Partnerships to Establish and Sustain Rural GME: Q and A with Marianna Worczak, MD of Champlain Valley Physicians Hospital
This interview is part of a series featuring Sponsoring Institutions and programs providing rural graduate medical education (GME) experiences. The series was initiated following the 2022 ACGME Annual Educational Conference presentation on Medically Underserved Areas/Populations: Partnerships to Establish and Sustain Rural GME, available in the ACGME’s digital learning portal, Learn at ACGME. Note: an account (free to create) is required to access most content in Learn at ACGME.
The University of Vermont Health Network (UVMHN) Champlain Valley Physicians Hospital (CVPH) is a large community hospital of about 300 beds that provides care to a wide radius of mostly rural communities and counties surrounding the immediate Plattsburgh area. CVPH is part of the larger UVMHN and one of three UVMHN hospitals in New York, the other two being critical access hospitals. The closest referral center is the University of Vermont (UVM) Medical Center (UVMMC), which is just over 20 miles away but takes a little over an hour and a ferry ride across Lake Champlain to reach. The Sponsoring Institution currently sponsors a family medicine program with 18 residents (six per year). The residents have continuity clinic at one of two sites, the CVPH Family Medicine Center in downtown Plattsburgh and the Hudson Headwaters Health Network (HHHN) Champlain Family Health Clinic, a Federally Qualified Health Center 20 minutes north of Plattsburgh in Champlain, New York. The program offers even more rural experiences at the two New York critical access hospitals. Key curricular highlights include a focus on rural health; rural rotations in either Elizabethtown or Malone, New York; a robust inpatient teaching service; heavy emphasis on mental health and addiction medicine; a new robust point-of-care ultrasound curriculum; and a wilderness medicine elective. Residents primarily stay locally following residency, with more than 60 percent choosing to practice in “The North Country” or nearby regions of rural northern Vermont.
Marianna Worczak, MD currently serves as both the residency program director and the designated institutional official for CVPH Family Medicine. She spends most of her time administering the program, which includes developing the curriculum, recruiting residents, working with hospital departments to ensure excellent education and training experiences, directly teaching residents, and evaluating resident performance. Clinically, she practices both outpatient and inpatient medicine with her outpatient clinic at the CVPH Family Medicine Center. Dr. Worczak is board certified in family medicine and lifestyle medicine. Her professional interests include addiction medicine/mental health as integrated into primary care, diabetes care, and lifestyle medicine.
ACGME: What drew you to academic medicine and to rural GME specifically?
Dr. Worczak: I am not sure exactly why, but I have always loved teaching. I grew up in a rural town in western New York, and my first job was as a children’s ski instructor. I ended up in academic medicine when my former residency program director, Dr. John King, transitioned from program director at UVM to start the program in Plattsburgh, New York where I currently practice. When I started as a core faculty member, I helped write the curriculum for the program. Shortly after starting here, one thing led to another and I became an associate program director, and then program director. The balance of teaching in medicine and practicing medicine seems natural to me. It allows me to keep my scope of medicine broad, keeps me clinically sharp, and I find it very rewarding to watch residents grow over three years. Nothing is more satisfying than seeing physicians we trained in the community doing well.
ACGME: Describe the rural GME experiences within your program (e.g., types of sites, structure, curriculum, etc.).
Dr. Worczak: Plattsburgh itself is a small city of about 19,000, but immediately outside of Plattsburgh and in the tri-county area of Clinton, Essex, and Franklin Counties, the communities are rural. The majority of the population we serve in the clinic and hospital is rural. Two residents per year have their continuity clinic at the HHHN FQHC clinic in Champlain, New York, a rural town of about 5,000 that sits on the Canadian border. Residents do a one-month rotation during their PGY-2 that is typically a mixture of inpatient and outpatient medicine at one of our nearby critical access hospitals. Several residents choose to return to these hospitals for elective rotations. We also have a wilderness medicine elective that includes a wilderness medicine first responder course. One of our program’s goals is community outreach. We offer several programs for this, but two we have recently grown are a monthly chapter of Walk-With-A-Doc and residents going to local elementary schools to teach in the after-school program. Teaching about social determinants of health is a key part of the didactic curriculum and part of daily teaching in clinics and inpatient rounds.
ACGME: How did your Sponsoring Institution/program become involved in establishing rural GME experiences?
