Spokane and Eastern Washington have significant shortages of physicians, and it's projected those shortages will worsen dramatically in the next 10 to 20 years, says a report by two task forces that studied development of a four-year medical school here.

The best way to expand medical education in Spokane and Eastern Washington would be through expansion of the WWAMI program here into a four-year branch of the University of Washington School of Medicine, located at the Riverpoint Campus and developed with Washington State University, the report says.

Dr. Paul Ramsey, dean of the UW medical school, and Warwick Bayly, provost of WSU, received the report recently after the task forces finished their work.

"I think both groups were very responsive to the charge," Ramsey says. "They did a good job of bringing together work-force needs."

He adds, "The need for health professionals will be changing. We need to be responsive to that and keep an eye on it."

The Spokane Project Committee, the task force charged with studying the feasibility of establishing a four-year medical school here, concluded that the size of each class admitted to the WWAMI program in Spokane should be expanded to at least 80 students, from 20 first-year students now.

WWAMI stands for Washington, Wyoming, Alaska, Montana, and Idaho, the five states from which the students come. Through the WWAMI program, 20 UW medical school students receive their first year of schooling in Spokane now, and 20 receive it in Pullman. The students receive their second year of education at the UW medical school campus, in Seattle, then receive their clinical education at locations across the five states.

The other task force evaluated whether there's adequate support in the medical community in Spokane and Eastern Washington for clerkships for third- and fourth-year medical students.

The report says the two task forces recognize that to maintain educational quality, the expansion of medical education in Spokane might need to be done incrementally, and that any expansion would be "dependent on new funding from the Legislature."

Ramsey says that state funds make up 3.5 percent of the budget of UW Medicine, which includes the medical school and its health-care system, but says those state dollars and the tuition paid by medical students are important sources of revenue.

He says he knows that the state budget is extremely tight, but adds, "That's where I come back to the question of return on investment. For the foreseeable future, the best return on investment is graduate medical education."

To blunt the current and impending shortages of physicians in Spokane and Eastern Washington, the Spokane Project Committee concluded that each class admitted to a four-year medical school program in Spokane should be increased, the report says.

"One suggestion was that 60 new students should be added to the Spokane class as soon as possible—raising the Spokane class size to 80," and eventually each class here should be expanded to 100 to 120 students, the report says. "Until changes are made in Idaho, it was suggested that the Pullman class of 20 students continue to go to Seattle for their second year, along with the students from Idaho with whom they spend their first year."

Meanwhile, the report says the U.S. also is facing a significant physician shortage, and because Spokane and Eastern Washington import more than 80 percent of their physicians from other states and countries, efforts to address the shortages here must be weighed in the context of the national shortfall of doctors.

"The newest information from the Association of American Medical Colleges Workforce Center indicates that the U.S. will face a shortage of almost 160,000 physicians by 2025," the report says. That national shortage will occur, it says, because population growth has outstripped the growth of medical education over the last 30 years; the population has aged, increasing demand for health care; new medical technologies have come into use; and the working habits of physicians have changed. If health-care reform passes this year, demand for physicians' services will increase further, it says.

As the national shortage becomes more severe and more states require graduates of state medical schools to practice within their borders to repay the states for their education, Washington state will face increasing challenges in recruiting physicians from elsewhere, "and will need to educate and train a larger percentage of Washington physicians in our state," the report says.

A pair of other national physician work-force trends is hitting Spokane and Eastern Washington. Because most of Eastern Washington is rural, the doctors who serve it are predominantly from primary-care specialties, the report says. "Unfortunately, the percentage of U.S. physicians choosing to practice primary-care medicine is declining sharply"—from 87 percent of all doctors in 1931, to 53 percent in 1960, to 31 percent in 2000, worsening the problems that Eastern Washington has in recruiting physicians.

Also, since the 1940s the number of doctors practicing in small towns and rural areas in the U.S. has remained flat while the population has grown. Compared with the U.S. average of 20.2 physicians per 10,000 population, Eastern Washington in 2005 had an average of 17.7 doctors per 10,000 people, and it has significant shortages of doctors in general internal medicine, general pediatrics, obstetrics and gynecology, and general surgery, the report says.

