Spokane’s medical school expansion a complex venture

OLYMPIA – Around the Capitol, the debate over physician education in Spokane is sometimes called the Apple Cup for medical schools.

Although some take sides as they do for the annual football game between the University of Washington and Washington State University, many state politicians – from Gov. Jay Inslee down – are wary of picking a favorite in the controversy over competing medical school plans for Spokane.

If both universities expand medical education in Spokane, the community would be turning out 240 medical school graduates a year by the middle of the next decade, or 120 from each university program. But that’s many years, and many budget decisions for future Legislatures, down the road. The 2015 debate will be about foundations.

It’s not strictly the money, although that sometimes is cited for a delay in supporting one or both. A total of $10.5 million is sought for the next two years: The University of Washington wants $8 million to expand its small medical school program to 40 students per year by 2016, and Washington State University wants $2.5 million to seek accreditation for a new medical school that would start with 40 per year in 2017. That figure is nearly insignificant compared to a state budget that likely will top $39 billion.

Inslee and key legislators say the state needs more doctors, particularly in rural areas, where a shortage is becoming acute, and in family practice. But they have yet to be convinced that one plan or the other is the way to meet that need, and some question whether a second medical school in the state is the most important part of that complex solution.

Residencies – the three years of training after medical school – may do as much or more to determine where doctors practice, some experts argue.

Supporters of expansion are well-placed

Sen. Barbara Bailey, R-Oak Harbor, chairwoman of the Senate Higher Education Committee, said recently she wants to study the different proposals. It might be possible, she said, to take the $2.5 million for WSU’s startup out of the $8 million UW wants for expanding its program in Spokane.

Some are waiting to see the second “memorandum of understanding” between the universities over medical education in Spokane. In October, WSU President Elson Floyd and UW President Michael Young signed the first such memorandum, in which they agreed to dissolve the two universities’ partnership in Spokane, go separate ways and not oppose each other’s requests for new money from the Legislature.

Continued rapprochement requires the second memorandum being successfully negotiated to divide funds and facilities used by the program they jointly operated in Spokane, a five-state consortium known by its acronym WWAMI. That deal must be struck before the Legislature starts on Jan. 12.

Inslee’s budget, released Thursday, is silent on both plans and would force the universities to make some tough choices on spending. Months of budget negotiations remain ahead, but proponents of expanded medical education in Spokane are well-positioned for what most expect to be a tough budget debate. In the House, Democrat Timm Ormsby and Republican Kevin Parker, both of Spokane, have key spots for their parties on the budget committee, and Democrat Marcus Riccelli is the vice chairman of Health Care. In the Senate, Republican Mike Baumgartner of Spokane is on the health care and higher education committees, and Mark Schoesler of Ritzville is the majority leader.

“At all costs, we want to avoid an either-or debate,” Parker said last week. Instead of getting mired in a turf war over medical education in Spokane, he views the UW expansion as important for the short term and WSU expansion essential to the long term. “Why not have two (medical schools) in Spokane?”

But if legislators decide WSU is at least part of the solution to producing more doctors for Spokane and Eastern Washington, agreeing to the money isn’t the only step. First they’ll have to change state law to make that legal.

War of words

Disputes between the state’s largest higher education institutions over who should provide what courses of study for specialized degrees aren’t as old as the intrastate football rivalry. But almost.

In 1917, the presidents of two schools waged a war of words over dividing college majors. Henry Suzzallo, the president of the University of Washington, drew the wrath of some in Spokane, including the editorial page of The Spokesman-Review, by suggesting the university should “do what we do best and give up to the other fellow what he can do best.” Washington State College, as it was then called, could have agriculture, but the Seattle university should have forestry and architecture and graduate degrees, Suzzallo said.

That prompted the newspaper to compare Suzzallo to Caesar, label him a mere “education theorist” and huff that what he really meant was “we will take what we want and give the other fellow the leavings.”

As Suzzallo and WSC President Ernest Holland lobbied that January for majors and money, legislators took sides. Competition for tight funds got so fierce the two presidents were ordered into Gov. Ernest Lister’s office to negotiate a settlement.

At 3:30 a.m. on Feb. 1, Holland and Suzzallo signed what was called “the Treaty of Olympia,” which divided certain majors between the schools. WSC would have agriculture and veterinary medicine, exclusively, and could continue undergraduate architecture and forestry. UW’s exclusive majors included law, commerce, journalism, marine and aeronautic engineering, fisheries, and graduate architecture and forestry.

Happy for a break in the fighting, the Legislature suspended its rules, unanimously passed a bill in both houses with those divisions and sent it to Lister. He signed it that day with both presidents in the room and handshakes all around.

