Refer to: Schwarz MR: The WAMI program: A progress report (Medical Education). West J Med 130:384-390, Apr 1979
Medical Education
The
WAMI
Program:
A
Progress Report
M. ROY SCHWARZ, MD, Seattle
IN THE LATE 1960's and continuing into the early 1970's, a series of innovations in medical education were initiated in the United States. These occurred concurrently with a massive increase in the number of applicants to medical schools' and a perception that this country was facing a health care delivery crisis.2 Among these educational innovations were the development of organ system approaches to teaching,3 independent study programs,4 the use of computers in learning,5 the development of family medicine departments in schools of medicineG " and the initiation of decentralized medical education programs.8'9 One of the latter efforts, the WAMI (an acronym for Washington, Alaska, Montana and Idaho) program was established in 1970 to meet the needs of the Pacific Northwest and Alaska. The preliminary outcomes of the WAMI program were encouraging and were reported in this journal in 1974.10 The present report describes the developments in the WAMI program since then and shows that the goals of the program are being or have been achieved.
The WAMI Region The states of Washington, Alaska, Montana and Idaho, the WAMI states, represent 22 percent of the land mass in the United States and contain approximately 6 million people. Two thirds of the physicians and other health professionals in this region live in three areas including the Puget Sound region of Washington, the Anchorage area The author is Associate Dean for Academic Affairs, and tor, WAMI Program, University of Washington School of cine, Seattle. Submitted February 8, 1979. Reprint requests to: M. Roy Schwarz, MD, Office of the University of Washington School of Medicine, Seattle, WA
384
APRIL 1979 * 130 * 4
Direc-
Medi-
Dean, 98195.
of Alaska and the Treasure Valley of Idaho. The remaining third practice in the towns and rural communities of a region stretching across five time zones. The University of Washington in Seattle has the only medical school in the WAMI region. Because much of the land is mountainous and inaccessible, the population is sparse and widely separated. In the past 15 years various local and regional attempts by state and federal agencies to find solutions to the health problems of this region have proved to be ineffective and at times coun-
terproductive. The Health Problems in the WAMI States The WAMI program, which was proposed in 1970, was designed to meet four major health challenges in the Pacific Northwest and Alaska. 1. Admission to Medical School Beginning in the late 1960's a progressively greater number of students applied for admission to medical school without a corresponding increase in the class sizes of medical schools. This increase was especially important for states without medical schools because state-supported schools have traditionally afforded their own residents preferential access to the positions available. Admissions of out-of-state students have been uncertain and in the face of increased resident applicants were expected to be curtailed. 2. Lack of Primary Care Physicians In 1970, or the year the WAMI program was proposed, the WAMI states had too few family physicians, primary-care internists and primary-
WAMI PROGRAM
care pediatricians. This deficiency was especially severe in the more rural areas of the WAMI states.
.AMl
3. Maldistribution of Physicians In the early 1970's the majority of the physicians were located in the cities and larger towns, leaving large, sparsely populated areas with too few health professionals. When the geographic maldistribution was coupled with an insufficient number of primary care physicians, a severe shortage in the remote areas of the WAMI states was evident. 4. Access to Education and Health Care Resources Physicians in isolated communities have restricted access to educational resources. Because of this, physicians have felt isolated and physician turnover has been significant. In 1970 only a limited number of tertiary health care centers existed in the WAMI states. Since 18 major health care centers-including a neonatology center, a burn and trauma center, an epilepsy center, and a child development and mental retardation center-existed at the University of Washington Health Sciences Center and since there are no additional centers of these kinds in the region, it seemed desirable to find a way to bring these resources to communities with health care needs. Finally, the WAMI states did not have the fiscal resources to build and maintain additional medical schools. It was recognized, therefore, that any program designed to meet the health care and health education needs of the region could not include capital expenditures for new facilities.
A Two-Phase Program There are two separate phases in the WAMI program. In the first or university phase, four universities that do not have medical schools provide the first year of the medical school curriculum to medical students. This has allowed expansion of the entering class from 102 to 175, with 10, 20 and 20 first year position being reserved for Alaska, Montana and Idaho, respectively. In the 1977-78 academic year, 73 of the 175 students received their first year of training at Washington State University, the University of Alaska, Montana State University and the University of Idaho. Courses for the university phase are planned conjointly by faculty from the five universities so
i;
a
0
L
rA .A
... .In
-
.s ::
.-
..
ees;
Figure l.-WAMI program sites, 1979. UWSM =University of Washington School of Medicine Univ. Phase=university phase Int. Med.=internal medicine Ob. Gyn.=obstetrics and gynecology Psych. = psychiatry Family Med.=family medicine Peds. = pediatrics
that a "single, region-wide course" is taught at five locations by a "region wide" faculty. Medical faculty from Seattle travel to the universities to cover those portions of the courses where more than local faculty resources are needed. To monitor the academic quality of the program and to determine whether students are learning in the required way, a continuous and extensive evaluation program is conducted.:" At the end of the first year all students go to the University of Washington campus in Seattle for the second year of the curriculum and for the initial clerkships in the third year of the undergraduate medical educational process. Students then have the opportunity of participating in the second or community phase of the WAMI program. In this phase, students spend six weeks in community clinical units (ccu's) working with private physicians in rural communities in the four states. House staff officers in residency programs are also assigned to the ccu's for two to six months. These experiences in family medicine, internal medicine, pediatrics, psychiatry, and obstetrics and gynecology (Figure 1) are designed to provide a participant with an understanding of how the community is structured and functions, what roles a physician must play in such a community, and what skills and knowledge are required to deliver high-quality health services in THE WESTERN JOURNAL OF MEDICINE
385
WAMI PROGRAM
such a community. It was hoped that with such exposure, larger number of physicians would be attracted to careers in primary care in underserved areas. At least once every six weeks medical faculty from the medical school in Seattle visit each unit. During these visits faculty members review the progress of the students and residents, act as consultants to the practicing physicians and provide formal continuing medical education to all health professionals in the area. In this way the educational and patient-care resources that exist in Seattle are made available to the faculty and patients of the community clinical units as well as to other health professionals who practice in the area.
