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.
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