Here’s the puzzle.

You have a landmass that takes up about 27 percent of the United States and contains about eight percent of its people. The terrain varies hugely, often dramatically; it is covered in glaciers, plains, forests, mountains — even urban sprawl. Some members of its population live in cities, but many live in small, remote communities. How can you possibly deliver adequate medical care to all these people, in all these places?

This landmass is the five-state area of Washington, Wyoming, Alaska, Montana and Idaho (called WWAMI, for short). And the answer to the puzzle is the WWAMI program — a partnership of those five states, the UW School of Medicine, Washington State University (Pullman and Spokane), the University of Wyoming, the University of Alaska, Montana State University and the University of Idaho. In 2011, WWAMI commemorates its 40th year.

Although this photo was taken decades ago in 1976, some things about the WWAMI program haven’t changed; it still benefits some very rural and remote areas. WWAMI — which trains people from the Pacific Northwest to provide healthcare in the five-state region of Washington, Wyoming, Alaska, Montana and Idaho — is going strong, 40 years after its inception. Pictured are Gerry Bell, M.D., and Roger A. Rosenblatt, M.D., the first resident in the WWAMI program.

The WWAMI program was founded in 1971, a response to a physician shortage and the brainchild of a number of visionary UW Medicine faculty members — including Jack N. Lein, M.D. ’55, M. Roy Schwartz, M.D. ’62, Robert Van Citters, M.D. — and of equally visionary community physicians. Its objective was, and still is, to train primary-care physicians and other healthcare personnel from the region and for the region, especially in areas with too few physicians.

One of the program’s novel components was providing medical education for more than one state; there are no other medical schools that cross state lines. A second was training medical students at their home WWAMI university during their first year. A third novel approach was the WWAMI program’s use of community-based educational settings to offer clinical training: sending medical students out, after their classroom sessions, to learn from doctors working in WWAMI communities large and small, rural and urban.

“The WWAMI medical education program is designed to have people go out and train in rural and remote communities so they understand all the benefits — but also the challenges — of providing care,” says Suzanne M. Allen, M.D., MPH, vice dean for regional affairs.

What are the challenges in rural or underserved communities? Balancing work and family, for one. “I want to be available to my patients and I want to take care of them all the time,” says Tobe H. Harberd, M.D. ’06, a family medicine doctor in Chelan, Wash., and the father of two young children. While it can be difficult to set boundaries in a small town, he counts satisfying relationships with his patients and the medical students he teaches among the benefits of living in Chelan.

In 1972, Roger A. Rosenblatt, M.D., Res. ’72, ’74, UW professor in the Department of Family Medicine and director of the Rural/Underserved Opportunities Program (R/UOP), was the first resident sent to a WWAMI site outside of Seattle. In the years that followed, he has seen the WWAMI program grow — from a handful of training sites in 1974 to more than 165 in 2011. He pinpoints WWAMI’s essential sources of strength and growth: the campuses, towns, community doctors, UW faculty members, legislatures, trainees and staff who partner together to deliver health care in the places that need it most, whether in Barrow, a town on Alaska’s northern tip, or an underserved neighborhood in a city like Seattle, Spokane, Cheyenne or Missoula.

Rosenblatt is amazed at the WWAMI program’s progress. “The variety and richness of the program defy whatever we might have imagined in the early days,” he says. “There are so many facets to it….I don’t think any of us would have dared dream that that was a possibility.”

By Delia Ward

WWAMI AND ITS ACRONYMS

WWAMI
A University of Washington School of Medicine network of partnerships in medical education that links community doctors, medical trainees and academic institutions in the five-state region of Washington, Wyoming, Alaska, Montana and Idaho. These academic institutions include the University of Washington, Washington State University (Pullman and Spokane), the University of Wyoming (Laramie), the University of Alaska (Anchorage), Montana State University (Bozeman) and the University of Idaho (Moscow).

R/UOP
Rural/Urban Underserved Opportunities Program. Students spend four weeks between their first and second year with a doctor-mentor in an underserved area.

WRITE
WWAMI Rural Integrated Training Experience. A 20-week clinical program in which third-year students fulfill a number of medical rotations at one rural site.

URBAN AND RURAL

Many medical schools focus on urban medicine — a function of location. With WWAMI, medical students at the UW School of Medicine can experience medicine at locations that vary from large urban hospitals like UW Medical Center in Seattle, to community-based clinics in small towns.

“It gives you a much broader perspective… about what and where you can practice,” says Jarod McAteer, M.D. ’09.

Here’s what McAteer and students Cassie Iutzi and KayCee Gardner found during their WWAMI training:

Pride. “They [doctors] are very proud of their patients in the rural facilities,” says Gardner. In urban hospitals, she says, patients are often seen by residents. In small towns, doctors know their patients and patients’ families.

Travel. In Juneau, Alaska, “You can’t just turn around and call a cardiology consult and have a doctor come by, because the nearest cardiologist is in a different town,” says Iutzi. The same holds true for many locales in the five-state region; often patients need to travel for specialized care.

Role-stretching. In cities, surgeons focus more on specific skills, says McAteer. In rural or semi-rural locations, the scope is typically broader — surgeons take on more types of cases.

Knowledge transfer. Gardner learned about an alcohol detox protocol at the Seattle VA. When she participated in the WRITE program in Montana, she found that the local hospital would benefit from using it. She subsequently had the process approved for use by the medical board in Lewistown, Mont.

Poverty. “Often, you don’t see [poor] patients until their problems are really large,” says Iutzi. She found this to be true both at Harborview Medical Center, which provides the most charity care in Washington state, and at clinics in Nicaragua, where she volunteers.