Program Developments Since 1974 A number of major developments have occurred in the WAMI program since 1974. * For the classes that entered in the fall of 1975, 1976, 1977 and 1978, 40 residents of Alaska, 79 residents of Idaho, 80 residents of Montana and 477 Washington residents were admitted to the University of Washington School of Medicine. This was achieved by establishing for each of the AMI states separate "interviewing" committees, which had as members University of Washington School of Medicine (uwsM) faculty and representatives from the individual states. A member of the UWSM faculty chaired each of the AMI interviewing committees. * Since the advent of the program, 403 students have been trained in the university phase of the program including 109 at Washington State University, 108 at the University of Idaho, 100 at Montana State University and 86 at the University of Alaska. Using 14 measures, including internal and external examinations, no significant differences in the performance of students have been found between the group,beginning at each university phase site and those who began at home base in Seattle." * The WAMI program has trained 837 students and 180 residents in the community phase of the program, including 414 and 43, respectively, in family medicine; 62 and 71 respectively, in internal medicine; 148 and 55 respectively, in pediatrics; 49 and 9 respectively, in psychiatry, and 158 students and 2 residents in obstetrics and gynecology. Using multiple types of evaluations including part II of the National Boards and a 386
APRIL 1979 * 130 * 4
Figure 2.-The number of students assigned to the individual WAMI program sites in January 1979.
comprehensive examination at the end of year III, no significant difference in performance was found in the subdisciplinary content areas between those students who had their basic clerkship experiences in the community phase of WAMI and those who had their experience in Seattle.'2 * Three family medicine community clinical units (ccu's) were closed because they no longer met program requirements. Six new units were opened, including family medicine units in Spokane, Washington; Pocatello, Idaho; Ketchikan, Alaska, and Anchorage, Alaska and Obstetric and Gynecology Units in Spokane and Anchorage. This has resulted in a total of 17 ccu's including seven in family medicine, one in psychiatry and three each in obstetrics and gynecology, pediatrics and internal medicine. At any one time, a total of 116 students out of a student body of 700 are receiving training in the university phase or the community phase of the program. (Figure 2). * A total of 24.86 full-time equivalents (FTE) and 69 different faculty members are involved in the university phase of the program at sites remote to Seattle. In addition, 186 community-based faculty are involved in the community phase and hold clinical appointments in appropriate departments at the UWSM. * Since 1975 faculty visits from the UWSM to each participating university have been made for the purpose of assisting in presenting courses at remote sites and helping to tie the regional system together. In addition to the "in-person" faculty visits, 120 faculty visits via satellite were made to the University of Alaska and Montana State University in the 1977-78 academic year and 120 are planned for the 1978-79 year. These satellite visits have involved full duplex audio and video interactive communication and have included the presentation of a nutrition course to students at the Fairbanks and Bozeman campuses,
WAMI PROGRAM
as well as presenting enrichment experiments in the various courses. * A total of 320 faculty visits from UWSM to ccu sites were conducted between 1975 and 1979. These faculty have presented continuing medical education courses to 12,800 attendees including physicians, nurses, physician extenders and other allied health professionals. * It has been shown that 97 percent of the students involved in the university phase and 87 percent of the students involved in the community phase have been enthusiastic about the program (T. C. Cullen, M. R. Schwarz, unpublished data). Diminishing student concerns have been heard concerning the quality of the program, isolation, fairness, uneven treatment, equivalency of learning and social amenities. * A longitudinal study of student career choices has been initiated designed to follow students for 25 years. Career preferences and expressions will be followed during medical school and residency training, and into active practice. * A total of 108 faculty workshops, seminars and "specialty days" have been presented to the faculty in the WAMI program during the past four years, with an average attendance of 35. Some of these have been scheduled in conjunction with the Annual Faculty Retreat. In addition, 33 physician preceptorships and faculty exchanges have been arranged through the WAMI Office of Continuing Medical Education. * Faculty performance evaluations have been provided by the Director of the WAMI program and the WAMI coordinators to appointments and promotions committees at the various universities. These have resulted in 21 faculty appointments or promotions for individuals involved in the WAMI
undertaking. * Each spring an annual WAMI faculty retreat is held involving university phase, community phase and University of Washington School of Medicine faculty members. The purpose of these retreats is to review the status of the program, resolve problems that have emerged, plan courses for subsequent years, share expertise and participate in continuing education in the form of speakers, panels and invited guests. Approximately 200 faculty attend these retreats, which have proven to be essential to the administration of this decentralized program. * Minor curriculum modifications have been made including a change in credits format and
hours of courses; developing common course objectives, contents, learning resources and evaluations, and the evolution of administrative procedures to govern the academic side of the program. The concept of "single courses taught at five sites by a single region-wide faculty" has been the guideline for curricular planning and implementation. * No major new facilities have been added to the program, although the student study areas at Montana State University, the University of Idaho and the University of Washington have been remodeled and modernized. In addition, a buildingremodeling program is being planned at Washington State University. * The total costs of the WAMI program are now appropriated by the legislatures of the four WAMI states. Cost increases due to inflation have averaged 5 percent over the last three years and are projected at 9.1 percent in fiscal year 1980 and 6.0 percent in fiscal year 1981. * In 1977 the WAMI program, along with the University of North Carolina Area Health Education Center (AHEC) system received the Richard and Hilda J. Rosenthal Award from the American College of Physicians for significant contributions to improving health care. * Regional health educational programs have been or are being developed at the University of Washington School of Medicine in laboratory technology, physical and occupational therapy, and dentistry. In addition, there has been significant interest in developing similar programs in other parts of the country by various health disciplines including dentistry, medicine, podiatry, veterinary medicine, optometry and allied health professions. This has mirrored an intense interest in regional cooperation by public policy makers at state and national levels. * In 1975 the WAMI program was reviewed by the Liaison Committee on Medical Education (LCME) and was granted full and unconditional accreditation for a seven-year period.
