Access to Care: Overcoming the Rural Physician Shortage
by Fred D. Baldwin
Appalachia has made substantial progress in health care in recent decades, but one problem—a chronic shortage of medical professionals in rural areas—still remains. Rural residents must often travel hours to consult specialists, and many rural communities lack even primary care physicians (physicians certified in family practice, internal medicine, pediatrics, obstetrics/gynecology, and psychiatry). In fact, rural Appalachia still labors under a double burden, according to Lyle Snider, research director in the University of Kentucky Center for Rural Health's Division of Community Programs, Research, and Health Policy: the fewest primary care doctors and the most severe health problems. These situations are related: having too few doctors means that dangerous conditions go undiagnosed too long.
One way the Appalachian Regional Commission (ARC) is working to improve—at least temporarily—primary health care in areas with few, if any, doctors is by taking advantage of the J-1 Visa Waiver Program. This national program waives a requirement that foreign medical graduates who have come to the United States for residency training return to their home countries for at least two years after receiving the training. Instead, the physicians are allowed to remain in the United States, provided they agree to work in medically underserved areas. ARC's J-1 program, which requires the physicians to spend at least three years in one of the Region's Health Professional Shortage Areas (a U.S. Bureau of Primary Health Care designation based on physician-to-population ratios and household income), has placed more than a thousand physicians in over 200 Appalachian communities since 1994, giving tens of thousands of patients in remote communities better access to health care. But the J-1 Visa Waiver Program is generally seen as a temporary solution to a long-term problem.
This article describes three state-initiated programs that have taken on the challenge of providing access to health care for Appalachia's rural residents. The first is a traveling pediatric diabetes clinic that saves children's lives by bringing specialists into rural areas to monitor patients' conditions; the second is a telemedicine program that appeals to patients, doctors, and accountants alike; and the third is a new medical school dedicated to training doctors for rural primary care practice.
Going Where the Need Is
"The day Jason turned two years old," says Donna Hurley, "I cried all day. I was thankful that he'd lived to two."
Jason, her son, is 17 years old today and will be a high school senior this fall. At the age of 15 months he was diagnosed with type 1 diabetes, which typically strikes children and teenagers. Every three months he and his mother visit a health department clinic in Pikeville, Kentucky, for consultation with specialists from the Department of Pediatrics at the University of Kentucky College of Medicine in Lexington. For almost 20 years, its staff has conducted a traveling clinic to help families in eastern Kentucky and nearby rural areas to manage a once-fatal disease.
Type 1 diabetes affects about one in 600 children and teenagers nationwide, according to the American Diabetes Association. Although no cure is known, the disease is manageable through careful attention to diet and regular injections of insulin. Before the discovery of insulin, diabetes was fatal; even now it remains the leading cause of blindness and kidney failure in adults.
Diabetes management is a demanding and never-ending process. Patients must check blood sugar levels several times per day. High or low levels are associated with everything from sluggishness (which affects school performance) to potentially fatal seizures. Hurley recalls many incidents like this in Jason's childhood.
"I'd be walking in the yard," she says, "and he'd be holding my hand and smiling. The next thing, he'd be passed out."
On the advice of her local physician, she made the four-hour drive to Lexington to consult with C. Charlton Mabry, M.D., at the University of Kentucky. As it happened, Mabry had already taken the lead in addressing the human and monetary costs of inadequate care for young diabetic patients.
"By the late 1970s," he recalls, "there were always one or two children in the [university] hospital with diabetes. They were almost always coming from eastern Kentucky. We'd treat them and send them back to their primary care doctors. But they were bouncing back. Someone needed to see them more frequently."
In 1982, with financial support from private foundations, the university established traveling clinics to visit eastern Kentucky counties using local facilities operated by the Kentucky Department for Public Health. Currently, the traveling doctors make quarterly visits to Pikeville and Barbourville, seeing about 100 patients at the sites. The university also operates a call-in service for patients three days a week during early morning hours, and twice a week in late afternoon.
ARC provided financial support during the 1989–1990 fiscal year. It did so again in 1997 with grants for specialized testing equipment and for providing clinics with computers and software to enhance the ability of patients to analyze self-collected data on their own blood sugar levels, an important element in diabetes management. The ARC funds also enabled the development of an extensive continuing medical education course on the pediatric management of type 1 diabetes. Some 150 doctors and other health care professionals participated, making it the best attended of the university's outreach programs.
The university's original program goals were to produce measurable improvement in the clinical indicators of the disease, to reduce sick days and school absences, and to reduce the need for homebound schooling. The first goal was the key to the others, and meeting it depended on impressing patients with the absolute necessity of careful self-monitoring.
After the first year of operation, Mabry recalls, the Department of Pediatrics checked the hospital admission records of roughly 100 children participating in the traveling clinic program. Fifty of the children were hospitalized for treatment the year before the clinic began; only two were hospitalized the year after.
