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.
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