Program Outcomes The WAMI program was established in 1971 to accomplish five goals: 1. Increase the number of students admitted to medical school from the states of Washington, Alaska, Montana and Idaho. 2. Increase the number of students being trained for careers in primary care, including THE WESTERN JOURNAL OF MEDICINE
387
WAMI PROGRAM TABLE 1.-Increase in the Number of Medical Students Under the WAMI Program.
Average_Numbe
State
Admitted Admitted Pre-WAMI WAMI Students in Class E63-E70 E71-E78 1963-70 1971-78
Percent Change
Washington . 556 Alaska ..... 6 Montana .... 11 Idaho ...... 19 Other states . 71
867 58 104 105 66
69.5 .75 1.38 2.38 8.88
108.4 7.25 13.00 13.13 8.25
+56 +867 +845 +453 -7
Total ..... 663
1,200
82.88
150.00
+81
TABLE 2.-Increase in the Number of Primary Care Physicians Entering 1970
Students in family medicine pathway ...... 38 Students in clinical specialist pathway* ..... 26 Students choosing primary care .......... 64
Entering 1976
Percent Increase
84
121.1
45
73.1
129
101.1
*Number of students expressing career preference for primary care
internal
medicine
or
pediatrics.
E=entering; for example, E63 indicates entering Fall 1963
TABLE 3.-Location of Practices
family medicine and primary care internal medicine and pediatrics. 3. Place physicians in areas of need. 4. Bring the resources of the Medical Center in Seattle to the communities throughout the four states that have need of them. 5. Accomplish the programmatic goals without new capital construction. After seven years of programmatic activity, the following progress has been made on each of the goals. Admissions As can be seen in Table 1, there has been an 81 percent increase in the number of students admitted to the University of Washington School of Medicine since the WAMI program began. Included have been increases of 867 percent from the state of Alaska, 845 percent from the state of Montana, 453 percent from the state of Idaho and 56 percent from the state of Washington. Since these increases have been achieved without a change in the quality of the performance of these students, it is concluded that this goal has been achieved. Primary Care As may be seen in Table 2, there has been a 100 percent increase in the number of students choosing to enter primary care training pathways. This choice is first expressed at the end of the second year of the human biology curriculum and before students enter full-time clinical components of the curriculum. It is reaffirmed through a graduation questionnaire which is administered to all students at the time of graduation. It is significant that in addition to the 45 percent to 50 percent of each medical school class who choose careers in family medicine, another significant percentage 388
APRIL 1979 * 130 * 4
Population of Town/City
Non-WAMI Number Percentage
100,000+ .... 10,000-100,000 1,000-10,000 Other ........
138 74 38 26
Totals ......
276
50 26.8 13.8 9.4
100
WAMI Number Percentage
27 21 28 4 80
33.7 26.3 35 5 100
choose the clinical specialist pathway and opt for careers in primary care internal medicine and pediatrics. Since these figures have now been observed for a period of four to five years, it is concluded that the second goal is being achieved. Maldistribution of Physicians While sufficient data are not available to draw firm conclusions relative to achievement of this goal, it is exciting to review the data that are available at present. It should be pointed out in this regard that access to the WAMI program can be obtained through two different methods. The first involves being a participant in the program in the university phase in the first year of undergraduate medical education and the second involves entering the program through its community phase as a house staff officer or resident. Since only nine university phase participants completed their undergraduate and graduate training, there are too few data to draw any conclusions relative to students who "entered the program" by the first route. On the other hand, 80 residents have rotated through the community clinical units, completed their training and have practices (Table 3). A corresponding control group of 276 residents who have not rotated through the units have also begun practice. It is interesting to note a significant increase in the number of WAMI trainees who are choosing small towns for practice and a corresponding reduction in the number who are choos-
WAMI PROGRAM
ing towns with populations greater than 100,000 people. Resources to Community The goal of bringing the resources of the Health Science Center in Seattle to communities which have need of them in the Pacific Northwest and Alaska has been implemented in the following way: * Faculty Visits In conjunction with the teaching program of the university phase and the required review and consultation in the community phase, routine faculty visits to the various program sites have been developed. In the 1977-78 year, 326 faculty visits were made to WAMI program sites. While reviewing the progress of students and residents, the faculty also act as special consultants to the practicing physicians in the area. In addition, faculty presented 162 continuing education programs which have been attended by 3,412 health professionals. In some areas these visits have now been formalized into contracts with the communities in which the cost of the visits are paid for the practicing physicians in the communities which are served. * MEDCON
The University of Washington School of Medicine, at the urging of Dean Dr. Robert L. Van Citters, established a regional medical consultation program called MEDCON. This telephone network allows a physician anywhere in the WAMI states (and Oregon) to call the University of Washington School of Medicine toll free and request consultation on patient problems. During the 1977-78 academic year, 9,332 calls were received from physicians in the four states. These calls, which represent virtually all subdisciplinary areas of medicine, have become progressively more numerous each year since the inception of MEDCON. For example, a 98 percent increase in calls was seen during 1977-78 as compared with 1976-77. All costs for MEDCON are assumed by the School of Medicine. * Satellite Communication Beginning in 1974 the University of Washington School of Medicine has conducted a series of experiments involving the use of highly advanced communication satellites. Both the ATS-6 satellite and the CTS satellites used in these experiments
have had the technical capability of simultaneously transmitting two-way color television images and voice (full duplex audio video). Among the experiments being conducted are those concerned with the admissions process, minority recruitment, faculty sharing (where faculty at the University of Washington present courses or course segments designed to enrich the curriculum at the peripheral sites), consultation process (where the clinical expertise of the Health Sciences Center is brought to bear on specific problems in the region) and independent learning (where the satellite has been used to determine to what extent travel can be replaced by this communication modality in the continuing medical education process). In all, nearly 350 broadcasts have been presented and the general conclusion has been reached that satellite communication has significant applications for health education and health care in the future. * Regional Orientation In addition to the decentralization of the WAMI program, other regionalized health services programs are developing at the University of Washington. Examples are the regionalized Physical and Occupational Therapy program, a Regional Dental Education program and a joint degree program involving the School of Public Health and two other institutions in the region.
