The WWAMI Puzzle

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.

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.

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.
Photo courtesy of the Department of Family Medicine.

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. Read more about Harberd.

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.”


Going Home

You can drive for a long time in Wyoming and see hardly anyone, says Jarod McAteer, M.D. ’09. Juneau, Alaska, says Cassie Iutzi, is accessible only by boat or plane. And KayCee Gardner, who spent some of her early years in a one-room schoolhouse in Montana, went from “having a backyard that stretched for miles” to having a few square feet of grass when she moved to Seattle.

Jarod McAteer, M.D. ’09, found it helpful that faculty and staff visited Laramie during his first year of medical school, dispensing advice on classes and life in Seattle. Now in residency, he’s shown here with a trout caught in Yellowstone Lake, Wyo.
Photo courtesy of Dr. McAteer.

McAteer, Iutzi, Gardner: all are from rural or remote areas, all are transplants to Seattle (albeit temporarily), and all share a special kind of WWAMI experience.

A central characteristic of the WWAMI program is the relationship between the UW School of Medicine and other academic institutions in the five-state region. While some students spend their first two years of medical school at the University of Washington in Seattle, others spend their first year at their WWAMI state university and their second year in Seattle. In their third and fourth years, all students travel to sites throughout the WWAMI region — in Seattle and outside it — to complete medical clerkships: hands-on training with patients, supervised by doctors.

The logic behind this educational plan is simple. WWAMI educators want students from those first-year WWAMI sites to return to their home states to practice medicine. The need for doctors in WWAMI — a largely rural area underserved by medical practitioners — is high. (In fact, according to the Association of American Medical Colleges, four out of five WWAMI states have fewer physicians than the national average: 254 doctors for every 100,000 people.)

Students find the first year in their home state helpful, even wonderful. One huge advantage, says McAteer, is getting to know the 20-some students in the local class. Even after you move to Seattle, he says, “you always have something in common with students from your first year.”

That kind of camaraderie is reassuring when finding your way in a new place. Iutzi remembers half of her Alaska class gathering at the Port of Seattle to unload the shipping container they’d rented to move their belongings. “It was like a small community in the late 1800s, packing up everything into their covered wagons and moving to a new town,” she says.

After 82-year-old Margaret Engelhardt underwent surgery to mend a broken leg, Cassie Iutzi, a third-year medical student from Alaska, listens to her breathing and talks to her about osteoporosis medication and fluid buildup. Such interactions are par for the course in a medical student’s rotations; this one was conducted at Northwest Hospital & Medical Center.
Photo: David Wentworth Photography

Still, the transition from the home state’s site to the Seattle site can be a challenge. The student-teacher ratio is vastly different (each second-year class has 220 students), and you have to learn the ropes all over again. But the School of Medicine steps in to help students from regional sites adjust.

“The best thing [the School] did was build the College Program,” says Gardner. In the Colleges, students are assigned to small groups under the guidance of a mentor; they get to know that mentor from day one of medical school, no matter what their location. During the second year, they work closely with their mentor, learning clinical skills at the bedside and in small-group settings. And during medical students’ third and fourth years, they stay in touch with their mentor — by email, telephone and, when geography works in their favor, in person.

Although Gardner, McAteer and Iutzi have a shared WWAMI experience, their backgrounds are quite varied. Gardner grew up on a Montana ranch and spent part of the summer helping her family harvest hay. McAteer completed his undergraduate degree at Yale but found that he preferred living out west. Iutzi, who is working on a master’s degree in public health as well as an M.D. degree, volunteers in community-based clinics in Ecuador and Nicaragua.

Even so, the WWAMI program is attractive to them for similar reasons. It keeps them connected to their home state. “I really liked the idea of coming back to Montana to do clerkships,” says Gardner. She, McAteer, and Iutzi all hope to return home — or someplace very much like it — to practice.


When Students Become Teachers

Kayaking is a great teaching tool. At least, that’s what Tobe H. Harberd, M.D. ’06, found.

Tobe H. Harberd, M.D. ’06, experienced one of the benefits of rural practice — enjoying the great outdoors — during his time in the R/UOP program.
Photo courtesy of Dr. Harberd.

