Q&A with Joshua Wynne, M.D., M.B.A., M.P.H., Vice President for Health Affairs and Dean of the University of North Dakota School of Medicine and Health Sciences

North Dakota has fewer physicians per capita than the national average and without an increase in medical school enrollment and residency positions, that number is projected to decrease. In Western North Dakota, the oil boom is increasing workforce demand three to five times that anticipated in the rest of the state even using low population estimates. The state’s rurality presents additional workforce challenges as more than a quarter of the population lives in isolated rural areas while only 6% of physicians in the state practice there: those physicians are also older on average. North Dakota has responded with a four-pronged approach: working on reducing chronic diseases, increasing medical school enrollment, retaining more graduating students for practice in the state, and helping to improve the efficiency of the state’s health care delivery system. Dr. Joshua Wynne, dean of the state’s only medical school, the University of North Dakota School of Medicine and Health Sciences, shares how the school collaborated with partners across the state to design and implement a plan to address these issues.

What physician workforce challenges does North Dakota face?

The two principal drivers of health care workforce needs in North Dakota as elsewhere are age of the population and size of the population. North Dakota has one of the more elderly populations in the nation; we are second only to Rhode Island in the percent of our population over the age of 85, and fifth in the fraction of our population over the age of 65. Additionally, the life expectancy in North Dakota is above the national average. Because of the relatively advanced age, we have a greater need for health care. It turns out that age is a simple but highly predictive indicator for health care needs; as we age, we consume more health care resources. For example, we spend about ten-fold as much on a senior citizen as we do on a child. As the impact of the baby boomers becomes increasingly manifest, we’ll see a burgeoning need for more health care providers as the boomers need more health care.

The second driver of workforce need is population growth. Although almost unimaginable before the explosive growth in the oil patch, the population of North Dakota is predicted to increase significantly (and perhaps dramatically) in the next 10-15 years. As the population grows, so too does the need for providers.

Thus, the aging of the population along with population growth will increase the demand for health care, and thereby the physician (and other provider) workforce needs.

A particular issue for rural states such as North Dakota is a mal-distribution of providers, with providers tending to cluster near larger towns and cities. Primary care providers, especially family physicians, tend to be relatively better distributed than specialists, but they too tend to favor population centers. This often leaves rural areas short of providers, especially the primary care providers they need most. Even non-physician providers such as nurse practitioners and physician assistants (PA) tend to practice in more populated areas, although PAs show the best balance overall between rural and non-rural areas.

Could you tell us about North Dakota’s four-pronged approach to addressing the state’s physician workforce needs?

By reducing disease burden, especially due to chronic diseases, we can reduce the need for health care providers. We’ve taken several concrete steps to accomplish this. First of all, our inaugural class of Master of Public Health students just began their studies. This program is a joint effort of the University of North Dakota and North Dakota State University. By focusing on behavioral aspects (among other public health issues), the graduates should be able to reduce the impact of chronic and other diseases. Additionally, we are developing a geriatrics training program to assist practitioners across the state in the health care management of elderly patients.

We have instituted a variety of programs to enhance the retention of graduates for practice in the state. One example is our RuralMed Program, which removes one financial barrier to rural primary care practice. It absolves a student from the tuition costs of all four years of medical school if they agree to practice family medicine in a rural area of North Dakota for five years.

And the expansion of class size has just begun. We welcomed the first cohort of students this summer and they are all hard at work, learning to become physicians, physical therapists, physician assistants, etc. Of course, it will be several years before they are ready to go out into the community and practice, which is why it is so critically important to institute workforce solutions as quickly as possible. The aging seniors aren’t going to wait!

What results are you seeing from this approach?

It’s really too early to tell for sure, but all the indicators are positive. We have twelve students enrolled in the RuralMed Program at present. And over 70 percent of the residents who graduated from a North Dakota residency training program this year are staying in North Dakota to practice. A graduate of our surgical residency program has settled in Williston, and four UND graduates are going to Hettinger. We now have third year medical students doing their clinical clerkship training in Minot. All of these are encouraging signs and should help North Dakota address its health care workforce issues in the foreseeable future.

