Makenzie Bartsch, MD, was entering her third year of her emergency medicine residency in the summer of 2021 when her medical school leaders called a meeting with her and the other emergency medicine residents from Wyoming who had been part of the WWAMI Medical Education Program, the UW School of Medicine’s multi-state medical education program. These residents were ready to find employment back in their home state of Wyoming—a requirement of the contract they signed with WWAMI on their first day of medical school—but the program directors had bad news for them: There were no emergency medicine jobs open in Wyoming. And if they couldn’t find employment in Wyoming within a year of finishing residency, they would be on the hook for the loans provided by the state to pay for their medical school education, plus additional financial penalties. It was an unexpected sucker punch to their future prospects.

Emergency medicine workforce issues play out across the country in a variety of ways, but the state of Wyoming has unique circumstances. It’s part of the WWAMI program, a partnership with the University of Washington to supply the states involved—Wyoming, Alaska, Montana, and Idaho—with a guaranteed physician workforce. (The WWAMI acronym stands for all the states involved.) Due to the scarcity of medical schools in these states, legislators partnered with the state of Washington and the University of Washington to allot a specific number of the medical school’s seats to each state. 

Wyoming receives 20 seats per year and those spots are funded by the state. Students from  Wyoming in the WWAMI program sign contracts requiring them to return to work in their home state within one year of completing their training. If they work in Wyoming for three years, the money that the state paid on their behalf to the University of Washington (estimated at approximately $240,000) will be forgiven. Once their training is completed, Wyoming WWAMI-funded physicians get a 12-month grace period to find a job before their contracts enter repayment status, with eight percent interest accruing during those 12 months. 

Wyoming native Carol Wright Becker, MD, FACEP, went to medical school through the WWAMI program and was working in different emergency departments in the state when she started precepting for WWAMI. As Dr. Wright Becker got more involved in the educational side of WWAMI, she was keeping an eye on what was happening at the national level. She was serving as president of the Wyoming Chapter of ACEP in early 2021 when the results of the Emergency Medicine Physician Workforce Report were released, projecting an oversupply of emergency physicians by the year 2030. (Visit acep.org/workforce to view the report.) Dr. Bartsch was actually one of the first medical students Dr. Wright Becker mentored as a preceptor.

The potential implications of the national workforce report hit home locally when Dr. Wright Becker was asked to help another WWAMI-funded emergency physician find a job in summer 2021, a couple of months after the workforce report results were made public. Finding work as an emergency physician in Wyoming had never been an issue before, Dr. Wright Becker explained, so she was confident this young physician could find employment in emergency medicine. “I was hired under critical staffing shortages,” she remembered. “Wyoming never has enough physicians.” 

It was the same story told to Dr. Bartsch and her fellow medical school classmates. Three years ago, Dr. Bartsch said they were consistently assured that Wyoming was “really hurting for doctors” and they’d “be able to work in any town they wanted.” 

But by summer 2021, the pandemic had changed the landscape in Wyoming. In a state used to ongoing physician shortages, there were suddenly no emergency medicine jobs to be found.

Perhaps the social distancing of the pandemic led emergency physicians to see the appeal of working in wide-open Wyoming with fresh eyes. Maybe those who were planning to retire felt so essential during the pandemic that they delayed their end date. It’s likely that the hospitals and facilities that desperately needed more staff during pandemic peaks brought in physicians from neighboring states as a temporary measure, and they ended up staying. Whatever the contributing causes, the end result was that for the first time ever, there was no urgent need for more emergency physicians in Wyoming.

Wyoming is not immune to scope-of-practice issues, either. Some of the acute care positions that could open up for emergency physicians are being filled by family physicians who are generally paid less. Historically, Wyoming WWAMI’s main goal was to fill primary care positions, but many WWAMI students are not going into that specialty. For the Wyoming students currently in WWAMI residency, 10 are pursuing emergency medicine—that’s tied with anesthesiology for second-highest total for any specialty. (Internal medicine is first with 20 residents.) 

Dr. Bartsch and the other emergency physicians coming out of the WWAMI program who wanted desperately to work in Wyoming were forced to scramble. Dr. Bartsch did what many young physicians have done in recent years—she went the fellowship route in hopes that her extra year of training would allow the Wyoming job market to open up. She made that choice knowing WWAMI will continue to produce new emergency physicians who need to find work in the state, so the workforce problem may not go away. At least the fellowship bought her some time.

Similarly to emergency physician workforce issues on a national level, Wyoming faces a complicated problem with a multitude of contributing factors. Job markets historically ebb and flow and eventually adjust, but that long-term outlook doesn’t help freshly minted emergency physicians who need to find jobs now to avoid serious monetary penalties.  

Altering the contractual obligations for Wyoming participants in the WWAMI program would require a legislative change, and state legislators are hesitant to fix something that is still working for the other specialties within the state. WWAMI’s return rate of 63 percent is “amazing,” said Sheila Bush, who has served as executive director of the Wyoming Medical Society for 16 years. “There has to be a balance so you don’t undermine WWAMI,” she explained. 

Senator John Barrasso, MD, worked 24 years as an orthopedic surgeon and once served as President of the Wyoming Medical Society. “Wyoming’s collaboration with Washington, Alaska, Montana, and Idaho delivers an innovative and state-based solution for medical education,” Sen. Barrasso said. “We need to keep WWAMI strong and able to educate the next generation of physicians, many of which come from rural communities.”

Sen. Barraso and Dr. Wright Becker

Sen. Barrasso believes the situation in Wyoming is indicative of a broader issue. “The challenges facing emergency medicine residents are part of a much larger problem with Graduate Medical Education (GME). Our federal GME funding structure is broken and does not reflect the health care workforce we need in the 21st century. Specifically, GME concentrates funding in large academic medical centers located on the east coast,” he said. “Senators from rural states, especially in the west, agree changes must be made. I’m personally committed to working with both sides of the aisle on GME reform. Fixing GME is essential to close health care disparities in rural America.”

There are no legislative proposals on the table as of this writing, but potential solutions are being discussed: Should the time for return to Wyoming be extended past one year so that physicians have more time to find work within the state without incurring such harsh financial penalties from their WWAMI contracts? Should the law be tweaked to specify that those WWAMI medical students who plan to return to work in Wyoming must pick a certain specialty with more guaranteed employment? Should Wyoming hospitals and health care facilities be incentivized to hire WWAMI graduates? Can the interest rate be reduced or eliminated?

With the clock ticking for Dr. Bartsch, she decided to “get creative” in her search for a position that would fulfill her contractual obligations. Six months into her search, she found a job back in Wyoming, allowing her to breathe a deep sigh of relief as she finishes her fellowship year.

For Dr. Wright Becker, navigating Wyoming’s current emergency medicine workforce issue—and improving the outlook for rural emergency medicine as a whole—has become a personal quest. After surviving cancer in 2019 and losing a colleague in a motorcycle accident, she was in a reflective state when this Wyoming workforce problem landed in her lap. “God kept me on Earth for something,” she explained. “Maybe I should work on this.” 

And so, she is. Dr. Wright Becker packed up her family and moved them to West Virginia, where she is developing an emergency academic program with focus on rural medicine inspired by her time in Wyoming. She hopes her program and research will help develop some long-term solutions for rural acute care. At the same time, she remains devoted to the students and residents she mentored in her home state and she is still working closely with her WWAMI colleagues back in Wyoming to look for solutions.

“I think what’s going on in Wyoming is the crux of what’s going on [nationally],” she said.  “Somehow, this tiny state is having the [emergency medicine] workforce issues play out in the biggest, baddest way.” 

Jordan Grantham is senior content manager at ACEP.