To address the widespread need for family doctors, Montana must train its own.

That was the idea behind establishing the Montana Family Medicine Residency more than a decade ago. Establishing a medical residency in a state with no medical school was a huge challenge that has paid off tremendously for the people of Montana. Since the first class of six graduated in 1998, 44 have gone to work in Montana and provide medical care in 18 Montana communities from Miles City to Libby.

The fact that 70 percent of the grads have stayed in Montana is even more impressive when considering that only 34 percent had lived in Montana before they started their residency training. The residency has helped Montana successfully recruit new doctors who came from all over the United States to practice medicine here.

The state of Montana provides a relatively small, but important, portion of the residency's funding, Residency Director Dr. Roxanne Fahrenwald said. The bulk of money for the program is Graduate Medical Education funding from the federal government. The program also receives lots of support from RiverStone Health, Billings Clinic and St. Vincent Healthcare.

The residency is a nonprofit corporation governed by its own board of directors drawn from across the state.

"It's the only residency in the whole state, so we really need to be statewide," said Fahrenwald. Although residents do most of their training at RiverStone and the Billings hospitals, each is required to work for at least a month of the second year and a month of the third year in a rural health facility. Lewistown, Whitefish, Hardin and Miles City have recently served as training sites.

"We really try to get them out there to see how medicine is practiced in rural communities," Fahrenwald said.

The residency has been successful placing doctors in Montana despite intense competition. Montana residents are heavily recruited for jobs outside of Montana, Fahrenwald said. When residents kept track of their job offers, they figured each was getting five a day. Fahrenwald receives about three recruiting pitches a day herself.

Despite high demand for primary-care physicians - family doctors, internists and pediatricians - fewer medical students are going into these basic medicine practices. Fahrenwald said some family medicine residencies have been unable to fill all their training slots and some are even closing, exacerbating the primary care doctor shortage. The Montana program has succeeded in keeping its program full with 18 residents, a fact that Fahrenwald attributes both to the state's natural beauty and to the varied, busy training opportunities the Montana residents have.

We agree with Fahrenwald that health care reformers need to address the "perverse incentives" in the health care payment system that reward doctors for doing more procedures and pay relatively less for preventive and primary care. The payment system ought to be such that young doctors can afford to go into primary care and that experienced doctors can stay in the field.

"Change the incentives so they are rationally connected with what we really need," Fahrenwald said. "Primary care provides the best outcomes with the lowest cost."

The federal medical education funding system also needs reform. Congress must start prioritizing funding to train more of the kind of doctors Americans need most. For now, there's a cap on the number residency slots that will be funded; no more are being added. Hospitals now decide what type of residents will be trained, and the strong financial incentive is to train those who will bring the hospital more money for procedures, Fahrenwald noted.

That's not what happened in Montana. Here, the residency was established to meet Montanans' needs.

Once again, there are a few things that the country could learn from Montana's experience. Primary care should and can be the foundation of a better quality health system that serves all Americans.

New doctors in state

All six 2009 Montana Family Medicine Residency graduates are planning to stay in Montana. Here's a rundown from residency director Dr. Roxanne Fahrenwald:

• Dr. Neil Sun Rhodes of Fort Kipp will work for Indian Health Service in Browning.

• Dr. Jenni Bigback of Lame Deer will work at the IHS hospital in Crow Agency.

• Dr. Chris Cunningham of Billings will start work at a new community health center in Lewistown.

• Dr. Zach Meyers of Kalispell will join the staff of RiverStone Health.

• Dr. Ryan Schwanke of Great Falls will work at Billings Clinic.

• Dr. Stephanie Draper of New York will graduate in December and plans to practice in Montana.