This interview is part of a 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 in the ACGME’s digital learning portal, Learn at ACGME. Note: an account (free to create) is required to access most content in Learn at ACGME.
John Andazola, MD, FAAFP is the designated institutional official (DIO) and program director of the Southern New Mexico Family Medicine Residency Program in Las Cruces, New Mexico – a community-based program that educates residents and is a semi-rural Health Professional Shortage Area. Dr. Andazola is also the DIO and Board Chair of the New Mexico Primary Care Training Consortium, which is a Sponsoring Institution currently developing a rural family medicine program in Española, New Mexico.
ACGME: What drew you to academic medicine and to rural GME specifically?
Dr. Andazola: I was born and raised in Las Cruces, New Mexico and my family history goes back to this area at least 500 years. It has always been my intent to serve the community where I was raised. Teaching residents in the community for the community has been a successful strategy across the country for retaining physicians in the local area. We have been equally successful in doing so in Las Cruces. With the development of the new program in Española, we are able to build on this success such that the consortium can support and develop other rural programs throughout the state.
ACGME: Describe the rural GME experiences within your program/Sponsoring Institution (e.g., types of sites, structure, curriculum, etc.).
Dr. Andazola: We know that physicians tend to practice in the communities where they finish their terminal education. Therefore, we focus on providing rural education and training opportunities in communities that have insufficient primary care resources. Simply placing physicians in rural communities, however, will not necessarily address the health equity issues we frequently see. Physicians must also be trained to address community challenges and concerns, as well as to build on community strengths. Our training in rural practice, therefore, focuses in two major areas. One is ensuring that residents are educated and trained in full-spectrum family medicine so that they have broad clinical skills to address the specific medical needs of the rural community where they practice. The second is ensuring that residents are trained in social medicine so that they also have the skills to both understand their practice in the social environment of the rural community and act to address population health concerns beyond the walls of the clinic or hospital by being engaged with community members.
ACGME: How did your Sponsoring Institution/program become involved in establishing rural GME experiences?
Dr. Andazola: The New Mexico Primary Care Training Consortium and the Southern New Mexico Family Medicine Residency Program were both developed in rural and under-resourced communities to address the health [practitioner] shortages present within the communities. From their inception, both institutions have had a focus on providing a strong primary care workforce educated and trained in and for rural and under-resourced communities.
ACGME: Describe the internal and external partnerships that have been important in establishing and sustaining these experiences.
Dr. Andazola: In creating rural programs, it is essential that collaborations are developed at a community and state level in order to support them. The New Mexico Primary Care Training Consortium is a consortium of all family medicine and psychiatric residency programs in the state of New Mexico and the two medical schools in the state (University of New Mexico and the Burrell College of Osteopathic Medicine). Additional partners, such as hospitals, federally qualified health centers [FQHCs], local physicians, and the state Medicaid program, regularly work with the Consortium to support funding, development, and sustainability of rural programs.
ACGME: Describe the challenges you have experienced in developing and sustaining rural GME partnerships and experiences; and explain how you have overcome them.
Dr. Andazola: I think there are two main areas that make developing and sustaining rural GME programs difficult – funding and faculty development. The up-front investment to establish a rural program can be an overwhelming barrier. To address this, the New Mexico Primary Care Training Consortium has been working with the state for several years to develop a Medicaid-based GME funding program that focuses on the state’s needs. The state has invested in rural training program development and has allowed community hospitals and FQHCs to obtain GME funding, which has enabled growth of GME programs throughout the state. This funding is focused on primary care and psychiatry residency program development. In addition, the state developed a Graduate Medical Education Expansion Board and has provided funding for residency program planning and development. Both of these have been effective in planning, development, and sustainability of new community-based rural programs. Faculty development is also a challenge, given that one reason to develop rural programs is the lack of health [practitioners] in rural communities. Rural programs have difficulty recruiting faculty members at the initiation of the program. Once the faculty foundation has been laid, the programs can recruit faculty members from their own pool of graduates. The residency program in Las Cruces has been very successful in building a strong and committed faculty using this strategy. These physicians have the experience of working in the community and provide quality education to residents regarding both clinical skills and social medicine.
ACGME: Describe some of your program’s/Sponsoring Institution’s outcomes since establishing rural GME experiences, including the impact to the surrounding community.
Dr. Andazola: The Southern New Mexico Family Medicine Residency Program and a similar program in Santa Fe, New Mexico have a high retention rate approaching 70 percent. Because of this, we have been able to retain family physicians for our communities. The New Mexico Primary Care Training Consortium was instrumental in developing a new rural training program in Alamogordo, New Mexico, which is just completing the training of its first class. Several of their senior residents are planning to join their faculty, which will directly support program sustainability. Most recently, the New Mexico Primary Care Training Consortium is developing a rural family medicine residency program based at an FQHC in Northern New Mexico. This program exemplifies a new model for rural education and training to address sustainability concerns. The Sponsoring Institution is a consortium of residency programs rather than a single hospital, giving the new program access to residency resources across the state. The continuity ambulatory experiences will be in an FQHC, providing residents with experiences specific to the populations served by FQHCs in rural areas. The inpatient experiences will be shared by two local hospitals, thus effectively utilizing the sometimes-limited resources for hospital-based education and training in rural areas.
ACGME: What advice do you have for those interested in establishing rural GME experiences?
Dr. Andazola: Long-term community partnerships and “relentless incrementalism” are required. Each community will have its own challenges to overcome. We know that educating and training physicians in rural communities is an essential component of meeting the needs of these rural communities. These physicians will be better prepared to meet the needs of the communities because they have been educated and trained within them. That being said, resources are much more limited in rural communities and must be developed intentionally. Working with state leadership, as well as with community partners like FQHCs, hospitals, and regional academic medical centers goes a long way to addressing these needs.
ACGME: Describe the resources that have helped your program/Sponsoring Institution to establish rural GME experiences.
Dr. Andazola: The Consortium has a collaborative relationship with New Mexico Human Services Department, which has been critical to developing innovative and sustainable funding models for rural GME in our state. In addition, the Consortium has worked to develop strong partnerships with hospitals and other health care sites across the state that may offer educational experiences for residents. The Las Cruces residency program has maintained relationships with its graduates working in other rural areas of southern New Mexico, which has led to new opportunities for current residents to learn and train in their clinics.
Email firstname.lastname@example.org if you want to get in touch with Dr. Andazola. 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.