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A Medical School for the Mountains: Training Doctors for Rural Care

by James E. Casto

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Photo of medical student Kari Lindsey and physicia

There's no category in the Guinness World Records for "Smallest College with Its Own Medical School." If there were, the listing surely would read: "Pikeville College."

The small eastern Kentucky college was founded in 1889 to provide educational opportunities for the youth of the mountains. Today the school's broadened mission includes training medical doctors to minister to the people of eastern Kentucky and Appalachia. Pikeville College itself has 950 undergraduate students studying a traditional liberal arts curriculum, while the affiliated Pikeville College School of Osteopathic Medicine (PCSOM) has 240 students.

PCSOM graduated its first class of physicians in May 2001. For the 53 new doctors, that graduation day marked the end of four years of work that began in 1997 when they enrolled as the then-new medical school's first students. For Paintsville attorney G. Chad Perry III, who originally envisioned the school and worked hard to make it a reality, that day was a dream come true.

"In the early 1990s," explains John A. Strosnider, D.O., vice president and dean of PCSOM, "Chad Perry decided he wanted to give something back to the people of eastern Kentucky who had helped make him a success. And he felt the greatest need in eastern Kentucky was medical care, especially family care. He dreamed of starting a private, nonprofit medical school, and specifically an osteopathic school because primary care is such an important emphasis in osteopathic medicine."

While Appalachia has made substantial progress in health care in recent decades, a chronic shortage of primary care physicians still exists in many rural areas.

"Physicians tend to cluster in urban areas," says Strosnider. "Here in eastern Kentucky, historically, because we're rural and isolated with our mountains and creeks and lack of infrastructure, it was difficult to get physicians to come and stay."

A 1997 report by the Good Samaritan Foundation revealed that each primary care physician in eastern Kentucky had an average of 2,075 patients to care for, compared with an average of 1,784 patients for other Kentucky physicians, and 1,226 patients for doctors nationwide.

A Mission of Service

Originally, explains Pikeville College president Harold H. Smith, Perry and the community leaders whose help he had enlisted were intent on building a medical school in Paintsville. But with no facilities there, it soon became clear that it would be tremendously expensive to start a school from scratch. At that point, the idea emerged of locating the school at nearby Pikeville College.

The college had an established campus with academic, laboratory, and library facilities. It had an experienced board of trustees, administration, and faculty. Moreover, training primary care physicians to practice in the medically underserved areas of eastern Kentucky and Appalachia seemed a natural fit with the college's historic mission of service."Nonetheless," says Strosnider, "it took a lot of vision and a lot of guts for the Pikeville College board to undertake such an ambitious enterprise."

Perry and his wife put up the first $1 million for the new school. A variety of other private and public donors also contributed, including the Appalachian Regional Commission (ARC), which provided funding to renovate and expand school facilities and to purchase needed equipment. Both Smith and Strosnider praise Governor Paul E. Patton for his help in getting the school off to a good start. Patton, ARC's 2001 states' co-chairman, has been a member of the Pikeville College board of trustees for 26 years, and First Lady Judi Patton is an alumna of the college.

"Paul Patton has been a wonderful supporter for us," says Strosnider. "If it weren't for him, we wouldn't be here. The first five years of a medical school are critical because of the costs. You have to buy all the microscopes; you have to buy all the computers and the other things you need. These resources have come from the community and regional leadership of east Kentucky and major corporations and foundations interested in enhancing and improving the welfare of the people of the region."

A native of Missouri, where he was in both private practice and osteopathic education, Strosnider was hired as the new school's dean and entrusted with the huge responsibility of getting the institution up and running.

"I started here in September of 1996, and we admitted our first class a year later, in September of 1997," he says. "It was a busy year. When I got here, there was an old metal desk and a Smith-Corona word processor, and that was it. That was the school. For the first five months, I was the school's only employee. My first faculty hire was in January of 1997."

That first year, PCSOM attracted 350 applicants, many of whom had been waiting eagerly for the new school to open. Of the 60 students in the first class, 53 graduated. Each year, the school admits another 60 students for the four-year course of study. "If we lose one or two students along the way, we add one or two to the next class to make up for them," Strosnider says.

"Admission to the school is very competitive. Last year we had 1,576 applicants. That's for 60 seats. So we can be pretty selective."

Strosnider says one of the things that attracted him to Pikeville was the opportunity to design a new curriculum that departed in many aspects from the traditional approach. The result, he says, is a course of medical study that's more hands-on, with early clinical involvement. "In their very first year, students are exposed to clinical situations. They're not just taking biochemistry, anatomy, histology, and physiology. They also have clinical skills. And 20 percent of our curriculum is behavioral medicine. They're taught about alternative medicine. They're taught to be compassionate.