"I remember those numbers so vividly," Mabry says, "and then thinking, 'We've got to keep doing this!' "
That's harder and harder financially every year. Kathryn Thrailkill, M.D., chief of pediatric endocrinology and the current director of the traveling clinic, keeps handy "for the insurance companies" a folder of journal articles citing clinical data demonstrating that patients' blood sugar levels are far more likely to remain within an acceptable range when they get help four times a year, compared with only once or twice a year. This in turn can reduce the incidence of complications, meaning kidney failure or severe vision problems, by 50 to 70 percent.
"What's involved isn't a lot of high-tech," says Thrailkill, "but education."
In the last year she kept records, Donna Hurley spent about $8,600 of her own money on Jason's treatment, so she understands medical economics. She also has no doubt that the education she and Jason have received through the traveling clinics has been, and remains, a matter of life-and-death for him. His father died from diabetes complications about two years ago. With a catch in her voice, Hurley recalls how Mabry sought out Jason, then age 15, and told him in no uncertain terms, "This isn't going to happen to you!"
Telemedicine in Eastern Tennessee
When it's too costly or otherwise impossible for health professionals and patients to meet in the same examining room, the next-best option may be telemedicine. Often, say patients who've participated in the University of Tennessee (UT) Telemedicine Network, a program operated out of the University of Tennessee Medical Center at Knoxville, telemedicine isn't just next best; it's actually better than a visit to a doctor's office.
The program, which began in September 1995, currently has top-quality connections to hospitals in four counties.
Samuel G. Burgiss, who holds a Ph.D. in electrical engineering and has an industry background, is manager of the UT Telemedicine Network, which is funded by the university, the Department of Health and Human Services, and the Department of Commerce. "One of the things we did from the beginning," he says, "was to put medicine first. We start with what the patient needs and what the care provider needs. And then we get to the technology. A lot of it isn't even technology, but technique. When a physician comes in, we make it as nearly as possible like his or her own office."
The examining rooms at the medical center in Knoxville and the rural hospital room have three cameras each. One provides a panoramic view; another transmits documents, X rays, and slides. The third, a carefully placed small camera about the size of a penlight, is positioned to give the patient perfect eye contact with the examining physician or nurse. At the patient's end, a handheld camera can be focused for close-ups of skin, eyes, and so on.
Among physicians, Burgiss says, initial skepticism is changing to support. "Physicians have been coming to us," he says. "It's shifting from us pushing to their pulling." Teledermatology, a specialty often based on visual examination, accounts for most cases. However, Burgiss points out, "Almost any specialty has something that can be done by telemedicine."
The medical center also sponsors a pilot home care telemedicine program called Home Touch for eight homes in Grainger County. The homebound patients have low incomes, and most are elderly. The interactive television connection reduces the number of home visits required by health professionals for services like heart problem and diabetes management, and even hospice care. The equipment permits not only observation and communication but tests for indicators like blood pressure, blood sugar, and heart sounds.
The Home Touch program uses a small monitor at the patients' end and transmits voice and images over ordinary phone lines. The technical quality of the visual signal is impressive: "We can see every mark on a syringe," says administrative and medical assistant Bertha Jarnagin, "and determine if the patient is filling it properly. We can see the medications and look into the pill box to see if they are being taken."
Family Touch and Baby Touch, also run by the center, are hospital-based programs that enable family members who can't visit relatives in intensive care to visit via interactive television.
Teresa Welsh, a graduate teaching associate in the university's School of Information Sciences who's helping to evaluate the program, notes that cost savings for Home Touch occur in several ways. There's the obvious benefit of permitting more frequent patient contact while reducing the number of physical visits. And there's the benefit of education (often a function of frequency of contact). One man in his 40s told staff that before the telemedicine program, he'd been in the hospital for up to ten days "every couple of months" because he'd mixed doses on a wide range of medications. Now, during a year of close video interaction with Home Touch nurses, he's been hospitalized only once, and that for only one day.
"Homegrown" Doctors for Eastern Kentucky
"We want to be the premier medical school in the country for producing doctors who'll practice in rural areas," says John Strosnider, D.O. "I can point out 10 to 15 members of the first class who can already tell you the addresses they're going to have in Harlan, Grundy, or Louisa [Kentucky]."
Strosnider is dean of the Pikeville College School of Osteopathic Medicine (PCSOM), a new school located in Pikeville, Kentucky, that enrolled its first class of 60 students in September 1997. Sixty more followed in 1998, and this year's class of 60 will begin its studies this September. The first class had 380 applicants for its 60 slots; its third class, 1,769 applicants. This demand, Strosnider notes, occurred in a period when medical school applications were down nationwide. PCSOM was created to address a chronic problem underlying virtually every symptom of rural Appalachia's health access problems: the shortage of primary care physicians. For example, in 1995, Kentucky's urban areas had one primary care physician for every 1,452 people. In rural Kentucky the same ratio was 1 to 2,251.
