Hope the following is helpful regarding recent discussions on indigent care, specialist roles, and the ideal family practice center. Also might be of interest to those who have only been academic folks. Would appreciate hearing from other Waco grads as well as those from other programs. Also since some time has elapsed (and many of my neurons), there may be some changes, biases, and lack of my correct interpretation.

Link To Analysis of FP Program and Public Health by Tim Henderson

Robert C. Bowman, M.D.

The McLennan County FPR was a result of the county medical association working with the city and the county and the two hospitals. The county had about 120,000 pop. The working poor and indigent population was fueled by the closure of the General Tire Plant, rural folks who left their lowlands, and its location on the I-35 corridor from Central America.

The medical association elects board member physicians. These have been a mix of fp and specialist docs. These pick the program director/President who administrates the FPR program, the faculty development arm, and the foundation. The creators of the program were some key attendings and Chris Ramsey, who basically took over the program as a 2nd year resident. Subsequent president/program directors have been faculty who have been residency graduates then in practice then in the faculty and moved up through the ranks. The feds and state supported the creation and the Foundation serves as a state resource to all programs, especially for preceptorships and faculty development.

The county established a sliding scale that discounted medical care from 10% to 90% off for the clinic and pharmacy based on income. Two social workers on site did the determinations. Also the clinic had a full time on site (busy) pharmacist.

The faculty included about 4-6 FP faculty, and an in-clinic surgeon, internist, pediatrician/oncologist, and ob-gyn. There were 2 non-MD faculty specializing in the psycho-social area and doing research on family structure. The specialists were actively involved in the board, the clinic patient care, and the hospital care.

The strengths:

• Improved access for patients
• Centralized health records for many who would be in multiple public health and clinic locations otherwise.
• The unique (for the US at that time) combination of government, medical education, and hospital and other local providers to provide adequate and diverse funding and coordination of resources.
• The independence of the program from academic centers (no dealing with multiple departments, different rotational demands, changes in schedule).
• The quality of the specialists and their willingness to prioritize resident education. Visiting specialists came to the clinic to see patients and donated their services. Resident present residency patients to the specialist-attendings in gyn, neuro, derm, pulmonary, ortho and other areas with the number of clinics based on need. Residents came to the specialty clinics if they had a patient or according to rotation. Residents interested in a certain clinic showed up more if they chose and many did. Visiting specialists came up from Baylor College of Medicine once or twice a week (until they dumped the relationship), then Southwestern took over a loose affiliation. Conferences were in the hospital every Tuesday and Friday and residents were expected to attend, food was pretty good for these and exceptional for evening meetings and medical staff meetings, which were well attended.
• The reward system for patient compliance with visits and treatment by assignment to a specific resident physicians.
• The pathology and educational process: Complicated patients were assigned to residents matching need for care with access and also giving more education through ambulatory care. The program had unsurpassed cardiac, obstetrical, ER, and in-patient training where residents made the decisions with faculty readily available and did the hands on work in ER and OR and ICU and CCU.
• Lots of ambulatory volume. We saw up to 16 patients in a half day, rarely less than 10. We saw patients more days than most programs with 1-2 half days in the first year, 4 in the second, and 5 in the third year or half time (except when on cardiology then 2 half days only). As senior residents we cared for 500-700 assigned patients, these were re-assigned within the team upon graduation.
• The program was far more ambulatory-based than other training programs where the specialists take over most patients and determine how much (or how little) clinic time they give up to the clinic.
• We had an information system in 1982 that took us till 1998 to exceed at UNMC, including current problems, medications, and recent visit diagnoses. Charts were filed at each team site of 8 residents alphabetically by resident. Some of us tagged the charts of more severely ill patients such as heart patients.
• Most regular patients were grouped in families and seen at our clinic by one of the 24 residents in 3 teams consisting of 2 faculty, an RN, and an LPN. Nurses tended to be experienced and since patients stayed within the team, continuity was improved. Other staff tended to stay with the clinic a long time also.
• 3 good rural moonlighting sites where 4-5 residents per site divided coverage for the weekends, ranging from low volume to medium (40 - 60 visits per weekend).
• Rural outreach sites
• One resident, me for 2 years, (for pay) took care of the Adapted Living Center patients - a home for the mentally retarded.
• Residents had monthly dinners for all residents in their homes where nearly all the married and most of the singles attended. One home in particular seemed to result in pregnancy for several couples, just a visit for a few hours was all it took (better than in vitro).
• International programs (a recent addition) provided by faculty who have been program graduates and served in Nigeria 10 years and others.
• The clinic moved from the hospital basement to a large, nicely-designed clinic building in 1982 with the help of donations from civic minded folks, specialists, government, and grants.

The weaknesses were

• Too many patients for the resources in ambulatory clinics
• Little or no faculty availability. This has improved since 1983.
• There was a two-tier system in that patients without a regular physician went to the Out Patient Clinic or OPC for care. Non-compliant regular patients were assigned there too. Patients could move to the "model" clinic by their request, by physician request, or by being complicated and in need of close follow up. This is a strength in that it tended to discipline patients, but some did fall through the cracks, but they did have an ambulatory place for care that was not the emergency rooms.
• Tthe lack of continuity for some patients, particularly in obstetrics because many patients went to the county women’s health clinic where they saw different FP resident physicians for prenatal care and delivery over time.
• Not everybody was as visionary as our directors, and they also left in search of higher callings, more than a few have returned, frustrated with working in academic centers. The visionary folks also made a few enemies, who vented on those left behind when the leaders took off (or were run off).

Of course in typical US fashion, the sliding scale and some of the volume was removed when Texas recently implemented the managed care system. This also impeded the centralized records somewhat.

My rural career began with Waco training when fellows there at Waco encouraged me to practice before going into teaching. One fellow who was the program director at residencies in Michigan twice, OKC, and Bartlesville took a chance on me (this is the truth) and recruited me into my solo rural practice in Nowata OK by making arrangements with the town fathers and giving me a .3 FTE faculty position nearby for the grand sum of $20 per hour, later moved up to $50 just before the state cut our jobs and then the residency.

Waco has an excellent track record for FP research in family development and faculty development through folks such as Maurice Hitchcock and Bill Mygdal and previous folks. The faculty development program, although in the same building, is fairly separate from the residency, mostly by resident choice. I was very interested in teaching and managed to show up for their stuff a lot and look how it warped me! I later left rural practice in 1987, taught at Baylor Family Medicine in Houston, and did the Waco FP fellowship. I established the faculty development minifellowship at East Tennessee based on the Waco model, with minifellows doing a rural project instead of the research project we did at Waco.

For those interested in an excellent faculty development program they should contact Waco folks or I could find the right numbers. They did have a stipend available and likely still do have one. They do take people from outside the state (yes Texas still pays if out of state). It requires attendance for 3 months (October, Jan, and April I think), a research project, and approval from your med ed boss. They also do refresher faculty development for a few days, a week or longer upon request.

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