We gratefully acknowledge the sponsorship of the Wright State University Boonshoft School of Medicine Department of Family Medicine) for funding the transcription and editing of this section of the Proceedings of the First National Conference on Community Health Center-Primary Care Residency Linkages (Lake Tahoe, Nevada, October 16, 1993):
James Cruz, MD, (Sequoia Community Health Center, Fresno, California): [Dr Cruz is a Fellow of the National Conferences on Primary Health Care Access.}
Good morning. I’d like to thank Bill Burnett and the Coastal Research Group for inviting me to speak today. If you notice in your program, it stated that Mr. Ventura Huerta, the executive director of Sequoia Health Foundation, was originally scheduled to be your speaker. Unfortunately, he couldn’t be here today, so he asked me to say a few words on his behalf.
I appreciated Dr. Prislin’s comments about CHC governance. My presentation will focus on the governance issue and the CHC administration of those linkages. A lot of the conflict that can arise from these educational linkages can come about through misunderstanding about these roles.
We are happy that people view the Sequoia program and its linkage with the Valley Medical Center family practice residency program as a success. More importantly, we, ourselves, believe that it is a success. But there have been times when there has been a great deal of tension. Where we have been able to work through that tension, great progress has been made.
In terms of governance, the CHC board is the equivalent of a medical school’s Regents and the CHC is the equivalent of the Deans. In the CHC, the Board of Directors act as our conscience and it is to them whom we are accountable. When, using a COPC model, we measure and evaluate what we have done, we go back to our community board and share our findings with them, what we have measured, and what the evaluation showed.
We ask them for guidance because they are the representatives of the community which we serve. When we look at how we should change, how we should modify our plan, and how we can better serve our patients and our community, we go to them for advice.
We are indebted to their wisdom and to their service to us. They continually remind us why we are there and whom we are there to serve. Unfortunately, sometimes what the board says is in direct conflict with the medical school, university, or county hospital.
Still, I think we have successfully been able to use the community board as a participant in the educational process. Our community board is involved with getting to know our residents, our nurse practitioner students, and our medical students.
Most, if not all, of our community board members actually know our residents by name. Several of them go to our residents as their own primary care givers. That’s the kind of interaction that we look for our community board to provide to our residency team.
In terms of governance, the biggest conflict arises in the role of administration. In a typical residency or medical school teaching program, power is very well delineated – it is not without politics – but very well delineated. It is clear who the university’s governing body is.
But, when we developed the residency linkage in our community health center, the lines of authority have become blurred. The CHC’s governing structure now thought of the educational side of the linkage as part of its responsibility as well.
That caused conflict, because such a linkage is much like a marriage between two organizations with two very different cultures. It’s not really possible, nor I think prudent, to try to delineate clearly the responsibilities of the community board, university, medical center, and county hospital.
It doesn’t work well to say that this area is the responsibility of the community health center and that area is the responsibility of the medical center and we won’t bother you if you don’t bother us.
It is not possible to do it and it is probably not wise to try. I think our greatest progress occurs when both the CHC and residency leadership are able to recognize that we are stepping on each other’s toes. By agreeing that an area is common ground, we can develop a mutually agreeable approach to where we want to go.
Financially, some of the things we have been involved with are: 1) the solvency, not only of the community health center, but of the residency program as a whole and 2) joint pursuit of grants from external sources. We’ve worked with the residency program on issues of productivity and management to help them become more financially secure. We’ve also looked at them to give us some direction on how we can become more solvent.
There has been sharing of ideas and responsibility in that area. Our administration has collaborated with the family practice department in the developing of training grant proposals. When we’ve been successful, we have been the recipient of some of the resources brought in by these grant collaborations.
The CHC administration has been able to collaborate with the residency program on resident selection. We have our own match number and, thus, could make our selections on our own. But, it has been a marriage between the two administrations. We have collaborated in choosing residents for the family practice program at Valley Medical Center, and we have looked to their advice in developing our own match list.
We have also been successful in developing a year round recruiting program for the entire residency program. This has paid a substantial dividend in the last couple of years. Prior to the linkage we were like a lot of other programs, suffering from a lack of applicants and having several positions unmatched.
By developing this collaborative recruiting and residency selection process, in the last two years we have seen not only a dramatic increase in the quality and number of applicants, but we have matched without problems in the last year. It’s been so successful that we are actually looking to expand the number of training slots that we have.
Both administrations have collaborated successfully in faculty selection. Again, this is something that both the university and resident program regard as their own responsibility and either may resent the community health center becoming involved in something they view as their responsibility. But in order to have a successful linkage, you have to have collaboration on faculty selection between the administrators of the community health center and the main program.
The faculty will be the individuals who teach your residents. If they do not have a strong commitment or perspective on community-oriented primary care you’ll wind up with an askew program. It may be very strong academically on one hand, yet ignore a lot of public issues and community-oriented primary health issues.
But, you also can’t have a residency program at the community health center which is very strong in the community-oriented care, but is not academically credible.
Lastly, our community health center administration has become integrated into the curriculum that the residents are taught. Like most health centers, we have a well-developed financial component. Our accounting department has a sophisticated billing system and a lot of experience dealing with managed care issues.
