Training doctors for rural practice helps meet statewide need

April 25, 2024

Dr. Michelle Clark-Forsting always knew she wanted to be a doctor. Growing up in Alma Center, Wisconsin, she worked during the school year as a nursing assistant at nearby Black River Falls Memorial Hospital. Physicians there were her role models. In 2005, she applied to medical school at the University of Wisconsin.

She didn’t get in.

Michelle Clark-Forsting

“I told myself, ‘time to pivot,’” Clark-Forsting recalled. “I went and got a two-year Master of Public Health degree at UW-La Crosse. And then the CEO of the hospital where I’d worked got word to me that a new program had been created within the medical school at UW, called WARM. And it turned out to be perfect for me.”

The Wisconsin Academy of Rural Medicine (WARM) is one of several rural medicine training programs in the UW School of Medicine and Public Health designed to address a growing shortage of rural physicians statewide. The need today is acute. Almost 28% of the state’s population is rural, but only around 11% of Wisconsin’s physicians practice in rural areas. Meanwhile, Wisconsin’s rural baby boomers are aging and require more care.  Out of roughly one million rural residents, more than 250,000 live farther than 15 miles from a hospital and for many, that distance is growing, as doctors retire or move elsewhere. In some areas, rural hospitals facing financial challenges have closed or consolidated.

“The disparities are enormous, and all specialties are needed,” said Dr. Joseph Holt, WARM’s director since 2018. “WARM takes applications from students interested not only in primary care, but in any specialty – surgery, OB-GYN — as long as they are steadfastly dedicated to rural care.”

Currently, 108 medical students are enrolled in the WARM program. During their four years of medical training, WARM students relocate to one of three statewide campuses (in Green Bay, Marshfield and La Crosse) for 28 months of their curriculum and can request rotations in smaller rural clinics around the state.  Students hone self-reliance, the ability to work in environments that might have limited resources – such as access to specialized equipment or infrastructure – and the confidence to stretch the limits of their scope of practice.

WARM students practice prepping fellow students for an MRI scan
While studying in La Crosse, Wisconsin, WARM students learn to use an MRI machine.
Photo courtesy of Gundersen Health System

Clark-Forsting recalled being on the front lines during her medical school rural rotations.

“During my OB rotation, I delivered 8 babies. During general surgery, we were the first assist, instead of being fourth or fifth in line. That made a huge impact on whether or not I would be ready for rural practice,” she said.

Prior to WARM, which was launched in 2007, only 5% of UW’s medical students chose to practice in rural areas. That figure has changed dramatically since the program launched; now, 49% of WARM graduates are serving rural Wisconsin, and 32% have returned to their hometowns.

To help meet the projected increase in need for rural physicians over the next decade, WARM is partnering with groups like Wisconsin Area Health Education Centers and the Native American Center for Health Professions to encourage more rural high school and college students to consider a career in medicine.

“There are lots of kids in rural Wisconsin who would be awesome health care providers, but they don’t know that’s even possible,” said Holt. “If we make sure their interest is supported, we increase their chances of success. You can hit a lot of bumps in the road and still become a doctor.”

Clark-Forsting, who graduated from WARM in 2012, is now president of the Krohn Clinic, the thriving primary care clinic where she has practiced since completing her residency in 2015. Black River Falls Memorial Hospital, where she worked in high school, is right across the street. The clinic welcomes medical students each year for training, and Clark-Forsting enjoys interacting with learners and demonstrating what rural practice is really like.

“These are my people,” she said. “I grew up here. It continues to be my dream to serve my neighbors and friends.”

Rural training for medical students is one part of the solution to statewide shortages. Another is rural training for residents. Most residencies — the postgraduate clinical training programs that newly-graduated MD and DO physicians must complete as they pursue board certification in their specialty — are in urban areas, and doctors tend to stay near where they trained.

The number of obstetric providers in rural areas is dropping and we have to work hard now on rural training.

– Dr. Ryan Spencer

To address this problem, UW offers several rural residency programs, including a rural general surgery program, a public health track in psychiatry and rural tracks in family medicine. In October 2023, the Rural Health Equity Track residency and the Baraboo Family Medicine residency program in the Department of Family Medicine were recognized by the Rural Medical Training Collaborative, a national non-profit coalition, for their strong track records of training and placing physicians in rural practices.

UW’s OB-GYN rural residency program, founded in 2016 by UW Health in partnership with the Department of Obstetrics and Gynecology, was the first of its kind in the nation. Dr. Ryan Spencer, director, said it’s critical to offer rural training for this procedural-based specialty.

“We are in a challenging situation,” he said. “The number of obstetric providers in rural areas is dropping and we have to work hard now on rural training, or it’s going to be monumentally worse in the next 5-10 years.”

Each year, the OB-GYN rural residency program selects one resident to complete approximately 6 months of their training at three rural partner sites. These partnerships are essential to the program’s success.

“A big focus for us is making site visits, getting to know rural physicians who might be champions, and working with the executives of the partner hospitals to make sure they have a vision for how this could benefit their organization,” Spencer said.

Eilidh Pederson, CEO of Western Wisconsin Health in Baldwin, Wisconsin, welcomes UW’s OB-GYN residents with open arms. Four hospitals within a 60-mile radius of her medical center have closed their labor and delivery units, she said, leading to increased volume for the two OB-GYN specialists at Western Wisconsin Health.

“Five years ago, we were delivering 100 babies a year. This year, we are on track to deliver 400 babies,” she said. “We see obstetric care as really the heart of what we do as a hospital. It’s one way we are redefining rural health here.”

Kaley Gyorfi uses a doppler instrument to listen to a baby's heartbeat
Dr. Kaley Gyorfi listens to a baby's heartbeat during an appointment with a patient at Waupun Memorial Hospital. Gyorfi is part of UW's OB-GYN rural residency program.

UW’s residents not only learn from the hospital’s two OB-GYN providers, but also share what they’ve learned from their training in Madison.

“They also lend a hand. Our residents deliver babies. They perform surgeries. Our staff are consistently impressed with the skill set of the residents,” Pederson said.

The hospital works hard to engage with the surrounding community, and residents help lead community childbirth classes, speak at local events, partner with midwives to talk about safe birthing practices, and more. What Pederson hears from community members, she said, is “gratitude that the hospital is hosting a physician-in-training who may consider working here one day.”

“Our hospital board sees residents as our succession planning,” she said. “They’ve become part of our strategic plan for ensuring a sustainable workforce. It’s important not only to the future of this hospital, but to medicine as a whole.”

WARM was launched with start-up funds from the Wisconsin Partnership Program (WPP), a grantmaking program within the University of Wisconsin School of Medicine and Public Health committed to improving health and advancing health equity in Wisconsin through investments in community partnerships, education and research.