Megan Svec knew she wanted to be a doctor when she served in the Peace Corps in West Africa.
"I was sitting in a hospital there, and there were no providers except a locally trained nurse for a ward of 20 women, some of whom were sleeping on the floor," Svec said.
Svec, a resident physician with Family Medicine Residency of Western Montana, saw the shortage of providers, and believed she might have the opportunity to learn something helpful and share it.
Now, she's working as a doctor in Missoula, among the first group of residents in the new program at the University of Montana.
"I love being some source of comfort, even if I'm not the one who can do any of the curing," said Svec, in her second year of the residency.
Saul Rivard came to the program after he received his medical degree from Warren Alpert Medical School of Brown University in Providence, Rhode Island.
For him, Livingston is home, and the mission of the residency to serve patients and communities in rural Montana is critical.
Rivard, also among the first group of residents, wants to work in a rural hospital when he completes the program.
"You always go back home, you know, and if home isn't the actual place, then a place like it," Rivard said.
Here in western Montana, these doctors and this residency program are shaping a new and different future. Here, compassion in care is the gold standard in medicine, and a commitment to community is paramount.
Ned Vasquez, director of the program, said the small group of family physicians who created the residency placed empathy at its core.
"That group wanted to make sure we weren't missing that point, that being a smart doctor or a technically good doctor is not all that's required to provide care to another human being, that you need to be compassionate," Vasquez said.
Right out of the gate, the program is earning high marks and strong interest. The Accreditation Council for Graduate Medical Education recently awarded the Family Medicine Residency its highest accreditation status, despite the fact its first residents haven't even completed all three years.
In its second year, the residency received more than 800 applications for 10 slots.
"It's amazing that we have been able to achieve that. It is fair to say we have been very successful in recruiting residents," Vasquez said.
In June 2013, western Montana had no resident physicians.
This July, 30 doctors will be at work in the program affiliated with the University of Washington Family Medicine Residency Network, along with nine core faculty, more than 100 community faculty, and five staff.
Kim Mansch, director of Partnership Health Center, said the clinic counts more than 50,000 patient visits a year. She said having the residents on staff adds some 6,900 additional visits at the center.
"The beauty of the program for us is it increases our access for the under-served populations in Missoula, which are huge," Mansch said. "So by having another avenue to get our patients in the door, that just provides excellent health outcomes for our community."
The program will be full in July, with another crop of residents coming on board. The doctors work at St. Patrick Hospital, Community Medical Center, Partnership Health Center, Flathead Community Health Center, and Kalispell Regional Medical Center.
In rural areas, they fan out to Anaconda, Browning, Dillon, Libby, Ronan, Plains, Polson, Hamilton and Stevensville.
Three of the residents from each class are based in Kalispell.
The doctors who are part of the inaugural cohort soon will enter their third and final year, and many want to stay in Montana when they're finished. Keeping them here is one goal.
"Montana historically has ranked 50th in the nation for graduate medical education slots, with only two residency positions for every 100,000 people," according to UM. "The U.S. average is about 25 per 100,000."
Vasquez said most physicians stay in the area where they complete their residencies, and Montana has been short.
"We don't produce enough doctors to serve our needs," he said.
The program's philosophy begins with this statement: "We believe that patient care must be compassionate to be excellent."
That ethic is infused into the residency in a variety of ways, beginning with instruction that is focused on patients as human beings.
Tim Caramore, a doctor at St. Patrick Hospital, is one of the physicians who guides the residents through their analyses. Last week, the doctors talked with him about their cases, and he asked them questions and offered suggestions.
"I do talk a lot about trying to get to know patients on a personal level and attending to the sort of social details, the story of their lives as opposed to the list of their medical problems," Caramore said. "We practice medicine best when we have a context."
Jennifer Robohm, a psychology faculty member at UM and part of the residency, observes the residents' visits when patients offer permission. Then she gives the doctors feedback on whether exams were "patient centered" and if they used accessible language.
"The hope is they are feeling the pressures of time and trying to cover a lot of ground, but also (making) sure they're being good listeners," Robohm said.
The program stresses personal wellness, too, Svec said.
Their hours can be long, sometimes 9 a.m. to 10 p.m., or even 24 hours for a second-year resident on delivery in obstetrics. To take care of others, then, the doctors need to take care of themselves.