PCSOM grew out of a campaign led by a Paintsville attorney, Chad Perry III, who had often represented coal miners on occupational health issues. Wishing to make a long-term contribution to area health needs, Perry generated support for an area medical school from other community leaders, corporations, foundations, and government agencies. ARC grants were used to build and equip a state-of-the-art anatomy laboratory and to add a new floor to an existing building.
At most medical schools, Strosnider says, fewer than 20 percent of graduates go into primary care after graduation, even for a few years, "and not half of those in a rural area." He expects about 80 percent of PCSOM graduates to practice primary care and most to stay in rural areas. In addition to capitalizing on Appalachian residents' strong love of home, PCSOM focuses its curriculum on primary care and is establishing primary care residency opportunities in eastern Kentucky.
The school's academic admission requirements are similar to those at other medical schools. But preference is given to applicants from eastern Kentucky, rural Appalachia, and other rural areas—in that order.
Strosnider notes that an emphasis on primary care is part of the osteopathic tradition. Physicians whose diplomas read "Doctor of Osteopathy" (D.O.), like those whose diplomas read "Doctor of Medicine" (M.D.), are physicians licensed to administer medication and perform surgery.
They must complete four years of basic medical training, pass state exams, and complete residency programs of at least three years. Osteopathic physicians differ from their M.D. counterparts, however, in their emphasis on the musculoskeletal system as a key to long-term health. They are specifically trained to consider "whole patient" issues—for example, family and community problems.
The PCSOM curriculum includes courses on community medicine and on the business aspects of setting up a small-town solo practice. There's emphasis on overcoming the physical isolation of small communities. All primary care clerkships (short-term assignments during students' first and second years) and 60 percent of the clinical rotations (during the students' third and fourth years) will be with primary-care practitioners. Strosnider has worked closely with Kentucky's Area Health Education Centers, which have arranged off-campus clinical training for the Pikeville students through six sites, in Ashland, Hazard, London, Norton, Paintsville, and Pikeville-Prestonsburg, all within 90 minutes of Pikeville.
Sarah Hughes, director of the Southeast Kentucky Area Health Education Center at Hazard, says that one initial worry—that M.D.s might be reluctant to accept osteopathic students—has proven groundless. Out of 60 doctors contacted, only two have expressed reservations based on degree-related issues. According to Hughes, "They say, 'They're local students, and we need them here.' "
PCSOM does not require a commitment to practice in a rural area. However, more than half of its students are receiving osteopathic scholarships created by the Kentucky legislature for state residents who agree to perform primary care in Kentucky.
William Betz, D.O., who chairs PCSOM's department of family medicine, says that his present students, like others he's taught elsewhere, are bright, competitive, and eager to become doctors. But they differ in one respect. "These folks," Betz says, "really are interested in taking care of their own. They want to stay in the area to take care of their family and friends. They really do want to take care of people in the hills and the hollows."
Talks with three students from eastern Kentucky confirm that. Scott Harrison, of Pikeville, did his undergraduate work at Western Kentucky University, across the state from his Appalachian home. Admitted to another medical school, he chose to come back to Pikeville to study. "I'll probably stay in Kentucky," he says. "Most likely it'll be in this region. I grew up here and know the people."
Beth Carlisle, from Carrollton, says: "I plan to practice in Kentucky—maybe home, maybe not, but definitely in a rural area."
Jody Brown is from Coal Run, Kentucky—"a suburb of Pikeville," he says with a grin. He'll be a third-year student this fall and is near the top of his class. After he completes his residency, he should be able to practice pretty much where he chooses. Any chance that'll be in Pike County?
"Of course," he says.
Taking the Long View
Health is such a complex matter that no single program could ever serve as a magic pill that would somehow take care of every problem. ARC is taking the long view by creating an Appalachian Health Policy Advisory Council (AHPAC) to determine if there are health policy issues that ARC should address. The University of Kentucky Center for Rural Health will provide staff support.
AHPAC will be a 15-member panel, with one member from each Appalachian state, one from the federal co-chairman's office, and one at-large member. Besides identifying new ways to increase the number of physicians in Appalachia, the advisory council will seek to review and clarify other important health issues, such as the impact of managed care on Appalachian health care systems and access to care for the indigent and uninsured. AHPAC will seek to use ARC's unique partnerships with federal, state, and local leaders to leverage entitlement funds and grant investment funds in support of health care efforts in the Appalachian Region.
In the meantime, the University of Kentucky's traveling diabetes clinic and the University of Tennessee's telemedicine program are addressing immediate needs and providing demonstrably effective models for providing specialist services to rural areas unable to support specialists. Finally, the PCSOM strategy—developing doctors for Appalachia from within Appalachia—promises to supply more and more of the primary care physicians so badly needed for the long-term health of the Region's residents.
Fred D. Baldwin is a freelance writer based in Carlisle, Pennsylvania.