Construction While some remodeling has been done at various campuses to accommodate special curricular needs, no new buildings have been constructed to date in the WAMI program. Therefore, the goal of accomplishing the program's objectives without new capital construction has been achieved. It is clear from the review of the goals of the WAMI program, that four of the five goals are being met and that the data on the remaining goal, offsetting the maldistribution of physicians, look very promising.
Future In the future the evaluation of the WAMI program will continue with an eye toward demonstrating continued equivalence of learning, assessing faculty and student attitudes, documenting educational experiences in community clinical units and following students with a longitudinal study through at least 25 years of their careers. In addition, a regional network for graduate medical THE WESTERN JOURNAL OF MEDICINE
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WAMI PROGRAM
education, which is tailored to the needs of the region and the training needs of the medical education network (including the needs of the hospitals which are involved), will most likely be developed. A similar continuing medical education network with decreased travel by the faculty and increased communication through telephone and satellite, may also be established. Finally, programs to sustain physicians who establish practices in the region may develop and most likely will be aimed at reducing the turnover of physicians observed in various communities. Such an activity could involve a cooperative arrangement between communities, the institutions of the region and the envisioned networks of undergraduate, graduate and medical education. REFERENCES 1. Ceithaml J: The admissions process, In Recent Trends in Medical Education-Report of a Macy Conference. New York, NY, Josiah Macy, Jr. Foundation, 1976, pp 21-35 2. Higher Education and the Nation's Health: Policies for Medical and Dental Education- A special report and recommendations
by the Carnegie Commission on Higher Education. New York, McGraw-Hill Book Company, Inc., Oct 1970 3. Bowers JZ, Purcell EF: Teaching the Basic Sciences: Human Biology-Report of a Macy Conference. New York, NY, The Josiah Macy, Jr. Foundation, 1974 4. Trzebiatowski GL: Independent study programs: The state of the art, In Recent Trends in Medical Education. Report of a Macy Conference, Josiah Macy, Jr. Foundation. New York, New York, 1976, pp 111-126. 5. Jamison D, Suppes P, Wells S: The effectiveness of alternate instructional media: A survey. Rev Ed Res 44:1-67, 1974 6. Geyman JP: Family practice in evolution: Progress, problems and projections. N Engl J Med 293:593-601, 1978 7. Geyman JP, Deisher JB, Gordon MJ: A family practice residency network: Affiliated programs in the Pacific Northwest. JAMA 240:369-371, 1978 8. Grove WJ: Regional medical education: The University of Illinois, In Recent Trends in Medical Education. Report of a Macy Conference, Josiah Macy, Jr. Foundation, New York, New York, 1976, pp 203-224 9. Schwarz MR, Flahanet D: The WAMI programme, University of Washington School of Medicine, Seattle, Washington, United States of America: Decentralizing medical education in personnel for health care, In Katz FM, Fulop T: Case Studies of Educational Programmes. Geneva, WHO, 1978, pp 229-250 10. Schwarz MR: WAMI-An experiment in regional medical education (Medical Education). West J Med 121:333-341, Oct 1974 11. Cullen TC, Dohner CW, Striker GE, et al: The evaluation of student performance in decentralized basic science medical education: Methods and results. J Med Ed 51:473-477, 1976 12. Moy MLY, Schwarz MR, Zinser E: Evaluation of the community phase of a regionalized medical education program. Proc 15th Ann Conf on Research in Med Ed. Washington, DC, AAMC, 1977, pp 42-47
Determining Hospital Test Accuracy I THINK ONE always has to remember that what we say here coming from the university center and what you read in the journals may have no applicability to yourselves if, even though you have a test, you don't believe it or don't trust it. Then, performing it is of no value to you. So, no matter how good it may be in the literature, if it's not a good test in your hospital then obviously you have to use something else. -THOMAS D. BOYER, MD, San Francisco Extracted from Audio-Digest Internal Medicine Vol. 25, No. 23, in the Audio-Digest Foundation's subscription series of taperecorded programs. For subscription information: 1577 East Chevy Chase Drive, Glendale, CA 91206.