Each residency program has to have a practice management curriculum. Our administration has become increasingly involved in having the residents participate in practice management from the community health care perspective. Our residents now have a rotation where they will spend some time with our chief financial officer and some of the administrators of the managed care component, just to get an economic perspective of managed care.
As you can see, in terms of governance, the community health center board and the central residency program administration have to agree to disagree. They also have to agree to collaborate. That is what you will have to consider with any type of linkage you develop with a residency program or medical school or university to be ultimately successful.
Terry Pitts, EdD, Moderator: We have a little time for questions for Dr. Cruz.
Carlos Garcia, MD, Medical Director, San Ysidro Health Center, San Diego, California): Dr. Cruz, you briefly touched on your administration view regarding productivity. As a medical director, this is something that will come up for us if we choose to set up a residency program. Am I to understand that you basically accept a lower productivity for your faculty which supervises your residents, or do you combine the productivity of the supervising physician and residents, or what?
Dr Cruz: What do we do? When we first started, we tried a variety of mechanisms. WE tried a Kaiser-like model. In Los Angeles, Kaiser has a residency training program and productivity is an issue with them. They have their supervising physicians and the resident whom they are supervising practice without interruption for several hours – let’s say in a four-hour block they will practice two and a half hours without interruption.
Then at the end of that two and a half hours that practice stops. Then they meet for the remaining hour and a half. They review all of the cases that the resident saw. Kaiser LA feels that this model fulfills their productivity needs and suits them well.
The Kaiser model works well when you’re dealing with a certain number of residents. There’s an economy of scale issue involved. The fewer numbers of residents you have, the less likely you’re going to be successful economically, in training residents and meeting productivity requirements. We tried it. But, based upon the number of residents we have, that model didn’t work.
What we have ended up with, after looking at various models, was a teaching agreement with the family practice department in which the CHC is compensated us for one full-time equivalent of teaching time. That allows us to precept the residents and to become involved in curriculum development and in all of the other issues that are important, yet be “non-productive” from the standpoint of number of patient encounters.
When the faculty staff physicians are not involved in teaching time, they are practicing uninterrupted with residents; then, when they are practicing, they are very productive. When they are teaching, their time would be a loss of revenue from a productivity standpoint. We’re able to compensate for most of that lost revenue. It’s a satisfactory agreement for us and for the department as well. I hope that answers your question. If you need further clarification, I’d be happy to talk with you later.
Kevin Malone, MD, (Sharp HealthCare, San Diego, California): Sharp HealthCare in San Diego is considering developing a residency linkage program. The biggest question I have is, how do you comply with the Residency Review Committee rules that state that a faculty person can’t be seeing patients when residents are there?
Dr Cruz: I’m not an expert with what the RRC does, but the Kaiser model apparently was granted some waivers for Kaiser to perform in such a way. We tried that briefly, as I stated, but we were not satisfied with the Kaiser model, not only because of the productivity issue, but because it just did not work well for us. Again, when you have faculty that need to be without any other obligation than teaching, obviously they’re not practicing.
There’s an economy of scale factor that the fewer residents that they are dealing with, the less likely that the interaction is going to be a productive one, not only in terms of patients, but also in terms of the use of faculty time. If they are only supervising one or two residents at a time there will be periods – several minutes in each hour – where the faculty will not be teaching residents.
They may have to do some paperwork or be involved in some other activity, but from the standpoint of teaching, it’s downtime.
What we have found is that there needs to be a critical number of residents or other learners involved to optimize the productivity of supervising faculty time. We’ve come up with a minimum. There needs to be four learners for each faculty person at any particular time to make sure that there is no down time in terms of actual teaching interaction. It’s not a perfect science. It’s really trial and error. But, that’s where we’re at right now.
Joseph Ferguson, MD, (Director, North Colorado Family Medicine Residency Program, Greeley, Colorado): At our program we have a CHC linkage and also some rural training tracks. The reason I’m standing up here is because we have worked with the RRC on this issue of productivity.
On the issue of precepting, the RRC has ruled on our models, which all have a single resident in a setting, that it is acceptable initially to reduce the usual required number of visits for the supervising attending by half. They have accepted that model in four separate sites under the argument that the ratio in the family practice center is one to four in terms of residents.
This is at least that good or better. There are also some models that are part of the Spokane training program’s rural training tracks, that have been allowed to work with a ratio that is reduced by less than half time, more like three-quarters time. So, there is a willingness by the RRC to work with individual programs.
Dr Cruz: Yes, I believe these issues are handled on a case by case basis. You have to state your case and let the RRC decide what they are willing to agree to.
Terry Pitts, EdD, Moderator: We’d like to thank Mr. Garcia and Dr. James Cruz for these presentations.
This presentation follows: Proceedings of the First National Conference on Community Health Center – Primary Care Residency Program Linkages, “Centering Primary Care Residency Training in a Teaching Community Health Center: Adventures in Academic Processes and Community Politics” (Part 2, Garcia)
This presentation is followed by: Proceedings of the 1st National Conference on Community Health Center – Primary Care Residency Program Linkages, “Issues in the Financing of Educational Linkages” (Part 4, Esselink)