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Rx for the Rural Health-Care Shortage

by James E. Casto

Studies suggest that America has more doctors than it needs.

Maybe it does. But even if the United States overall has an oversupply of doctors, that's certainly not the case in the nation's rural areas, especially the rural areas of the Appalachian Region. A recent report from the National Governors' Association indicates that U.S. urban areas have 96.2 primary-care physicians for every 100,000 people, compared with rural areas' 55.6 physicians for every 100,000 residents.

Some doctors avoid rural medicine because they prefer to work in high-tech specialties that cannot be supported through a rural practice. Some simply prefer big-city life. Then there are the family issues. Spouses' careers. Schools for the kids. Shopping. Entertainment. Social life.

Whatever the reasons, it's not unusual for a big city to have one primary-care doctor for every 600 residents, while a neighboring rural county might have only one doctor for every 2,000 residents.

Little wonder that the Appalachian states are trying a number of initiatives aimed at recruiting and keeping rural doctors. Some are offering to refund the medical-school tuition paid by newly graduated doctors if they agree to set up practice in a rural community. Others are extending tax credits to doctors who relocate to rural areas.

The architects of the curriculum at the Marshall University School of Medicine in Huntington, West Virginia, were convinced that the only way to encourage more students to enter rural primary care was to give them actual training experience in rural areas.

To that end, Marshall, which accepted its first medical students in 1978, required from the outset that all its students spend time working at rural clinics in the state.

More recently, West Virginia's two other medical schools—the West Virginia University School of Medicine in Morgantown and the West Virginia School of Osteopathic Medicine in Lewisburg—also have started requiring their students to do the same.

Thus, West Virginia is literally rewriting the book on medical education by requiring that every medical student in the state, no matter what his or her future plans, put in a stint at a rural clinic.

West Virginia Governor Gaston Caperton takes a broader view. "West Virginia's innovative rural health-care program serves as a model for the nation," he says. "Through this rural health-care initiative and other programs, West Virginia is emphasizing primary and preventive care."

Meanwhile, East Tennessee State University (ETSU) in Johnson City, Tennessee, has undertaken another significant departure from traditional health-care education. In partnership with communities in the rural areas of east Tennessee, ETSU is teaching medical, nursing, and public and allied health students actually living in those communities.

And there's a common connection to what's happening in West Virginia and Tennessee—the financial support of the W.K. Kellogg Foundation of Battle Creek, Michigan. Established in 1930, the foundation targets its grants toward specific focal points or areas, including health care.

In 1991, the Kellogg Foundation awarded a $6 million grant to the university system of West Virginia, which used it to fund a network of rural clinics to be staffed in part by medical students from the state's three medical schools. The West Virginia legislature then allocated $6 million for additional clinics. That same year, the Kellogg Foundation awarded ETSU $6 million, the largest grant in the school's history, for the school's Community Partnerships for Health Professions Education Program.

A Common Denominator

The common denominator of the new medical education efforts in West Virginia and Tennessee, explains Ron Richards, program director with the Kellogg Foundation, is that "both were linked with their communities, both were multidisciplinary in nature, and both were moving to provide care outside the usual hospital setting.

"Each program has developed in its own distinct fashion, but both have been successful beyond our expectations," says Richards.

When Marshall University dispatched its first medical students to rural communities, its vision of a "medical school without walls" was unorthodox indeed. The strategy paid off, however, helping Marshall to become one of the nation's leaders in producing doctors who practice in the frontline specialties of family practice, general internal medicine, and pediatrics.

The school-without-walls concept takes Marshall's medical students outside of the classroom and places them where they're needed—in the medically underserved communities of rural West Virginia. From the state's southern coalfield counties to its northern and eastern panhandles, Marshall medical students spend one to six months at a time at rural sites in 30 of the state's 55 counties.

"The rural experience gives students a new understanding of medicine at the human level, and they always carry that with them," says Dr. Patrick I. Brown, associate dean of academic and student affairs at Marshall. "It also lets students learn firsthand that so much of primary-care medicine can be practiced quite effectively with the technology available in smaller communities."

Each Marshall medical student spends a total of at least four months in rural communities, often forging deep ties.

"Students at the very least become emotionally attached to these communities and feel responsible for 'their' patients there," says Brown. "It's not uncommon to see students sign up for a second rotation in one of these communities. Through this experience, they really take on the mantle of a health-care provider, with the responsibility that entails."

In Spencer, West Virginia, Marshall University medical students play a major role in fulfilling the goals of the clinic operated by Roane County Family Health Care.

"Through their time and effort, students bring the community increased access to health care," says Chuck Conner, who coordinates student activity at all participating health-care sites in Roane and Jackson Counties. "They provide educational presentations to the community at large, as well as screenings and health clinics that were never available before. Because of the students, we can provide these at no cost."

The Roane County center started taking medical students five years ago and encourages students to come for several months at a time.

"I think if we're really going to succeed in meeting the needs of the community and address the long-term issue of keeping these students in West Virginia—or at least having them return—the students need to be part of our family," says Conner. "Students who come here for five or six months don't leave as students, they leave as friends."

The students take courses emphasizing community, rural, and primary health care during their second year and live and train in small communities for a portion of their third and fourth years.

A Link to the World

Computer technology links the rural-based students to the Marshall campus in Huntington and to medical resources around the world.