When Harberd was fulfilling his Rural/Underserved Opportunity Program (R/UOP) experience with Mike Luce, M.D., Luce took him into the small-town clinic where he worked in Dayton, Wash. After all, that’s the point of R/UOP — to introduce students to clinical care between the first and second years of medical school. But Luce did more than that. Harberd stayed with Luce’s family, and they shared meals. They even went kayaking together.

“It wasn’t just medicine, it was the whole rural experience,” says Harberd, a native of a small town in Idaho who now practices family medicine in Chelan, Wash. “Because of my experience with Dr. Luce, I’ve tried to set up my R/UOP experiences with my students in a similar fashion.”

Old guard, new guard

Known as clinical preceptors, the community-based doctors who teach medical students and residents are a tremendously influential part of the WWAMI program. Medicine is only part of what they teach. Like Luce and Harberd, they provide students with the opportunity to think about what it will be like to live and practice in a specific community.

Alaska native Bob L. Urata, M.D. ’77, Res. ’80, always knew he wanted to go home to practice medicine. Urata, now a preceptor, is shown with medical student Shannon Son, visiting for her R/UOP experience.
Photo courtesy of Dr. Urata.

Another UW School of Medicine graduate-turned-preceptor, Bob L. Urata, M.D. ’77, Res. ’80, conducts a WWAMI Rural Integrated Training Experience (WRITE) program site in Juneau, Alaska. In the five consecutive months that selected third-year students can spend with him, they are exposed to outpatient services in family medicine, internal medicine, pediatrics and psychiatry. As an Alaskan who returned to Alaska to practice, Urata has high hopes that the experience will sway his first WRITE student to return, too.

Those hopes are motivated as much by necessity as by regard. Alaska — like other WWAMI states and, more generally, states across the nation — is facing a doctor shortage. Especially in primary care, and especially as doctors like Urata, now 60, approach retirement. “We’ve got to replace old guys like me,” says Urata.

Hooked on WWAMI

Paula Carvalho, M.D. ’84, Res. ’87, FCCP, pulmonary section head and head of the ICU at the Boise VA Medical Center in Idaho and UW professor of medicine in the Division of Pulmonary and Critical Care, agrees that WWAMI is crucial to retaining doctors in the region. But at one point, this self-described “Seattle-centric” medical student was reluctant to leave the Seattle campus. Would she learn as much about medicine outside of the city as she had in it?

“We really want to teach our trainees how to teach, because we think that’s going to be the name of the game,” says Paula G. Carvalho, M.D. ’84, Res. ’87. More teachers in the region mean more opportunities for students to learn. In this photo, Carvalho (the woman near the center of the frame) is about to teach fourth-year medical students and internal medicine residents how to insert a central line in a mannequin — part of a simulation exercise.
Photo courtesy of Dr. Carvalho.

Then came her obstetrics-gynecology rotation in Anchorage, Alaska. “I absolutely loved it,” says Carvalho. Ob-gyn was followed by other rotations — including pulmonary medicine — in Boise, Idaho. “Then I really got hooked,” she says.

Today, Carvalho designs innovative learning experiences for first- and second-year residents, third- and fourth-year medical students and trainees completing advanced pulmonary fellowships, among others. For example, she started a critical-care medicine curriculum a few years ago for medical students, one that prepares them for starting an internship.

Carvalho also works directly with UW Medicine faculty like Brian Ross, M.D. ’83, Res. ’87, UW professor in the Department of Anesthesiology & Pain Medicine, to teach trainees. Boise is a satellite site for the UW Medicine-based Institute for Simulation and Interprofessional Studies (ISIS), which uses sophisticated mannequins and computer models to offer medical training. Using such simulation exercises allows trainees to hone specific skills, like placing a central line for long-term intravenous drug therapy, doing a lumbar puncture, or caring for patients receiving mechanical ventilation.

The trainees appreciate these programs, Carvalho says. Last year, the fourth-year students (who are a little anxious when they arrive), wrote her a thank-you card. “We’re no longer afraid to be interns,” it said.

Big investment, big reward

If medical students benefit from the WWAMI program, says Urata, so do the states that participate in the partnership. With WWAMI, Alaska can help its citizens become doctors, and, he says, “we get to take advantage of one of the best primary-care medical schools in the U.S.”

