The Heart of Innovation at Waco Family Medicine
An Update On Our Street Medicine Program
Our street medicine program is off and running, and exceeding expectations. The national average for street medicine programs is to see 5 patients per half day. That rate would put our team at around 220 encounters, but they are closing in on 300! Congrats to Dr. Humphrey and her team.
Waco Family Medicine Institute
It is July, which means that there are 12 fresh faces walking the halls of Waco Family Medicine. Well, there’s more than that, but I’m specifically referring to our new class of 2029 medical residents who started this month. That’s 12 graduates of medical schools who applied and were accepted into one of the nation’s best residency programs.
You might think I’m being a homer and employing hyperbolic language, but I’m not. Waco Family Medicine’s Institute (AKA our residency program) is in the top 2% in the country. Over 550 applicants applied for 12 spots, and these lucky 12, along with their stellar applications, were selected to do their work here. How do I know it’s in the top 2% in the country? Doximity’s national residency ranking lists the program among the top 2% in the country.
There are indicators that allow one to make such claims. For example, the national average for the first-time pass rate for medical boards is 88%. The first-time pass rate for WFM graduates is 100%. And those passing scores, on average, finish around the 90th percentile among all test takers nationally.
Here’s another interesting metric, if you can wrap your mind around it. Family Medicine is not considered a “prestigious” specialty like Dermatology or Radiology. But the test scores and caliber of applicant interviewed and accepted by WFM is at or above the level of some prestige specialties in the US.
But it’s not just the data; it’s the program itself. It’s the opportunities that residents are given. Because Waco Family Medicine is a federally qualified health center, our family medicine residents get full-spectrum training, which includes vaginal deliveries, operative OB, critical care, and work with newborns and infants. It also means they get community clinic exposure as well as training in hospital settings. And because our family practice care is integrated within the larger organization, our residents also get experience addressing patients’ social determinants of health. Said differently, they are trained to address patients’ needs that impact health through lack of access to healthy food, shelter, transportation, and other social factors.
Residents can also opt to focus their residency program with tracks. These are focused areas of emphasis that specify the nature of family medicine training. Those track options are community health, Spanish language proficiency, comprehensive maternity care, and global health. Beyond the family practice residency, the Institute also offers three fellowship programs in sports medicine, hospice & palliative medicine, and clinical informatics.
Origins
The Institute didn’t arrive in a vacuum or without cause. In the late 1960s, there was a growing problem in Waco: a lack of primary care physicians to care for the indigent population. In February of 1962, then-city manager Terrell Blodget presented a report on the abiding concern for the health problems in the community. The report included the fact that the one physician in charge of the indigent clinic at 605 Columbus Ave. was quarter-time. Blodget recommended that the city establish a contract with Providence Hospital to allow the outpatient indigent clinic to exist within the hospital, giving access to the hospital’s lab, X-ray, and pharmacy services. He also recommended making the one physician at least half-time.
The McLennan County Medical Society took note. They assembled a steering committee to help address the concern. By the late sixties, it was evident that the problem wasn’t just one of logistics and facilities, it was one of workforce supply. Dr. David Dow made a report to the Society with some startling data. In McLennan County, the average age of the physicians was 51 compared to the national average of 45. In addition, more than 60% were over 50, and 33% were from 50 to 59, whereas those in the 40-to-49 group made up less than 20%. The math for the replacement rate was bleak.
What was more, the Texas Medical Association was reporting that, in recent years, fewer than half of the new physicians coming to practice medicine in Texas were native Texans. Texas had a doctor supply problem.
Central Texas was particularly vulnerable. At the time, the national average doctor-to-population ratio was one doctor for every 600 people. Texas’s average was slightly worse at one doctor for every 800 people. But McLennan County was at an abysmal one doctor for every 1,200 people. And the local physicians were feeling the strain.
The problem of caring for the indigent population was addressed with a makeshift solution. Waco’s doctor population suffered from maldistribution. There were 13 general practitioners, 22 internists, and 44 surgeons, with the remainder of physicians in other specialties. Said differently, if there were 100 doctors, only 9 of them would be primary care physicians. This meant a team effort that put specialists on a rather robust volunteer schedule to attend to the indigent clinic. Some specialists, like ear, nose, and throat physicians and neurosurgeons, were on the “call roster” every 3 nights.
When Dr. Dow made his report in 1962, it was on the heels of a particularly bad week when two primary care physicians had recently died and several others were limiting their practices.
Over the next several years, a steering committee was formed out of the medical society, and those efforts eventually yielded a family practice residency program that opened on July 1, 1970, in the basement of Providence Hospital, which at that time was located on the property adjacent to our central administration building. Fifty-five years later, Waco Family Medicine’s Institute has interviewed over 15,000 applicants, sat through nearly 4,000 interviews, and graduated almost 550 primary care physicians.
