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Montana faces a doctor shortage — one-third of its physicians are over age 60 and nearing retirement — so you’d expect a lot of excitement in the medical community about two new proposals to open doctors’ colleges here.
Yet the idea of for-profit colleges of osteopathic medicine has sparked alarm among some Montana doctors.
It may make money for investors and it may be an economic boon for cities and construction contractors, they say, but they have serious doubts it would benefit Montana patients or provide quality training of Montana doctors.
This month’s announcement that two for-profit colleges are interested in Montana – one in Bozeman, one in Missoula – has excited community leaders. Missoula’s mayor and economic development chief estimated one college’s annual benefit to the state at $45 million.
In Bozeman, the Burrell Group of investors, founded by New Mexico real estate developer Daniel Burrell, is looking into building the Montana College of Osteopathic Medicine in a public-private partnership with Montana State University.
Burrell has started the application process for accreditation in Bozeman, and plans to announce results of a prefeasibility study by its consultants Tripp Umbach soon, possibly Friday. It is already building an $85 million for-profit school, set to open next year, called the “Burrell College of Osteopathic Medicine at New Mexico State University,” though its website states it is not part of the state university.
Meanwhile in Missoula, the Manipal Education Americas firm, owned by one of India’s richest billionaires, announced a week ago that it’s interested in opening its first U.S. school there. Manipal describes itself as one of the largest owners of medical schools in the world, running schools in India, Malaysia, Nepal and the Caribbean.
Both for-profit colleges would enroll 150 students a year for four years. With up to 600 students at each school paying tuition of around $48,000 a year, each college could generate more than $28 million a year in tuition alone.
Skeptics in the medical community argue that Montana’s doctor shortages are mainly in rural, American Indian and low-income communities. They don’t think for-profit colleges can solve those problems because students graduating from expensive private schools with hundreds of thousands of dollars in loan debt couldn’t afford to work where pay is lower. They’d face financial pressures to work in cities and go into specialties that pay better.
Some physicians fear the for-profit colleges would prove fatal to the award-winning WWAMI program. A partnership with the University of Washington, it trains students from rural states — Wyoming, Alaska, Montana and Idaho — that don’t have medical schools. Montana’s WWAMI program struggled for years to persuade the Legislature to expand training from 20 to 30 Montana medical students a year, and finally succeeded in 2013.
Physicians predict if private schools can train doctors at no cost to the state, legislators will pull the plug on WWAMI.
That’s unlikely, argues MSU spokesman Tracy Ellig, who pointed out that the Legislature has committed to subsidizing tuition for Montana’s medical students with about $49,000 a year.
“We don’t see how having a medical school in Montana would change the motive behind helping Montanans become physicians,” Ellig wrote in an email.
“We are committed to preserving WWAMI and have made it clear to the Burrell family that we want to see any new program be complementary, not competitive with WWAMI.”
D.O. schools growing
Gov. Steve Bullock and MSU President Waded Cruzado lent their names to a press release Wednesday from the Burrell Group, which announced that its proposal has been granted applicant status — a key step before a six-month feasibility study required for accreditation.
“In addition to the successful WWAMI program, the Burrell proposal could provide students from Montana another option to be educated and stay here,” the governor said. “I look forward to reviewing the final results of their feasibility study.”
Cruzado’s statement said MSU is proud of its 42-year relationship with WWAMI “and we look forward to learning how this proposed project could help enhance and strengthen medical education in Montana.”
The Montana Medical Association president, Roman Hendrickson, sent a letter to the Montana Board of Regents saying that adding as many as 300 third- and fourth-year medical students “could adversely impact” current medical education, and may unintentionally reduce clinical training spots for physician assistants and nurse practitioners.
“Any potential economic gain afforded by a school should be weighed, keeping in mind what is best for the current and future health of Montanans,” Hendrickson wrote.
One outspoken critic of the for-profit colleges is retired Missoula internist Dr. William Reynolds, past president of the 140,000-member American College of Physicians and a professor emeritus with WWAMI.
Reynolds charged in a letter to Cruzado that a for-profit college would be a “diploma mill” and a “second rate medical school” that could tarnish MSU’s reputation. He predicted a “devastating likelihood that the Legislature will stop funding WWAMI.”
It would be “impossible,” Reynolds wrote, to find training in Montana for an additional 150 students a year, so they would likely go outside the state.
After graduating from medical school, new doctors still require years of training in residency programs, and graduates of for-profit osteopathic schools have a harder time competing, Reynolds said. Those who couldn’t get residencies would end up unable to practice medicine or repay their massive federal loans.
Burrell spokeswoman Joanie Griffin responded that Reynolds is entitled to his opinion, but the Burrell school would be neither a diploma mill nor second rate, and it doesn’t intend to hurt WWAMI.
“Our intent,” Griffin said, “is to graduate top-performing physicians who are going to make a difference in the state of Montana in providing medical care that’s so badly needed.”
In a press release, Daniel Burrell said the input from Montana’s medical community would be critical as it moves ahead with seeking accreditation from the Commission on Osteopathic College Accreditation, or COCA.
“We certainly believe Montana and the intermountain region have a need for more physicians and training opportunities, but we — and COCA — need the final study to determine if the school can be successful,” Burrell said.
The number of accredited osteopathic colleges has doubled in the United States — from 14 to 30 schools — between 1980 and today, the New York Times reported last year. The number of osteopathic students has quadrupled, from about 5,000 to more than 23,000.
Osteopathic schools now turn out 22 percent of medical school graduates.
About 60 percent of doctors of osteopathic medicine, called D.O.s, go into primary care, vs. 30 percent of medical doctors or M.D.s.