"By the way," Strosnider says, "We have a dress code. The male students have to wear a shirt and tie to class, and we have an attendance policy. If they're going to be professionals, they're going to look professional, and they're going to attend."

Providing What They Need

In another departure from the way other schools operate, the students are provided computers, textbooks, and the equipment they need. Explains Strosnider: "When students enter here, they're given state-of-the-art laptop computers and all the software they will need. We buy all of their textbooks. Last year we spent $330,000 on books. We buy their stethoscopes and other equipment, even their scrubs and lab coats. Many of these kids are coal miners' kids. They don't have any money. So we provide what they need. Think about the textbooks. Typically, a medical student will buy a text, use it, and then, the minute they get out of that class, they sell it. So they never develop a reference library. By our buying textbooks for all the students, they don't have any reason to sell them—and, really, they don't have anyone to sell them to. So they develop a beautiful reference library. I know of no other medical school that does all that for their students. They may require them to have laptops, but they don't buy them for them."

Tuition at PCSOM is $24,250 a year. That may seem pricey, but, Strosnider says, it's a bargain compared with other private medical schools across the country.

Approximately 150 of the school's 240 students have scholarships funded by Kentucky's coal severance tax. Kentucky residents who are accepted at the school and agree to provide primary care services in the state after they have completed their schooling—exchanging one year of service for each year of aid—can receive a scholarship that equals the difference between PCSOM tuition and the tuition at state medical schools in Lexington and Louisville.

One such scholarship recipient is Kari Lindsey of Pikeville, a third-year student who says it's long been her dream to be a doctor, a desire that was born when her older sister was fatally stricken with cancer. Her current work at the nearby Mud Creek Clinic has only added to that resolve. Even if her scholarship didn't require it, Lindsey says, she would want to practice in or near Pikeville: "This is my home."

After graduation, medical students are required to complete a three-year residency training program. PCSOM's first graduates are doing residencies at facilities as close as Pikeville and as far away as Orlando, Florida, and Brooklyn, New York. Twenty-one of the 53 are doing residencies in Appalachia, either in Kentucky or elsewhere in the Region. Had spots been available, more than half of the graduates would have stayed in Kentucky, says Strosnider.

"If graduates move to other regions of the country for post-graduate training, they are less likely to return to Appalachia," he says. Thus, PCSOM has joined with a dozen hospitals and regional medical centers to form a new, nonprofit corporation called the Appalachian Osteopathic Postgraduate Training Institute Consortium, with a mission of providing high-quality primary care internships and residencies.

James "Dusty" Chaney of Hazard, a member of PCSOM's first graduating class, is now in a residency program at a Hazard hospital. Chaney says he's eager to complete his residency and join his two uncles in family practice there. One of the reasons, he says, is that Hazard is a place where patients treat the doctor as if he or she were part of the family.

New Approaches to Health Care

While its first graduates are undertaking their residencies, PCSOM is continuing to innovate new approaches to health care and medical education. In cooperation with the University of Kentucky College of Dentistry, the school has introduced a new dental curriculum aimed at teaching students how to evaluate the need to treat patients or to refer them for oral health care, and to recognize the important role doctors can play in educating patients about oral disease prevention.

"This is oral health taught by oral health specialists," says William T. Betz, D.O., PCSOM's assistant dean for clinical sciences and chair of its Department of Family Medicine. "The approach with our students is to teach them to treat the whole body—not just focus on the patient's chief complaint, but look at the whole patient."

In another new program, PCSOM is providing telemedicine services through the $2.5 million Pikeville College Osteopathic Telemedical Center, which opened in December 2000. The center also offers a new medical library, as well as teleconferencing facilities that give students, interns, and residents access to educational programs outside of the area. Strosnider praises Governor Patton and U.S. Representative Hal Rogers for their efforts in funding the center.

Next, says Strosnider, will be an emphasis on research that can help improve the health of many Appalachians: "We need to start a program in biomedical and clinical research on diseases that are especially common in eastern Kentucky and Appalachia, and there are plenty of them to look at. Seeking the funding for that is my major initiative right now."

When the idea of a medical school in Pikeville was first proposed, says Strosnider, "many people felt it was foolish and impossible. We've proven them wrong. We've graduated our first class, and 90 percent of our graduates went into primary care. That's an unheard-of percentage, higher than we dared hope for. We have residency programs established. We have post-doctoral programs established. So we pick students from the mountains and train them in the mountains. They can do their residencies in the mountains, and we believe most of them will stay and practice in the mountains."

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