390
APRIL 1979 * 130 * 4
Medical Education
The
WAMI
Program:
A
Progress Report
M. ROY SCHWARZ, MD, Seattle
IN THE LATE 1960's and continuing into the early 1970's, a series of innovations in medical education were initiated in the United States. These occurred concurrently with a massive increase in the number of applicants to medical schools' and a perception that this country was facing a health care delivery crisis.2 Among these educational innovations were the development of organ system approaches to teaching,3 independent study programs,4 the use of computers in learning,5 the development of family medicine departments in schools of medicineG " and the initiation of decentralized medical education programs.8'9 One of the latter efforts, the WAMI (an acronym for Washington, Alaska, Montana and Idaho) program was established in 1970 to meet the needs of the Pacific Northwest and Alaska. The preliminary outcomes of the WAMI program were encouraging and were reported in this journal in 1974.10 The present report describes the developments in the WAMI program since then and shows that the goals of the program are being or have been achieved.
The WAMI Region The states of Washington, Alaska, Montana and Idaho, the WAMI states, represent 22 percent of the land mass in the United States and contain approximately 6 million people. Two thirds of the physicians and other health professionals in this region live in three areas including the Puget Sound region of Washington, the Anchorage area The author is Associate Dean for Academic Affairs, and tor, WAMI Program, University of Washington School of cine, Seattle. Submitted February 8, 1979. Reprint requests to: M. Roy Schwarz, MD, Office of the University of Washington School of Medicine, Seattle, WA
384
APRIL 1979 * 130 * 4
Direc-
Medi-
Dean, 98195.
of Alaska and the Treasure Valley of Idaho. The remaining third practice in the towns and rural communities of a region stretching across five time zones. The University of Washington in Seattle has the only medical school in the WAMI region. Because much of the land is mountainous and inaccessible, the population is sparse and widely separated. In the past 15 years various local and regional attempts by state and federal agencies to find solutions to the health problems of this region have proved to be ineffective and at times coun-
terproductive. The Health Problems in the WAMI States The WAMI program, which was proposed in 1970, was designed to meet four major health challenges in the Pacific Northwest and Alaska. 1. Admission to Medical School Beginning in the late 1960's a progressively greater number of students applied for admission to medical school without a corresponding increase in the class sizes of medical schools. This increase was especially important for states without medical schools because state-supported schools have traditionally afforded their own residents preferential access to the positions available. Admissions of out-of-state students have been uncertain and in the face of increased resident applicants were expected to be curtailed. 2. Lack of Primary Care Physicians In 1970, or the year the WAMI program was proposed, the WAMI states had too few family physicians, primary-care internists and primary-
WAMI PROGRAM
care pediatricians. This deficiency was especially severe in the more rural areas of the WAMI states.
.AMl
3. Maldistribution of Physicians In the early 1970's the majority of the physicians were located in the cities and larger towns, leaving large, sparsely populated areas with too few health professionals. When the geographic maldistribution was coupled with an insufficient number of primary care physicians, a severe shortage in the remote areas of the WAMI states was evident. 4. Access to Education and Health Care Resources Physicians in isolated communities have restricted access to educational resources. Because of this, physicians have felt isolated and physician turnover has been significant. In 1970 only a limited number of tertiary health care centers existed in the WAMI states. Since 18 major health care centers-including a neonatology center, a burn and trauma center, an epilepsy center, and a child development and mental retardation center-existed at the University of Washington Health Sciences Center and since there are no additional centers of these kinds in the region, it seemed desirable to find a way to bring these resources to communities with health care needs. Finally, the WAMI states did not have the fiscal resources to build and maintain additional medical schools. It was recognized, therefore, that any program designed to meet the health care and health education needs of the region could not include capital expenditures for new facilities.
A Two-Phase Program There are two separate phases in the WAMI program. In the first or university phase, four universities that do not have medical schools provide the first year of the medical school curriculum to medical students. This has allowed expansion of the entering class from 102 to 175, with 10, 20 and 20 first year position being reserved for Alaska, Montana and Idaho, respectively. In the 1977-78 academic year, 73 of the 175 students received their first year of training at Washington State University, the University of Alaska, Montana State University and the University of Idaho. Courses for the university phase are planned conjointly by faculty from the five universities so
i;
a
0
L
rA .A
... .In
-
.s ::
.-
..
ees;
Figure l.-WAMI program sites, 1979. UWSM =University of Washington School of Medicine Univ. Phase=university phase Int. Med.=internal medicine Ob. Gyn.=obstetrics and gynecology Psych. = psychiatry Family Med.=family medicine Peds. = pediatrics
that a "single, region-wide course" is taught at five locations by a "region wide" faculty. Medical faculty from Seattle travel to the universities to cover those portions of the courses where more than local faculty resources are needed. To monitor the academic quality of the program and to determine whether students are learning in the required way, a continuous and extensive evaluation program is conducted.:" At the end of the first year all students go to the University of Washington campus in Seattle for the second year of the curriculum and for the initial clerkships in the third year of the undergraduate medical educational process. Students then have the opportunity of participating in the second or community phase of the WAMI program. In this phase, students spend six weeks in community clinical units (ccu's) working with private physicians in rural communities in the four states. House staff officers in residency programs are also assigned to the ccu's for two to six months. These experiences in family medicine, internal medicine, pediatrics, psychiatry, and obstetrics and gynecology (Figure 1) are designed to provide a participant with an understanding of how the community is structured and functions, what roles a physician must play in such a community, and what skills and knowledge are required to deliver high-quality health services in THE WESTERN JOURNAL OF MEDICINE
385
WAMI PROGRAM
such a community. It was hoped that with such exposure, larger number of physicians would be attracted to careers in primary care in underserved areas. At least once every six weeks medical faculty from the medical school in Seattle visit each unit. During these visits faculty members review the progress of the students and residents, act as consultants to the practicing physicians and provide formal continuing medical education to all health professionals in the area. In this way the educational and patient-care resources that exist in Seattle are made available to the faculty and patients of the community clinical units as well as to other health professionals who practice in the area.