Nationally, students who can’t get into M.D. schools often turn to osteopathic colleges. Students entering M.D. schools averaged 31 on the MCAT test for medical school, vs. 27 for students who entered D.O. schools.
Each year thousands of students who can’t get into U.S. medical colleges enroll in schools in the Caribbean.
M.D.s say that today the two disciplines give very similar training. D.O.s can prescribe medicine and do surgery, just like M.D.s. One difference is that osteopathic students still learn techniques that go back to its founding a century ago, such as manipulating the spine and muscles.
According to the American Osteopathic Association, osteopathic medicine has a different philosophy, focusing more on the whole patient and keeping people well, rather than focusing on disease.
The AOA’s accreditation arm takes its job seriously, a spokeswoman said, and in the best-case scenario, the accreditation review can take two years.
Numbers vs. nurturing
If Montana has a looming doctor shortage, training an additional 150 or 300 medical students a year sounds like a great way to solve the problem.
But doctors say it just isn’t that easy. Only 57 students from Montana entered medical school in 2014. Thirty went into WWAMI, and 27 attended medical colleges outside the state. That means most of the 150 students entering the proposed osteopathic colleges would come from outside Montana.
Montana has some shortages in cities in particular specialties, but the bigger shortages are in rural, low-income and Indian communities.
“You can’t solve that by throwing numbers at it,” said Dr. Jay Erickson of Whitefish. “You need to get the right students and nourish them along the way. Sheer numbers are not going to create a rural student.”
Erickson is clinical dean for the WWAMI program and chair of the Montana Graduate Medical Education Council. He focuses on the key part of training to become a doctor that doesn’t happen in classrooms or studying textbooks, but requires working in clinics and hospitals with doctors and patients.
Today WWAMI puts more emphasis on experience with patients, even in the first two years of medical school. Once students graduate from medical school, they still need three to five years experience in residencies, working in hospitals or with doctors willing to teach.
In the last five years, Erickson said, “We really worked hard to go from six to 24” residencies in Montana, “a huge achievement.”
In the next 10 years, Erickson said, it may be possible to add another 10 or 20 residency slots, which would mean 34 or 44 medical grads total could get training in Montana – nowhere near the number of medical students the osteopathic colleges are talking about.
In Billings, “I have six pediatric slots. I can’t get any more, and that’s our largest city,” Erickson said. “Teaching takes time and effort, it’s difficult to do well. I always tell doctors it’s going to take an extra one to two hours a day.”
Neighboring states of Idaho and North and South Dakota don’t have excess capacity to take on hundreds more students either.
“There is a limited number of physicians who want to teach,” Erickson said.
“We don’t know where we could find that quality teaching capacity.”
Rural success stories
How do you find new doctors willing to work in Montana’s small towns?
WWAMI starts by accepting many medical students who come from small communities.
In 2008, it launched the TRUST program, or Targeted Rural UnderServed Track. It matches 10 WWAMI students with mentors in rural areas for half of their third year.
One of this year’s TRUST students is Kena Lackman, 25. She grew up on a family farm in Hysham, population 306, and has wanted to be a doctor since high school.
“I always liked science and math, and I enjoy helping people,” Lackman said.
Today she’s a third-year WWAMI medical student, doing an 18-week clerkship in Miles City. Working with a family medical doctor, she’s learning about everything from delivering babies to working in the emergency room.
Lackman started at the Miles City clinic even before med school started, and over the past three years has spent summers and weekends there, driving over from Bozeman.
“I love it. I think it’s exciting,” Lackman said. “I think my time at the TRUST community has been the highlight of my experience so far.
“Eventually I want to come back somewhere rural,” and practice family medicine or obstetrics and gynecology, she said. “The best way to recruit doctors back to Montana is to recruit medical students from Montana.”
Lackman said her preceptor in Bozeman, Dr. Mike Spinelli, had a challenge lining up more preceptor doctors when WWAMI added just 10 more students.
“What happens if we add 150 more students, where are we supposed to get good training?” she asked.
Dr. Christina Marchion, 32, is a WWAMI success story. Since graduating in 2010, she has worked as a doctor in Lewistown.
During medical school, Marchion spent months in Lewistown learning from the doctors there, working in the hospital and getting to know the town. She said it was fun to return to Lewistown for her rural residency and hear the doctors and nurses she knew saying, “Please come here. We want you. We like you.”
Dr. Laura Bennett, her mentor throughout med school, was a big part of her decision to practice in Lewistown.
“She does the real-deal family medicine from cradle to grave, delivering babies and taking care of their grandparents. And she likes to teach,” Marchion wrote. “Pretty much that’s who I want to be in the next 10 to 20 years.”
Marchion said she’d strongly oppose any osteopathic schools in Montana, especially private and for-profit schools. Serving on admission committees during “match season,” when med school grads are matched with residencies, she has seen that those from new and for-profit osteopathic schools are often ranked lower because of what she called “substandard” education.
Marchion wrote in an email that students from new and for-profit osteopathic colleges are nice people who try hard, but she’d rather not teach another.
“I just don’t have the energy and time to deal with the lack of quality and structural support that comes from these programs,” she said.
Erickson said if Montana really wants to build up the rural doctor workforce, it makes more sense to create more rural residencies, and to get help from Montana’s congressional delegation to free up some federal funds to pay for them.
One “biggie” that would really help, Erickson said, would be to increase the pay for primary care doctors. WWAMI can do its best to get students to think about working in rural areas and primary care, but these students are smart, he said. They know they can make a much better income in a specialty or in a bigger community.
Originally published by the Bozeman Daily Chronicle.