In Eastern Washington, only Spokane, Chelan, and Walla Walla countries were at or above the national average for physicians per 10,000 population in 2005. Douglas, Ferry, Pend Oreille, Lincoln, Adams, Garfield, Columbia, and Klickitat counties had some of the most severe shortages of physicians in the state. Nine other counties were below state and national averages.

It's projected that the population in Spokane and Eastern Washington will increase by about 29 percent by 2025, while the over-65 population will rise by 85 percent in Spokane and 77 percent in the rest of Eastern Washington, further increasing the demand for doctors. Maintaining 2005 ratios of 225 physicians per 100,000 population in Spokane and164 physicians per 100,000 population in Eastern Washington would require 281 new physicians in Spokane County and 640 in Eastern Washington, the report says.

"It is important to note that many members of the committee feel that the present ratio already represents a shortage and is far from optimal," it says.

It says the task forces considered a number of projection scenarios. One involved maintaining the current medical student class sizes of 20 incoming students in Spokane and 20 in Pullman, with the current proportion—5 percent to 10 percent—of the class returning to the area to practice medicine. At the other end of the spectrum, it considered the increase of the total Eastern Washington class to 100 incoming students, and increasing the percentage of those who practice in the area by a factor of four by creating four years of medical education in Spokane and by expanding graduate medical education so that all graduates could complete their residencies in the area. The report says "studies clearly indicate that completing both medical school and residency in an area provides the greatest likelihood for a physician to settle in an area."

The report adds, "In all scenarios, current shortfalls worsen and dependence on physicians trained elsewhere increases, but the situation is much better with a much larger class in Spokane and with more GME (graduate medical education) in Eastern Washington and Spokane."

Because the medical education pipeline is so long—at least seven years beyond college for a primary-care physician—even adding a four-year medical school here and increasing graduate medical education in Spokane wouldn't produce any results until 2017, and maximum output of new physicians wouldn't occur until 2024.

"Thus, the committee recommends that action should be taken expeditiously," the report says.

It also says students in an expanded medical education program here should be from Spokane and Eastern Washington to increase the likelihood they would practice in those places after they complete their training.

The report says the UW medical school's second-year curriculum would need to be modified to make it applicable to a site outside of Seattle. That likely would result in a hybrid between the current curriculum "that is very faculty intensive and very dense in lectures" and a second-year curriculum that utilizes five hours of lectures a week and is grounded in problem-based learning. "Delivery of a hybrid second-year curriculum in Spokane will require additional basic science and clinical faculty members."

The report says that the capacity of clinical clerkships for third- and fourth-year students "must be equal to the size of the class size that is taught in Spokane and Pullman." It adds, "Failure to expand the clerkships will decrease the yield of graduates who will stay and practice in the area. Just as the clerkship spots must be expanded to match the class size, the number of first-year seats in graduate medical education programs in Spokane and Eastern Washington must also be expanded to match the class size."

Currently, there are 193 clerkships in Spokane and Eastern Washington, and another 183 would be needed to assure there was at least one slot in each required clerkship for each of the 40 first-year medical students in Spokane and Pullman, the report says. It says the committee found the quality of the current clerkships is "quite good" overall.

"Spokane medical leaders have noted that there are many possibilities for new clerkships in the Spokane area," the report says. A survey of physicians in the Spokane County Medical Society found more than 40 percent already are involved in medical education in some capacity, and more than 80 percent agreed that Spokane is an appropriate site for a medical school, and a medical school would be important in the community.

"Of those not currently involved in medical student education, nearly 75 percent would like to be involved," the report says. "A clear majority felt that contributions to medical education would be valuable in their work settings."

The two task forces recommended as "next steps":

•An expeditious review of the second-year medical school curriculum to make it "transportable."

•A financial analysis of resources required for a four-year branch campus in Spokane.

•Acceleration of clerkships to meet the goal of one slot for each of the current 40 first-year students in Spokane and Pullman.

•Acceleration of the expansion of graduate medical education programs.

•"Development of a communications strategy to deal with the public enthusiasm and desire for information about this topic."