Program Developments Since 1974 A number of major developments have occurred in the WAMI program since 1974. * For the classes that entered in the fall of 1975, 1976, 1977 and 1978, 40 residents of Alaska, 79 residents of Idaho, 80 residents of Montana and 477 Washington residents were admitted to the University of Washington School of Medicine. This was achieved by establishing for each of the AMI states separate "interviewing" committees, which had as members University of Washington School of Medicine (uwsM) faculty and representatives from the individual states. A member of the UWSM faculty chaired each of the AMI interviewing committees. * Since the advent of the program, 403 students have been trained in the university phase of the program including 109 at Washington State University, 108 at the University of Idaho, 100 at Montana State University and 86 at the University of Alaska. Using 14 measures, including internal and external examinations, no significant differences in the performance of students have been found between the group,beginning at each university phase site and those who began at home base in Seattle." * The WAMI program has trained 837 students and 180 residents in the community phase of the program, including 414 and 43, respectively, in family medicine; 62 and 71 respectively, in internal medicine; 148 and 55 respectively, in pediatrics; 49 and 9 respectively, in psychiatry, and 158 students and 2 residents in obstetrics and gynecology. Using multiple types of evaluations including part II of the National Boards and a 386
APRIL 1979 * 130 * 4
Figure 2.-The number of students assigned to the individual WAMI program sites in January 1979.
comprehensive examination at the end of year III, no significant difference in performance was found in the subdisciplinary content areas between those students who had their basic clerkship experiences in the community phase of WAMI and those who had their experience in Seattle.'2 * Three family medicine community clinical units (ccu's) were closed because they no longer met program requirements. Six new units were opened, including family medicine units in Spokane, Washington; Pocatello, Idaho; Ketchikan, Alaska, and Anchorage, Alaska and Obstetric and Gynecology Units in Spokane and Anchorage. This has resulted in a total of 17 ccu's including seven in family medicine, one in psychiatry and three each in obstetrics and gynecology, pediatrics and internal medicine. At any one time, a total of 116 students out of a student body of 700 are receiving training in the university phase or the community phase of the program. (Figure 2). * A total of 24.86 full-time equivalents (FTE) and 69 different faculty members are involved in the university phase of the program at sites remote to Seattle. In addition, 186 community-based faculty are involved in the community phase and hold clinical appointments in appropriate departments at the UWSM. * Since 1975 faculty visits from the UWSM to each participating university have been made for the purpose of assisting in presenting courses at remote sites and helping to tie the regional system together. In addition to the "in-person" faculty visits, 120 faculty visits via satellite were made to the University of Alaska and Montana State University in the 1977-78 academic year and 120 are planned for the 1978-79 year. These satellite visits have involved full duplex audio and video interactive communication and have included the presentation of a nutrition course to students at the Fairbanks and Bozeman campuses,
WAMI PROGRAM
as well as presenting enrichment experiments in the various courses. * A total of 320 faculty visits from UWSM to ccu sites were conducted between 1975 and 1979. These faculty have presented continuing medical education courses to 12,800 attendees including physicians, nurses, physician extenders and other allied health professionals. * It has been shown that 97 percent of the students involved in the university phase and 87 percent of the students involved in the community phase have been enthusiastic about the program (T. C. Cullen, M. R. Schwarz, unpublished data). Diminishing student concerns have been heard concerning the quality of the program, isolation, fairness, uneven treatment, equivalency of learning and social amenities. * A longitudinal study of student career choices has been initiated designed to follow students for 25 years. Career preferences and expressions will be followed during medical school and residency training, and into active practice. * A total of 108 faculty workshops, seminars and "specialty days" have been presented to the faculty in the WAMI program during the past four years, with an average attendance of 35. Some of these have been scheduled in conjunction with the Annual Faculty Retreat. In addition, 33 physician preceptorships and faculty exchanges have been arranged through the WAMI Office of Continuing Medical Education. * Faculty performance evaluations have been provided by the Director of the WAMI program and the WAMI coordinators to appointments and promotions committees at the various universities. These have resulted in 21 faculty appointments or promotions for individuals involved in the WAMI
undertaking. * Each spring an annual WAMI faculty retreat is held involving university phase, community phase and University of Washington School of Medicine faculty members. The purpose of these retreats is to review the status of the program, resolve problems that have emerged, plan courses for subsequent years, share expertise and participate in continuing education in the form of speakers, panels and invited guests. Approximately 200 faculty attend these retreats, which have proven to be essential to the administration of this decentralized program. * Minor curriculum modifications have been made including a change in credits format and
hours of courses; developing common course objectives, contents, learning resources and evaluations, and the evolution of administrative procedures to govern the academic side of the program. The concept of "single courses taught at five sites by a single region-wide faculty" has been the guideline for curricular planning and implementation. * No major new facilities have been added to the program, although the student study areas at Montana State University, the University of Idaho and the University of Washington have been remodeled and modernized. In addition, a buildingremodeling program is being planned at Washington State University. * The total costs of the WAMI program are now appropriated by the legislatures of the four WAMI states. Cost increases due to inflation have averaged 5 percent over the last three years and are projected at 9.1 percent in fiscal year 1980 and 6.0 percent in fiscal year 1981. * In 1977 the WAMI program, along with the University of North Carolina Area Health Education Center (AHEC) system received the Richard and Hilda J. Rosenthal Award from the American College of Physicians for significant contributions to improving health care. * Regional health educational programs have been or are being developed at the University of Washington School of Medicine in laboratory technology, physical and occupational therapy, and dentistry. In addition, there has been significant interest in developing similar programs in other parts of the country by various health disciplines including dentistry, medicine, podiatry, veterinary medicine, optometry and allied health professions. This has mirrored an intense interest in regional cooperation by public policy makers at state and national levels. * In 1975 the WAMI program was reviewed by the Liaison Committee on Medical Education (LCME) and was granted full and unconditional accreditation for a seven-year period.