The university's Department of Academic Computing designed RuralNet, a sophisticated computer network that connects more than 130 rural hospitals and clinics in West Virginia. RuralNet users have access to MEDLINE and other key medical library resources. In addition, they can electronically access case simulations, practice quizzes, case studies, and statistics from the Centers for Disease Control and Prevention.

At West Virginia University (WVU) in Morgantown, Dr. Gregory Doyle, who coordinates off-campus educational experiences for the Department of Family Medicine, emphasizes the hands-on experience that WVU's medical students get at the state's rural clinics.

"Students on rural rotation become better clinicians because of their experience," Doyle says. "And the education they receive in a rural location is impossible to duplicate at the [Robert C. Byrd] Health Sciences Center. Many of the patients that students see in Morgantown are very ill. But out in the doctors' offices, students see it all. They come back excited and enthusiastic."

The most important thing the new West Virginia program has done is bridge the gap between academic medicine and rural communities, says Hilda Heady, WVU's associate vice president for rural health. Heady has seen that gap from both sides, as a hospital administrator in rural Preston County and as the key organizer of WVU's participation in the state's new rural health-care effort.

"I think there were a lot of stereotypes in people's minds at first," Heady says. "But once people came in contact with one another on a more regular basis, that started to dissolve. At the university, we now know that 'rural medicine' does not mean 'substandard medicine.' And in the community, they've learned that 'Health Sciences Center' does not mean 'ivory tower.' "

Working with physicians around the state gives students the opportunity to be exposed to "a wider range of skills and practice styles than they could find on campus," says Dr. Norman Ferrari, associate dean at WVU. "The preceptors—physicians, nurse practitioners, physician assistants, midwives—are the key to the program and are the guarantee of quality. We couldn't do it without them."

Shawn Stern, a fourth-year student at the West Virginia School of Osteopathic Medicine in Lewisburg, has high praise for the community involvement that's a key element of the rural training. Stern put in a stint last year at the Cameron Community Health Center in Cameron, West Virginia.

"In urban areas, you're at the hospital or the doctor's office all day," Stern says. "At Cameron, we went to high schools, did home visits, [participated in] health fairs, and conducted programs for the community."

Stern is a Cameron native and plans to set up practice there. "This is my hometown, and all my family live around here," he says. "It's very rewarding treating teachers, family, friends—patients that I know personally."

Meanwhile, in the rugged mountains of east Tennessee, the Division of Health Sciences at East Tennessee State University and two rural counties—Johnson and Hawkins—have teamed up in a new approach to medical education.

High Rates of Disease

Johnson is the easternmost county in Tennessee, and one of the most mountainous and isolated. In 1991, its only hospital had been closed for years, and many of its health professionals had retired or left the county. Designated by the Department of Health and Human Services as both a health professional shortage area and a medically underserved area, the county reported deaths due to heart disease and cancer at rates much higher than national averages. Prevention services were few.

Hawkins County lies in Tennessee's Holston River Valley, surrounded by mountains. Although the rural hospital in Rogersville remained open, many of the county's key health-care providers were elderly or had moved away. Like Johnson County, it was designated a health professional shortage area and a medically underserved area, and its high rates of heart disease and chronic obstructive lung disease suggested inadequate preventive care.

The two counties are located 50 miles from Johnson City, the home of East Tennessee State University. Established as a teachers college in 1911, the university has become a center for health professions training in the resource-poor Appalachian Region. In 1988 ETSU formed its Division of Health Sciences by bringing together its College of Medicine (now the James H. Quillen College of Medicine), its College of Nursing, and its College of Public and Allied Health.

Using its Kellogg Foundation grant, the Division of Health Sciences established teaching medical practices in both Johnson and Hawkins Counties with full-time medical and nurse practitioner faculty serving as health-care providers. Facilities and other resources were provided by the two communities. Today these practices handle over 20,000 office visits a year, and the program has enabled 120 students to gain experience in clinical medicine.

Now the Kellogg Foundation has approved a second grant for the ETSU partnership. The $1.8 million grant focuses on developing community-based, multidisciplinary educational experiences for graduate-level health professions students, including family practice medical residents, nurse practitioners, and students of communicative disorders and environmental and public health.

"This second grant will allow the university to establish a regional network of sites where groups of our health professions graduate students can learn together throughout the region," says Dr. Paul E. Stanton, vice president for health affairs and dean of the James H. Quillen College of Medicine.

"We hope that the experiences planned in the community and practice-based settings in this program will help our health professions students learn to work together in teams," says Dr. Wilsie S. Bishop, ETSU's dean of public and allied health. "With the apparent push toward managed care and prevention that we see taking place in our region's health-care system, graduates of our programs who receive this additional training should be well suited to adapt to the changes of the future."

ETSU has had a strong record in producing primary-care practitioners throughout the years. "Over three-quarters of the graduates of our nurse practitioner program have settled in underserved communities in Tennessee and southwest Virginia," notes Dr. Joellen Edwards, dean of nursing. "This movement towards meeting the region's needs is also evidenced by the fact that over 70 percent of this year's College of Medicine graduates selected a residency in primary care."

Where is this evolving curriculum—with its revamped courses and varied clinical pathways—taking medical education? Ever closer to the basics of medicine, suggests Dr. Linda Savory, professor of family and community health at Marshall.

"Earlier in the century, medical education was taken away from the bedside and put into the classroom. Later on we put it in high-tech hospital settings. Now we think we may have gone too far," says Savory. "We want to take it back to the bedside, or at least to the rural health clinic."

James E. Casto is associate editor of the Herald-Dispatch in Huntington, West Virginia.