What’s in it for the preceptors themselves, besides a significant addition to their workload? They love working with young people who are so enthused about medicine. And it reinforces a commitment to lifelong learning. “Working with trainees definitely keeps me on my toes,” says Harberd. Community doctors have to be prepared to answer trainees’ many questions — and they have to be prepared to teach.

“It’s fun to continue to learn, and I think that’s the key when you’re teaching students,” says Urata. And, like all good teachers, he knows that learning is a balance between watching and doing. Take this summer’s R/UOP student, for instance, whose clinical experience included delivering babies.

“We had her do a couple of deliveries,” says Urata. “And we were right there helping her.”


Moe & Miner: Returning Residents

After medical-school graduation, doctors move on to residency training — additional, advanced years of training in which they learn a chosen specialty such as surgery or radiology. Residency provides another opportunity for WWAMI to encourage doctors to practice in the Northwest. There are 18 family medicine residency programs in WWAMI that educate more than 400 residents; in addition, there are residency positions for internal medicine, obstetrics-gynecology and pediatrics, as well as training opportunities for psychiatry in Spokane and Boise. These graduate medical education programs are vital to the future of healthcare in WWAMI; statistics show that doctors like Lanae Miner and Moe Hagman, featured below, are most likely to settle in or near their residency training location.


Lanae K. Miner, M.D. ’09
Pediatrics resident at Seattle Children’s

Melissa “Moe” Hagman, M.D. ’99, Res. ’02 Associate Program Director, UW Boise Internal Medicine Residency Program, Boise VA

  Lanae Miner checks in on Jude Ahvakana, referred from Alaska for diagnosis and treatment — WWAMI in action.Photo: David Wentworth Photography Moe Hagman is seen here in scenic Winthrop, Wash. Hagman recently moved back to Boise, Idaho, where she received training.Photo courtesy of Dr. Hagman.
Where did you grow up? Snohomish, Wash. “There was one high school and three stoplights.” Boise, Idaho. “Boise got its first mall around the same time I got my driver’s license. We thought the world had truly arrived.”
What was it like working in WWAMI communities as a student? Eye-opening. “I worked with a family medicine preceptor in White Salmon, Wash., as part of the R/UOP program in medical school. We’d be in clinic during the day, then we’d go to a nursing home to do rounds at lunch. In the morning or the evening, we’d go to the hospital to see newborns and patients referred by the clinic. It was my first exposure to what practicing medicine would be like if I were more than 30 minutes away from a big city.” Friendly. “I did my third- and fourth-year student rotations in Pocatello, Idaho, and the Boise VA. The people were really welcoming. Basically, they said, ‘You’re important. We have a role for you.’”
Talk about your residency experience. Diversity. “I spend a lot of time at Seattle Children’s, but I rotate through Harborview Medical Center and UW Medical Center. Residents are also required to spend two months at a site outside Seattle. I went to Yakima. When I was working at the community hospital, I learned that the resources were more limited than they are at Children’s. You have to anticipate in those situations — to take stock of the interventions you can provide, and figure out whether you can provide them, or if you should transfer the patient.” Relationships. “My co-residents at the Boise VA during the second year of residency are the greatest group of folks I could ever have hoped to work with. We are now scattered throughout Montana, Alaska, Washington and Idaho, but I know that I can call them anytime for advice on topics ranging from patient care to the best places to vacation.”
Where do you want to practice medicine? Washington. “Washington is my home, and I love it here! I’m hoping to stay in the Pacific Northwest.” Idaho. “I just moved back to Boise and the Boise VA, because I got hooked on it — like a lot of internal medicine residents who went through the WWAMI program. I’m a teacher at heart, and many trainees come to the Boise VA. Plus, I have nieces and nephews in Boise. They’re fast becoming teenagers, and I wanted to come back to Idaho to go to their birthday parties and go boating with them before they think I’m uncool.”
Final words on WWAMI? Gratitude. “I could not be where I am today were it not for the physicians throughout WWAMI who opened their offices and shared their patients with me. They have provided me with immeasurable knowledge and experience!” Fantastic. “WWAMI is fantastic. I’d probably give a good chunk of my paycheck and my left arm for it to continue.”



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