This interview is the first in a new series featuring Sponsoring Institutions and programs providing rural graduate medical education (GME) experiences. The series was initiated following the 2022 ACGME Annual Educational Conference presentation on Medically Underserved Areas/Populations: Partnerships to Establish and Sustain Rural GME, available on the ACGME’s digital learning portal, Learn at ACGME.
Billings Clinic is a community-governed, not-for-profit health care organization in Billings, Montana based on the medical foundation model, with an integrated 500-provider group practice, a 325-bed hospital, and approximately 4,300 employees. Dr. Virginia Mohl serves as designated institutional official (DIO) and medical director at Billings Clinic, as well as on the Board of Directors for the Montana Family Medicine Residency. A Fellow of the American College of Family Medicine, Dr. Mohl still practices outpatient family medicine and provided the following answers to the ACGME’s questions about rural GME partnerships.
ACGME: What drew you to academic medicine and to rural GME specifically?
Dr. Mohl: As Chief of Regional Medicine for seven years, I witnessed first-hand how difficult it was to recruit and retain physicians in our rural and frontier communities. I practiced for 10 years in a rural community and taught residents at the University of Wyoming Family Practice Residency in Casper, Wyoming, so I understand what it takes to train rural physicians. When Billings Clinic decided to become a Sponsoring Institution of graduate medical education and create an internal medicine residency, I was interested. But when we decided to incorporate two rural sites, I was immediately passionate to help this succeed.
ACGME: Describe the rural GME experiences within your Sponsoring Institution.
Dr. Mohl: Billings Clinic offers multiple rural GME experiences. Our R2 and R3 internal medicine residents spend two months each year working and living at each of two rural sites. In addition, we have built a similar experience for a general surgery fourth-year rotation and rural track with the University of Arizona. Residents will travel with our trauma surgeons to work in rural and frontier Critical Access Hospitals (CAHs). We also created an unaccredited rural critical care fellowship, which has successfully recruited its second class of fellows. These fellows split their time between trauma, intensive care (ICU), pediatric intensive care, and working in multiple CAHs. Finally, our University of Washington psychiatry residency Montana track at Billings Clinic is developing rural rotations for our psychiatry residents. Currently, R3 psychiatry residents participate in Project Echo, where they support local health care teams in improving care for their psychiatric patients through case discussions and education.
ACGME: How did your Sponsoring Institution become involved in establishing rural GME experiences?
Dr. Mohl: Several articles were key in pointing out to us that the lack of general internal medicine physicians was not going to be solved by existing programs. Only 20-25 percent of all internal medicine graduates pursue general medicine careers, with decreased medical student interest in internal medicine.
[Dr. Mohl provided the following article references:]
West CP, Dupras DM. General Medicine vs Subspecialty Career Plans Among Internal Medicine Residents. JAMA. 2012;308(21):2241–2247. doi:10.1001/jama.2012.47535
Schwartz MD, Durning S, Linzer M, Hauer KE. Changes in Medical Students' Views of Internal Medicine Careers From 1990 to 2007. Arch Intern Med. 2011;171(8):744–749. doi:10.1001/archinternmed.2011.139
ACGME: Describe the internal and external partnerships that have been important in establishing and sustaining these experiences.
Dr. Mohl: In each rural internal medicine site, one of our graduates is now serving as a faculty member. Internally, our senior executives, medical staff members, and leadership, as well as our nurses, pharmacists, and other members of the health care team helped share their connections to rural sites. The Billings Clinic Board of Directors has been unflagging in their support for GME. Externally, the state of Montana has a volunteer collaboration, the Montana GME Council, that has helped to guide needed legislation to support rural GME experiences. The Alliance of Independent Academic Medical centers served as a source for mentors and encouragement. The ACGME’s institutional accreditation team was critical in providing guidance during important challenges.
ACGME: Describe the challenges you have experienced in developing and sustaining rural GME partnerships and experiences; and explain how you have overcome them.
Dr. Mohl: The establishment of our Office of Medical Education (OME) was critical to our success. The initial work in creating rural sites faltered when one of the initial sites had support from the Board and leadership, but not from the medical staff. The OME has allowed us to systematically work with our Regional Team and individual departments to create sustainable models. Because we work across our system to provide support for medical education, we have deep relationships on which to base new rural experiences that are meaningful to both residents and local communities.
ACGME: Describe some of your Sponsoring Institution’s outcomes since establishing rural GME experiences, including the impact to the surrounding community.
Dr. Mohl: In five years, the internal medicine residency has graduated 39 residents (2017-2021). Of those, 15 residents (38 percent) are practicing in our region. In addition, four of our 17 graduates are returning in critically needed specialties, such as rheumatology (Montana has fewer than 20 rheumatologists currently in practice). Overall, we have had a 44 percent retention rate of our categorical internal medicine residents.
As Billings Clinic transformed into a Sponsoring Institution, our work on faculty development and understanding the importance of the clinical learning environment also unexpectedly and positively impacted our relationship with the Montana Family Medicine Residency (MFMR). This has resulted in more MFMR graduates deciding to remain in our region.
ACGME: What advice do you have for those interested in establishing rural GME experiences?
Dr. Mohl: Be humble and know that you do not know everything before you start. Be prepared to learn from the rural community and the ones that serve them. Do not underestimate the importance of clear communication and shared values. They are as important as the business plan.
ACGME: Describe the resources that have helped your Sponsoring Institution to establish rural GME experiences.
Dr. Mohl: We have received generous support through time and resources within Billings Clinic and from our regional partners. The Helmsley Foundation was key in encouraging us to not only start an internal medicine residency, but to include sustainable, meaningful rural experiences.
ACGME: Is there anything else you would like to add we haven’t asked about?
Dr. Mohl: The biggest challenge we face is that most of our region is not just rural, but frontier. This poses challenges as to how to adapt program requirements to allow for frontier experiences as well. We are also blessed in Montana to have many Native American communities and are challenging ourselves to think differently and humbly about how to make health care workforce development accessible to those communities.
Email email@example.com if you want to get in touch with Dr. Mohl. Is your Sponsoring Institution/program already providing rural GME experiences and want to be featured in a future post in this ACGME Blog series? Respond to this short questionnaire to share what you’re doing and provide input on how the ACGME can engage stakeholders in this important work. Visit the MUA/P web page to learn more about the ACGME’s efforts.