelihood of HRSA and VA GME funding. 

Recommendation 3:  Teaching Health Center
A teaching health center is a multidisciplinary outpatient clinic operated by a local consortium.  Alaska does not have a teaching health center that has applied for HRSA GME funding.  Between 2022 and 2024 HRSA provided $330 million for the development and operation of GME teaching health centers in 24 states.  Currently, no organization in Alaska is leading an effort to create a GME teaching health center.  A GME teaching health center would provide interdisciplinary training around primary care and could prioritize telemedicine and rural community consultation.  A GME teaching health center would improve access to care.  

Recommendation Summary
These recommendations would increase the number of physicians in Alaska and would improve access to medical care in Alaska.  A GME council would help the Alaska governor and legislators understand GME.  A GME council would provide recommendations about GME expansion.  Using Alaska Medicaid for GME may create opportunities for VA GME funding, HRSA GME funding, and maybe Medicare GME funding (for hospitals that do not yet have a Medicare resident cap).  Alaska VA GME would increase access to care for Alaska’s Veterans.  A HRSA supported GME teaching health center would increase access to care and would train physicians and others specifically for providing care to Alaskans. 

Increasing GME in Alaska will increase the number of physicians in Alaska and will improve access, quality, and outcomes of medical care – goals we all share.

Do you want to learn more?
A GME Summit will be held in Anchorage at the BP Energy Center April 25-26, 2024.  Please attend if you would like to learn more about GME and how other states overcame obstacles to expand GME.  https://www.uwmedicine.org/school-of-medicine/resources/gme-summit

Alexander von Hafften, MD
President, Alaska Psychiatric Association

This article was published in the Alaska State Medical Association Heartbeat February 2024.
It is posted with permission of the Alaska State Medical Association.



31. Rockey PH, Rieselbach RE, Neuhausen K, Nasca TJ, Phillips RL, Sundwall DN, Philibert I, Yaghmour NA. States Can Transform Their Health Care Workforce. Journal of Graduate Medical Education 2014. December;6(4):805-808.