Program Outcomes The WAMI program was established in 1971 to accomplish five goals: 1. Increase the number of students admitted to medical school from the states of Washington, Alaska, Montana and Idaho. 2. Increase the number of students being trained for careers in primary care, including THE WESTERN JOURNAL OF MEDICINE
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WAMI PROGRAM TABLE 1.-Increase in the Number of Medical Students Under the WAMI Program.
Average_Numbe
State
Admitted Admitted Pre-WAMI WAMI Students in Class E63-E70 E71-E78 1963-70 1971-78
Percent Change
Washington . 556 Alaska ..... 6 Montana .... 11 Idaho ...... 19 Other states . 71
867 58 104 105 66
69.5 .75 1.38 2.38 8.88
108.4 7.25 13.00 13.13 8.25
+56 +867 +845 +453 -7
Total ..... 663
1,200
82.88
150.00
+81
TABLE 2.-Increase in the Number of Primary Care Physicians Entering 1970
Students in family medicine pathway ...... 38 Students in clinical specialist pathway* ..... 26 Students choosing primary care .......... 64
Entering 1976
Percent Increase
84
121.1
45
73.1
129
101.1
*Number of students expressing career preference for primary care
internal
medicine
or
pediatrics.
E=entering; for example, E63 indicates entering Fall 1963
TABLE 3.-Location of Practices
family medicine and primary care internal medicine and pediatrics. 3. Place physicians in areas of need. 4. Bring the resources of the Medical Center in Seattle to the communities throughout the four states that have need of them. 5. Accomplish the programmatic goals without new capital construction. After seven years of programmatic activity, the following progress has been made on each of the goals. Admissions As can be seen in Table 1, there has been an 81 percent increase in the number of students admitted to the University of Washington School of Medicine since the WAMI program began. Included have been increases of 867 percent from the state of Alaska, 845 percent from the state of Montana, 453 percent from the state of Idaho and 56 percent from the state of Washington. Since these increases have been achieved without a change in the quality of the performance of these students, it is concluded that this goal has been achieved. Primary Care As may be seen in Table 2, there has been a 100 percent increase in the number of students choosing to enter primary care training pathways. This choice is first expressed at the end of the second year of the human biology curriculum and before students enter full-time clinical components of the curriculum. It is reaffirmed through a graduation questionnaire which is administered to all students at the time of graduation. It is significant that in addition to the 45 percent to 50 percent of each medical school class who choose careers in family medicine, another significant percentage 388
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Population of Town/City
Non-WAMI Number Percentage
100,000+ .... 10,000-100,000 1,000-10,000 Other ........
138 74 38 26
Totals ......
276
50 26.8 13.8 9.4
100
WAMI Number Percentage
27 21 28 4 80
33.7 26.3 35 5 100
choose the clinical specialist pathway and opt for careers in primary care internal medicine and pediatrics. Since these figures have now been observed for a period of four to five years, it is concluded that the second goal is being achieved. Maldistribution of Physicians While sufficient data are not available to draw firm conclusions relative to achievement of this goal, it is exciting to review the data that are available at present. It should be pointed out in this regard that access to the WAMI program can be obtained through two different methods. The first involves being a participant in the program in the university phase in the first year of undergraduate medical education and the second involves entering the program through its community phase as a house staff officer or resident. Since only nine university phase participants completed their undergraduate and graduate training, there are too few data to draw any conclusions relative to students who "entered the program" by the first route. On the other hand, 80 residents have rotated through the community clinical units, completed their training and have practices (Table 3). A corresponding control group of 276 residents who have not rotated through the units have also begun practice. It is interesting to note a significant increase in the number of WAMI trainees who are choosing small towns for practice and a corresponding reduction in the number who are choos-
WAMI PROGRAM
ing towns with populations greater than 100,000 people. Resources to Community The goal of bringing the resources of the Health Science Center in Seattle to communities which have need of them in the Pacific Northwest and Alaska has been implemented in the following way: * Faculty Visits In conjunction with the teaching program of the university phase and the required review and consultation in the community phase, routine faculty visits to the various program sites have been developed. In the 1977-78 year, 326 faculty visits were made to WAMI program sites. While reviewing the progress of students and residents, the faculty also act as special consultants to the practicing physicians in the area. In addition, faculty presented 162 continuing education programs which have been attended by 3,412 health professionals. In some areas these visits have now been formalized into contracts with the communities in which the cost of the visits are paid for the practicing physicians in the communities which are served. * MEDCON
The University of Washington School of Medicine, at the urging of Dean Dr. Robert L. Van Citters, established a regional medical consultation program called MEDCON. This telephone network allows a physician anywhere in the WAMI states (and Oregon) to call the University of Washington School of Medicine toll free and request consultation on patient problems. During the 1977-78 academic year, 9,332 calls were received from physicians in the four states. These calls, which represent virtually all subdisciplinary areas of medicine, have become progressively more numerous each year since the inception of MEDCON. For example, a 98 percent increase in calls was seen during 1977-78 as compared with 1976-77. All costs for MEDCON are assumed by the School of Medicine. * Satellite Communication Beginning in 1974 the University of Washington School of Medicine has conducted a series of experiments involving the use of highly advanced communication satellites. Both the ATS-6 satellite and the CTS satellites used in these experiments
have had the technical capability of simultaneously transmitting two-way color television images and voice (full duplex audio video). Among the experiments being conducted are those concerned with the admissions process, minority recruitment, faculty sharing (where faculty at the University of Washington present courses or course segments designed to enrich the curriculum at the peripheral sites), consultation process (where the clinical expertise of the Health Sciences Center is brought to bear on specific problems in the region) and independent learning (where the satellite has been used to determine to what extent travel can be replaced by this communication modality in the continuing medical education process). In all, nearly 350 broadcasts have been presented and the general conclusion has been reached that satellite communication has significant applications for health education and health care in the future. * Regional Orientation In addition to the decentralization of the WAMI program, other regionalized health services programs are developing at the University of Washington. Examples are the regionalized Physical and Occupational Therapy program, a Regional Dental Education program and a joint degree program involving the School of Public Health and two other institutions in the region.