Dr. Worczak: Starting in about 2012, CVPH began investigating the feasibility of a rural residency program. They looked at available community needs assessment data and hired a Residency Program Solutions consultant. Discussions were also held around what types of GME to invest in to meet the patient population’s needs. It was determined that, on average, about 60 percent of residents stay within a 60-mile radius of their residency program upon graduation. So investing in GME made sense. Likewise, it was determined that family medicine, having the broadest and most flexible scope of specialties, could best serve the rural area. To make education and training in the North Country more attractive, five local health care facilities agreed to support a loan repayment plan for residents who completed residency at CVPH and took jobs in their institutions upon graduation.
ACGME: Describe the internal and external partnerships that have been important in establishing and sustaining these experiences.
Dr. Worczak: The program started with many partnerships. At the time, CVPH had just begun integration into the UVMHN. Our founding program director was the prior program director at the UVMMC program. The costs of starting the program were largely supported by local partners donating to the CVPH Foundation on our behalf; and we started with >$2 million dollars. The Miner Institute was one of our key initial sponsors. As I mentioned, five local health care organizations agreed to provide initial loan repayment for graduates of the program who chose employment with them after graduation. We partnered with our academic medical center, UVMMC, for some rotations (like obstetrics and gynecology) and collaborated with their existing residency program for policies and procedures. HHHN has been a very active partner, and one of its clinics serves as one of our FMP sites. For clinical rotations, we drew from hospital, network, and private offices. We partnered with the health department, NAMI, Hospice for the North Country, several county behavioral health organizations, and Champlain Valley Family Center for some rotations and education in the social determinants of health. Lectures and didactic presentations were provided primarily by volunteer faculty members who shared teaching interests.
ACGME: Describe the challenges you have experienced in developing and sustaining rural GME partnerships and experiences; and explain how you have overcome them.
Dr. Worczak: We have experienced our share of challenges. One is that in a rural area, if a specialty exists at all, it is often the only one of its kind. We’ve struggled with specialty rotations. At times we’ve had to be creative. For example, dermatology is lacking in our area; so our dermatology experience includes both dermatology office and plastic surgery office time, as our plastic surgeon in town does most of our skin biopsies. We’ve also had to be flexible with where residents have experiences, and at times provide housing if an experience is more than a 60-minute drive away. We often will look at what we do have volume of and try to build experiences around that. For care of ill children, there are volume amounts for both emergency department (ED) and inpatient rotations. We do send our residents away for a true inpatient pediatrics rotation, but to complement this, we created a pediatric ED rotation in which the residents are scheduled at evening/night hours when kids tend to go to the ED, and they intentionally see each pediatric visit.
ACGME: Describe some of your program’s outcomes since establishing rural GME experiences, including the impact to the surrounding community.
Dr. Worczak: The biggest impacts I can comment on include primary care physician retention and options for Opioid Use Disorder (OUD) treatment. We have graduated 29 residents since our program began and more than 60 percent have stayed in the community. We also train all residents to treat OUD in the outpatient setting with buprenorphine, and have nearly 200 patients in our primary care clinic receiving this treatment as a result.
ACGME: What advice do you have for those interested in establishing rural GME experiences?
Dr. Worczak: I think that rural areas can provide great opportunities for residents. A strong family medicine continuity clinic is key. Forming partnerships early and often with specialists in the community is very important. It’s also important to help specialists see the value of educating and training skilled family physicians so they can become skilled colleagues. Recruitment of solid residents is also key to a strong program. We have found that looking at characteristics like grit and emotional intelligence are crucial and much more important than high test scores. International medical student applicants have often been some of our best residents. Rural areas also often can sponsor J-1 visas or other options for these graduates and can help them establish roots in rural communities after graduation.
ACGME: Describe the resources that have helped your program to establish rural GME experiences.
Dr. Worczak: I believe we had an initial consultation with the American Academy of Family Physicians’ RPS program at the onset of our program. This helped us establish financial plans and assess size-of-program and other feasibility concerns.
Email muap@acgme.org if you want to get in touch with Dr. Worczak. Is your Sponsoring Institution/program already providing rural GME experiences and would you like to be featured in a future post in this ACGME Blog series? Email muap@acgme.org to share what you’re doing. Visit the MUA/P web page to learn more about the ACGME’s efforts.