That law, or what’s left of it after some changes over nine decades, would have to be changed next year to allow WSU to start its own medical school. Medicine wasn’t among majors assigned UW in 1917. That happened later, after the Legislature set aside some $4 million in 1945 to start a medical school in the state, and housed it at UW.

Medical education evolves

Medical education in 2015 is a far cry from medical education in 1945.

Before World War II, a student graduated from medical school, spent one year as an intern and could begin practice, said Dr. Susanne Allen, vice dean for regional affairs at the UW School of Medicine. After the war, as more medical specialties developed, they began doing postgraduate work, or residencies.

Now a typical physician in training spends four years in medical school – two in the classroom and two in a hospital or clinical setting – then three years in a residency. UW is reworking curriculum, however, to trim the time spent by students in the classroom, with 1 1/2 years spent in class and 2 1/2 years in clinical settings.

Residents originally were paid by the hospitals where they trained because they saw patients and generated some revenue, said Allen, who teaches in the WWAMI program and helps develop residency programs around the region. In the mid-1960s, the need for doctors grew rapidly when Congress passed Medicare. Hospitals said they couldn’t afford to ramp up residencies on their own, so Congress agreed to help pay for graduate medical education.

But the 1997 Balanced Budget Act capped the number of residencies Congress will pay for in existing programs. Only new programs can qualify for new federal money, but they must first have the teaching staff and facilities to have the program accredited, Allen said.

“It’s a lot of work to start a new program from scratch,” she said. “There’s a lot of upfront work and cost before you get any residents to start working.”

Expanding the number of medical school students in Spokane won’t necessarily expand the number of physicians practicing in rural communities or in family practice – which some legislators have as a primary goal – unless the residencies for those specialties also expand. Most residency programs are in the eastern United States, because historically there have been more hospitals there. In Washington, most are in King County, and that has at least one Eastern Washington legislator critical of the current setup.

Rep. Larry Haler, R-Richland, told UW lobbyists recently he was unhappy that all but about 100 of the state’s 1,500 residency slots are in King County, and was considering legislation for an independent board to oversee that distribution.

Medical schools don’t operate residency programs, but they do help to encourage new ones at hospitals and clinics, Allen said. “As UW talks about expanding its medical school, I feel obligated to expanding (residency) programs.”

Will numbers add up?

If the two proposals for expanded medical education in Spokane are approved, the schools each would be enrolling 120 medical students a year by the middle of the next decade. That’s up from the 40 first-year and nine second-year students right now, plus another 40 third- and fourth-year students in clinical rotations.

WSU would like to start its first class of 40 students in 2017 if it receives accreditation. When the first class of students graduates in 2021, WSU wants to enroll 120 first-year students and continue enrolling that number each year after that.

UW is asking for money for 40 first-year students in 2015, 80 in 2017 and 120 in 2021. Within four years, each would be producing 120 graduates seeking residencies.

Where would they all go? In the early years, that probably wouldn’t be a problem. The Pharmacy and Biomedical Sciences Building on the WSU-Spokane campus can accommodate 240 students, spokeswoman Terren Roloff said. Working out an arrangement for the two universities to share the facility in the early years is a requirement of the second memorandum still under negotiation.

But key to WSU’s pitch for its own medical school is low capital costs. “We have no plans to build another (classroom) building, forever,” Roloff said.

That means UW would eventually need its own building for its Spokane-based WWAMI students, and that might mean another “Treaty of Olympia.” The state could build another structure for WWAMI on the campus that many in Spokane refer to as Riverpoint but university officials are aggressively “rebranding” as WSU-Spokane. Or it could go across the Spokane River. UW and Gonzaga University officials recently began discussing a public-private partnership, but a future Legislature could be asked for construction money for the public half of that partnership.

The Legislature may then have to turn its attention to residency programs. Some argue the current residency program is overstressed and wonder if it can expand enough to meet the demand from the additional medical school graduates from Spokane and other new programs.

“Residency programs are not expanding at the same rate as medical schools,” UW’s Allen said.

But they can grow faster because they don’t take as long to establish, said Dr. George Novan, assistant dean of WSU’s College of Medical Science, who formerly oversaw residency programs at Providence Sacred Heart Medical Center. The competition for American graduates is mainly for medical specialties, and about half the primary care slots go to international students.

“Everything will become more competitive, but that competition will most likely be felt by foreign students,” Novan said. The solution to creating more primary care and rural doctors isn’t just more residency slots, it’s getting more students into medical school interested in that work and making those jobs more attractive to graduates.

“We have to come up with the secret sauce for that,” Novan said.