What types of collaboration, partnerships and networking have made this work possible?

None of this would have been possible without a wide array of partnerships. Funding from the Legislature has been critical, as has additional support and guidance from the Dakota Medical Foundation. High-level guidance and direction has come from the School of Medicine and Health Sciences Advisory Council, a legislatively-mandated group of 15 representatives from various constituencies from across the state. A critical partnership has been the very productive relationship the School has with all six major hospital systems in the state, as well as the 36 smaller critical access hospitals. The single most important factor has been the dedicated and selfless efforts of the nearly 1,000 clinical faculty members across the state. Unlike larger medical schools, we rely on volunteer faculty from across North Dakota to teach our medical and health sciences students; we literally could not do it without them!

What are some of the biggest challenges to coordinating workforce resources in North Dakota?

Any industry that comprises almost one-fifth of the state’s economy as health care does is necessarily a complex system with many moving parts involving multiple providers, payers, and interests. Getting all of those parts to work together in a harmonious fashion is necessarily a major challenge. Perhaps the greatest challenge is to correctly balance the rural health care needs of the state with those of the cities; the resources, priorities, and goals can differ significantly depending on geographic region. Similarly, we need both primary care providers as well as specialists, and it is important to get the balance between the two just right.

What advice do you have for other states who are working with their legislators to fund similar programs?

Be sure of your facts; focus on the needs of the state and its citizens rather than the needs of providers; be transparent; always demonstrate integrity; and most important of all, build and nurture personal relationships with the legislators. The saying that “all politics is local” is critical to remember; legislators respond best when they see the potential advantages of a given approach to their constituents in their corner of the world.

What are some admissions factors the school considers to help address the state’s primary care physician workforce needs, particularly for rural areas of the state?

Perhaps the best predictor of practicing in a rural area is coming from a rural area. Two additional reliable predictors are an interest in primary care and an interest in eventually practicing in a rural area at the time of matriculation to medical school. We use these predictors to inform and shape our School’s admission policy. Thus, in our admission process we give extra credit for rural upbringing, an interest in family medicine or primary care, and an intention to practice in a rural area.

What other innovative workforce programs from the school would you like to highlight?

Securing state funding to allow the expansion of our residency programs is important. Most residency training in this country is supported by the federal government, mainly through the Medicare program. But growth in the number residency slots has been effectively capped by the Balanced Budget Act of 1997. By garnering state support, we have been able to expand our residency offerings with two goals in mind: provide residencies that meet the health care workforce needs of North Dakota and appeal to our graduating medical students. Why are residency programs so important? Because residency program graduates tend to practice near where they complete their residency training. For example, two out of three doctors who went to medical school at the University of North Dakota and then did a residency in-state remain in North Dakota to practice.

What is your vision for addressing health workforce needs in North Dakota? Given additional funding and resources, what other goals or projects would you pursue?

We have a proposal pending with the North Dakota Legislature that would allow us to fully implement our class size expansion. The full Health Care Workforce Initiative calls for a total of 16 more medical students per year (total of 64), 30 more health sciences students (total of 90), and 17 residency slots per year (total of 54). Because of space limitations in our main instructional building, which is a 60-year old converted hospital, additional facility space is essential. Of the various proposals for facility expansion, the most logical over the long haul is construction of an entirely new facility, thus eliminating the legacy costs of maintaining an aging building that was never intended to function primarily as an educational building. A committee of the Legislature that has been studying the Health Care Workforce Initiative during the interim while our Legislature is in recess has concluded that building a new facility is the preferred option, and has recommended that option by unanimous vote.

Dr. Wynne can be reached at joshua.wynne@med.und.edu or (701) 777-2514.

Please note that the views expressed in this article are the opinions of the interviewee and do not reflect the official policies, positions, or opinions of the Health Workforce Information Center or its funder.