Dr. Mandeep Kaur is training to become a family doctor in a clinic less than an hour from Madera, where she grew up and graduated from high school a decade ago.
It's no coincidence that her graduate medical training is so close to home.
The Sierra Vista Family Residency Program looks for doctor applicants who have ties to the Valley or an interest in being trained and practicing medicine here. The goal is for the doctors to stay after residency training.
Kaur, 26, wanted to return to the Valley after graduating from Ross University School of Medicine in the Caribbean. "This is my community so this is my chance to give back," she said.
The three-year Sierra Vista residency program is part of an effort in the San Joaquin Valley to "grow-our-own" doctors and reduce physician shortages.
Valley health professionals say training doctors is essential. The demand for doctors already outstrips the supply and the disparity is only going to increase as the population ages and as more people gain insurance through the Affordable Care Act.
But residency programs are expensive to start and maintain. And funding is tenuous.
On Monday, the federal Health Resources and Services Administration awarded $1.2 million to the Sierra Vista program to continue for another year. The program enrolled its first class of four residents in 2012. The federal agency also gave $900,000 to salvage a primary-care residency program in Kern County.
However, funds for the programs through the Affordable Care Act are set to expire on Sept. 15, 2015.
Kaweah Delta Health Care District in Visalia started a new four-year psychiatric residency program this summer. The district expects to be reimbursed $325,000 from Medicare for the program's first year.
New residency programs are needed for the Valley to add doctors. There's no federal money to expand established graduate medical education programs, such as the family medicine program at University of California at San Francisco-Fresno Medical Education Program. UCSF-Fresno has operated a three-year residency program in family medicine for more than 35 years. It enrolls 11 students each year.
Without government support, the full cost of training programs falls on hospitals and teaching health centers, said Joan Voris, UCSF-Fresno dean. Fresno hospitals have been generous in allocating money to training programs, she said, but there's a limit as to how much hospitals can spend on training.
UCSF-Fresno is applying for some Medicare-funded residency slots that are opening nationwide because of hospital closures or for other reasons, but it's a long shot to win approval, Voris said.
And California may not get any of the vacant residency slots, she said. The state has the median number of physicians recommended for its population. The physician-to-patient ratio doesn't take into account that doctors are plentiful along the coast but scarce here, she said.
Statewide, California has 64 primary care doctors per 100,000 residents and 130 specialists per 100,000 people. But a stark disparity can be seen between the Bay Area and the San Joaquin Valley in a 2014 California Healthcare Foundation report. The Bay Area in 2011 had 86 primary care doctors and 175 specialists per 100,000 residents, while the San Joaquin Valley had only 48 primary care doctors and 80 specialists per 100,000.
Voris said she's supportive of the new programs in Fresno and Kern County. "Their teaching health center programs are very good and deserve sustained funding," she said.
The Valley was successful in getting a portion of $83 million in federal funds for its two new family residency programs largely because they are based at "teaching health centers." Up until recently most training programs were hospital-based, where more emphasis is on acute health problems. At health center programs, residents practice at clinics where the emphasis is on primary care.
Clinica Sierra Vista applied for and received funding to run the family residency program in Kern County to keep a residency program alive, said Stephen Schilling, chief executive officer. "This is the family medicine program that the county hospital decided to eliminate last year," he said. The new Rio Bravo Family Medicine Residency Program has six residents.
Healthy Communities Access Partners, a Fresno nonprofit, sought funding for the Sierra Vista residency program. The residents work at the Clinica Sierra Vista clinic on Divisadero Street in downtown Fresno.
It costs about $150,000 a year to train a resident at the Sierra Vista program, Schilling said. And the challenge now is to secure funding beyond Sept. 30, 2015, when the Affordable Care Act funding is scheduled to end, he said.
Doctors-in-training have a sense that they can affect the community, said Dr. Elizabeth Tully, program manager for the new psychiatry residency program at Kaweah Delta.
"We can never guarantee what one of our graduates will do," Tully said, "but we certainly were interested in talking about their interests in the Valley and the goals they had for themselves."
Dr. Michael Serna, one of the first-year psychiatry residents, said a new program in a small community appealed to him. Serna, 33, grew up in the Bay Area. Visalia has "a nice community feel to it," he said. "It is a place that I see myself raising a family or continuing to raise my family."
The Fresno and Kern County family residency programs have found it easy to attract medical residents who either have connections to the Valley or want to practice in small communities.
"Their expectation is they are able to train near home, near their roots, their families," Schilling said. "Our expectation is the retention and service to the local community will be very high at the end of training."
Besides Kaur at Sierra Vista, three other residents who started training this summer have ties to the Valley: Dr. Armandeep Kahal was born in Madera; Dr. John Djabrayan lived in Fresno for 20 years; and Dr. Michael Klug grew up in Yuba City but has relatives in Fresno.
Klug said having an aunt and uncle in Fresno helped make his residency decision, but it wasn't the only factor. "I wanted an area that was underserved -- that's where the learning opportunities are," he said. "And I can have an impact."
Kaur has the same outlook. She's glad to be back in the Valley with her family and feels at home at the Sierra Vista residency in Fresno. And, she said, "This is where we are needed most."
The reporter can be reached at (559) 441-6310, email@example.com or @beehealthwriter on Twitter.