It’s easy to calculate the impact. The national average is 27 primary care physicians per 100,000 people. McLennan County’s is 62 PCPs per 100,000 people, which is also substantially higher than Texas’s average as a whole. In fact, there are only five counties in the entire state of Texas that beat that average. What’s more, 81% of the primary care physicians in Waco are graduates of the Institute.
In every measurable way, that visionary decision of the steering committee accomplished its goals. And it’s not just that we have great physicians in Waco; it’s also that we are all saving tangible dollars because of it. Even though Waco’s poverty rate (26%) is almost double Texas’s state average (14.3%), McLennan County ranks in the bottom 20th percentile for standardized Medicare costs per capita. And that’s because primary care has consistently proven to be the most cost-effective medical investment that can be made. For every $1 spent on primary care, taxpayers save between $6 and, in its most efficient form of practice, $13 downstream.
Incoming Residents
I had the opportunity to steal a half hour with our incoming residents to ask them about why they applied to Waco Family Medicine’s residency program and what drew them to it. This is what they said.
Alex Kriegl: “The data about the residency program and its accolades is impressive and it’s part of the reason I looked at the program early on, but more than that I noticed that when I did internships during medical school the most compelling work being done was being done by alumni of Waco Family Medicine’s program.”
Junior Clark shared a similar sentiment: “I personally knew graduates from Waco Family Medicine when I was shadowing physicians in Amarillo. The training I got with them was great compared to other family physicians in the community. I also appreciate the holistic care aspect with everything they do with SDOH.”
Clark is referring to the “social determinants of health,” that I mentioned earlier in the article. The non-medical drivers that impact our health like food deserts, lack of transportation, etc. These SDOH concerns were grafted in the architecture of our new building. Something that Waco native and Midway High School graduate Paul Koester noted, “I was born and raised here and I knew that I wanted to come back to the community that raised me. When I look at this building and all the amenities it offers; the wellness center, teaching kitchen, specialty clinics, and pharmacy … It represents an entire community under one roof and it was built in the heart of a medically underserved area. These services are here for the people that need them most. It makes me proud to be part of a program that is committed to investing so much in the health and well-being of our underserved communities.”
This theme of community focus was mentioned by a few residents. Karen Woody said, “When I was looking I loved that WFM was very mission driven. It’s clear that they identified a problem in the community, generated a plan to address it, and then raised the funds to make that happen. It’s really inspiring.” Aaron Wise reflected something similar, “As an FQHC it has more heart [than individual primary care clinics]. The focus on behavioral health, addiction medicine, and the alignment with community partners. All of that is about the community.”
For some, like Ethan Blythe, Waco itself was part of the decision, “When I interviewed the people made a great impression on me. This seemed like a good place to build a family. I grew up in a small town and so I wanted the rural clinical experience in case I end up in an environment like that in the future.” That contextualized training was reiterated by one of the more charming comments I heard. Cameron Keomanivong said that “early on in my medical training I was told to find an image of what I thought a doctor should be and that I should pursue that,” Cameron paused to chuckle, “for me that was an image of a doctor riding on a horse to remote locations to provide care for those who might not otherwise get it, and I feel like Waco Family Medicine will equip me to do that.”
One of the claims to competitive advantage that the institute makes on its website is that the program offers full-spectrum training. To be honest, I didn’t know what that meant so I asked. Aaron Wise again, “one aspect is that this program is heavy on procedural training. It could include colonoscopy exposure, obstetrics, all the work done in the specialty clinic to give a few examples.” Nato Kimball added,”if you look up all the different kinds of jobs graduates of this program have taken, you can really see the evidence of the full-spectrum exposure. Graduates get jobs doing community health education, global health, obstetrics, point of care ultrasound, muscle-skeletal, among others.” Here I was offered a helpful clarifying word by incoming third year and chief resident Drew Baxley, “full-spectrum training doesn’t just refer to the type of care being done, it also refers to the settings in which the training happens. So our residents get experience in rural clinics, community clinics, and inpatient settings. That’s another unique feature of our program that really makes our graduates like swiss army knives in terms of their scope and utility.”
Brittany Uebbing is an example of a successful recruitment process. “I really love the Centering model for expecting mothers.” Uebbing is referring to a program in which groups of expecting mothers are given the opportunity to move through a nine-month program as a group in which our women’s and children’s services team take them through. A program that has yielded notable data points like a reduction in preterm birth. Uebbing continued, “I helped lead a group like that where I came from, and when I was here visiting, I had the privilege of sitting in on one of the Centering sessions.”
And all of this is happening without competition. Nato Kimball again, “It’s unopposed.” When I asked Nato about that he said, “There are other programs in neighboring cities that have residency programs in many different specialties, and many times those residents are competing for the same opportunities, but here in Waco, it is just us and that’s unique. It definitely enriches this experience.”
Waco Family Medicine’s Institute is something to be proud of. Not just for the residents, or even our physicians, but for Waco. This concluding thought from Carol Schroeder is succinct, “I noticed that the culture was excellent. Everyone is on board with the same vision.”