Construction While some remodeling has been done at various campuses to accommodate special curricular needs, no new buildings have been constructed to date in the WAMI program. Therefore, the goal of accomplishing the program's objectives without new capital construction has been achieved. It is clear from the review of the goals of the WAMI program, that four of the five goals are being met and that the data on the remaining goal, offsetting the maldistribution of physicians, look very promising.
Future In the future the evaluation of the WAMI program will continue with an eye toward demonstrating continued equivalence of learning, assessing faculty and student attitudes, documenting educational experiences in community clinical units and following students with a longitudinal study through at least 25 years of their careers. In addition, a regional network for graduate medical THE WESTERN JOURNAL OF MEDICINE
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WAMI PROGRAM
education, which is tailored to the needs of the region and the training needs of the medical education network (including the needs of the hospitals which are involved), will most likely be developed. A similar continuing medical education network with decreased travel by the faculty and increased communication through telephone and satellite, may also be established. Finally, programs to sustain physicians who establish practices in the region may develop and most likely will be aimed at reducing the turnover of physicians observed in various communities. Such an activity could involve a cooperative arrangement between communities, the institutions of the region and the envisioned networks of undergraduate, graduate and medical education. REFERENCES 1. Ceithaml J: The admissions process, In Recent Trends in Medical Education-Report of a Macy Conference. New York, NY, Josiah Macy, Jr. Foundation, 1976, pp 21-35 2. Higher Education and the Nation's Health: Policies for Medical and Dental Education- A special report and recommendations
by the Carnegie Commission on Higher Education. New York, McGraw-Hill Book Company, Inc., Oct 1970 3. Bowers JZ, Purcell EF: Teaching the Basic Sciences: Human Biology-Report of a Macy Conference. New York, NY, The Josiah Macy, Jr. Foundation, 1974 4. Trzebiatowski GL: Independent study programs: The state of the art, In Recent Trends in Medical Education. Report of a Macy Conference, Josiah Macy, Jr. Foundation. New York, New York, 1976, pp 111-126. 5. Jamison D, Suppes P, Wells S: The effectiveness of alternate instructional media: A survey. Rev Ed Res 44:1-67, 1974 6. Geyman JP: Family practice in evolution: Progress, problems and projections. N Engl J Med 293:593-601, 1978 7. Geyman JP, Deisher JB, Gordon MJ: A family practice residency network: Affiliated programs in the Pacific Northwest. JAMA 240:369-371, 1978 8. Grove WJ: Regional medical education: The University of Illinois, In Recent Trends in Medical Education. Report of a Macy Conference, Josiah Macy, Jr. Foundation, New York, New York, 1976, pp 203-224 9. Schwarz MR, Flahanet D: The WAMI programme, University of Washington School of Medicine, Seattle, Washington, United States of America: Decentralizing medical education in personnel for health care, In Katz FM, Fulop T: Case Studies of Educational Programmes. Geneva, WHO, 1978, pp 229-250 10. Schwarz MR: WAMI-An experiment in regional medical education (Medical Education). West J Med 121:333-341, Oct 1974 11. Cullen TC, Dohner CW, Striker GE, et al: The evaluation of student performance in decentralized basic science medical education: Methods and results. J Med Ed 51:473-477, 1976 12. Moy MLY, Schwarz MR, Zinser E: Evaluation of the community phase of a regionalized medical education program. Proc 15th Ann Conf on Research in Med Ed. Washington, DC, AAMC, 1977, pp 42-47
Determining Hospital Test Accuracy I THINK ONE always has to remember that what we say here coming from the university center and what you read in the journals may have no applicability to yourselves if, even though you have a test, you don't believe it or don't trust it. Then, performing it is of no value to you. So, no matter how good it may be in the literature, if it's not a good test in your hospital then obviously you have to use something else. -THOMAS D. BOYER, MD, San Francisco Extracted from Audio-Digest Internal Medicine Vol. 25, No. 23, in the Audio-Digest Foundation's subscription series of taperecorded programs. For subscription information: 1577 East Chevy Chase Drive, Glendale, CA 91206.
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