Most of the residents are active people, and the group is social, Svec said. The activity, both physical and social, helps them maintain sanity, and Missoula itself gives them outlets.
"Almost everyone in our program is very outdoorsy and was attracted to Montana, to Missoula ... for the opportunities to be outside," said Svec, who received her medical degree from the University of Washington School of Medicine.
The program just formed a wellness committee, too, Rivard said. It's a way for the doctors to talk about balancing work and life and to promote awareness of their limitations when it comes to fatigue.
"The habits we form here are going to be reinforced later on, so I think it's important that we start good habits here," Rivard said.
Last week, Svec walked into an exam room at Partnership to see Caitlin Aguilar for a follow-up appointment. Aguilar had been feeling low, and her medication was making her feel nauseous.
"I puked in the shower yesterday. It's getting pretty bad," Aguilar said.
Before they talked about changing her dosage or medication, though, Svec checked in about Aguilar's plans for the future. Aguilar soon will get married, and then she and her husband will go on an adventure.
"You’re going to travel the world, right?" Svec said.
The doctor sat close to the patient, taking notes on her laptop, looking up often at Aguilar. Aguilar, in a chair next to Svec, confirmed she still planned to hit the road.
"We've been saving up a bunch of money, so we're just going to go," Aguilar said. "We're thinking about Indonesia right now. Somewhere warm, different."
When they talked about adjusting medication, Svec said she knew Aguilar had an understanding of some of the difficulties of finding the right mix since she studied psychology.
At one point, Aguilar mentioned her cat, and Svec wondered how the pet would fare when Aguilar was away.
"What are you going to do with the cat when you leave?"
Aguilar has a small dog, too, and she said the pets were coming along. As they planned, the doctor talked about making sure the patient had a way to get medication when she was far from home.
Aguilar has seen many doctors since she was a little girl, and Svec and her pediatrician are her favorites. On her way out of the clinic, she remarked on Svec's abilities.
"She remembered so much about me. She remembered my fiancé, what I studied ...," Aguilar said. "It shows she actually cares."
The patient had a diagnosis to deliver, too: "With doctors like her, you don't dread going to the doctor."
Svec wants to keep seeing her patients here in Missoula, and she hopes to be hired here when she completes the residency.
In Billings, an estimated 70 percent of the resident graduates stay in the state, Vasquez said. In Montana, he said, some 23 percent of physicians are older than 60 and will retire within five years.
"So by creating a residency program, we are expanding the pipeline of physicians that are available to go to the rural places in our state," Vasquez said.
The medical community has been largely supportive of the program, Rivard said. In the future, he believes the state will be better off for it.
"I think once we graduate our first class, it will be even more reinforced that training good physicians is really important. It's important for the overall health of Montana," Rivard said.
So far, the residency looks like a win for the community. It's good for patients, a boon for doctors who want to practice in a beautiful part of the country, a feather in the cap of UM.
"The loser would be if we were unable to run the program within a reasonable budget. The hospitals could say, this is too expensive for us to sustain," Vasquez said.
So far, he said, the family residency is on track with its original budget. The three main hospitals made some initial investments in the program, but he doesn't anticipate the money will be an ongoing requirement.
In the future, he said, the program may seek funding from the new purchase of Community Medical Center, and it may seek support from the Montana Legislature.
"We'll be seeking to diversify our funding to ensure that we are fiscally viable and our three hospitals are protected from excessive deficits," Vasquez said.
At Partnership last week, Justin Perry talked with Caramore about one of his patients.
Perry, of Fort Benton, got his medical degree from the University of Nevada School of Medicine after working as an engineer in Montana. He was led to medicine after volunteering with AIDS patients in Cambodia and in leprosy camps in Vietnam. (See his resident profile with this story.)
Perry's patient wanted to lose the weight he gained while in prison, but it had been a challenge. In the mornings, the man rode his bike, but he was limited in activity the rest of the day.
"In the afternoons, he's kind of locked down in the pre-release," said Perry, in his first year as a resident.
The man had other medical concerns, too, but when it came to weight loss, the doctors agreed a referral to a dietitian would be helpful.
"Weight loss is overwhelmingly a function of diet," Caramore said.
"Yeah. I told him that. You can only burn so many calories with exercise," Perry said.
After they finished, Caramore praised the group of doctors who had come aboard, many specifically because they had an interest in shaping a new program. Then, he was onto the next resident.
"All right. Who's up?"