This state, so sparsely populated in parts that five counties have no doctors at all, has struggled for years to encourage young doctors to relocate to rural communities, where health problems are often exacerbated by a lack of even the most basic care.
On Friday, a new medical school campus opened here to provide a novel solution to the persistent problem: an inaugural class of eight aspiring doctors who will receive all their training in exactly the kind of small community where officials hope they will remain to practice medicine.
The new school, operated by the University of Kansas, is billed as the smallest in the nation to offer a full four-year medical education. More important, supporters say, the students will remain personally and professionally rooted in the agricultural center of the state ”” a three-hour drive from the university’s state-of-the-art medical and research facilities in Kansas City.
This would warm the heart of one of my mother’s late cousins, a long-time small town doc in Western Kansas.
Very nice, Bill; it is on the front page of today’s paper copy of the newspaper at the bottom. Good for Kansas.
Having lived nearly my entire life in rural areas and small towns I’m well aware what a challenge it is to provide good medical service in such regions. There are two very different sorts of needs, and they really need two different approaches.
One is trauma of various types and degrees. Rural areas are usually based on farming, ranching, or forestry each of which tends to generate assorted injuries. The best you can hope for is a good regional trauma center within an hour or so drive. Some folks just aren’t going to make it — tractor crushings come to mind — and it has to be accepted as part of life.
Most relatively minor rural trauma — broken ribs, cuts less than about 1/2 inch deep, broken foot, bad sprains, etc — will probably be dealt with at home and usually puts little demand on the system.
The other important rural medical need is for “wellness” type things like basic annual exams, immunizations, well-baby, blood samples and so on. These can be handled well by Nurse-Practitioners who are also able to write prescriptions, sew up deep gashes, and recognize when a patient needs better care than that available in the clinic. This is one thing the Canadians tend to do rather well, especially in Québec, and we would be smart to start doing something like that here.
Lots of small towns can support a Nurse-Practitioner, but not a physician. The program in Salina is a good start, but it does not address what I believe to be the current weaknesses of rural care
We need to ask why the doctors are leaving rural America. It is not sufficient to think that they can be replaced with semi-volunteer idealists when the money and infrastructure is just not there to support them.
I practiced solo for 4 years in a medically underserved area and loved every minute of it. Many of my patients from there are still friends.
However, eventually I just could not justify the cost to my family, the debt, the high risk of a devastating lawsuit or government audit, etc and had to find a deep pocket to keep me afloat in another town. I’m still paying off the debt I accumulated from the idealistic venture, but my patients loved it while it lasted.
I believe that the only model which will work long term for rural America is for MD’s to supervise groups of PA’s and NP’s, perhaps through a revamped health department system, for the provision of health care to those who basically can’t pay for it. The docs and physician extenders will need to be salaried, since there is no way they can make a living otherwise. States, businesses, cities and counties will need to decide how much it is worth to them to have a doctor in town, put together the money and support docs who are willing to give up good schools, restaurants, etc and live in the country.
We also need to come to an understanding that if you are getting subsidized medical care, patients and their lawyers cannot raid the healthcare system for jackpot justice lawsuits.
I think it will take many, many years and much suffering for rural communities to realize that they are going to have to pay up to make this happen over the long term, and unfortunately the only doctor people listen to is Dr. Pain. Doctors will continue to quit and leave not only rural practice, but primary care in general across the country until the point where the average person has to experience an unmet medical need. At that point, there will be enough pain for society to do what it will take to induce medical providers to reenter the market.
Idealism and youthful vigor will not hold out for more than a few years at best. Mine didn’t. I can do missionary medicine without worrying about overhead, angry demanding patients and lawyers anytime I want. It’s a wonderful liberating experience. However, I fail to see where it is good stewardship for that impulse to be consumed in propping up our dysfunctional medical system that is designed more for political gain than for the care of patients.
Hear, hear! Capn Jack. I practice in what most would consider a small town, but because of the rural nature of all of my state, it plays out more like a small city. The cost to my family has been huge in terms of games not attended, weekends not spend camping, etc. That is not to say it has been terrible – to the contrary, it has been wonderful. But there is a significant cost. I cannot fathom how those practicing in really rural areas do what they do. I regard them as ‘the real deal’ and the rest of us are only a shadow of them.
There is good data that the best way to get docs into small towns is to select people who grew up in those towns, to do training in rural areas, etc. I disagree about physician extenders in those places, as studies show that NP’s (in particular) and PA’s look cheaper because their salary requirements are lower. However, they tend to order more tests than primary care physicians and raise the cost of care so that it is higher than the primary care docs. Additionally, for all the hype the PA associations and the NP lobby make about being the solution, studies again show they are no more likely (and some show even less likely) to practice in those underserved areas.
Oops – thought I was going to another paragraph, but apparently hit “Submit” instead.
It is absolutely true that small communities will have to decide whether to fund physician presence, just as they have done for hospitals to remain in them – and they should have a robust debate about the pluses and minuses before deciding. Additionally, states need to recognize rural service and have loan forgiveness and higher payments (many have started to do this, but only on limited scales).
The degree to which the medical malpractice system serves no one but those in the legal system well is also a problem. A harmed patient (one harmed by substandard care, not just an unavoidable bad outcome) should be given money to treat complications (both medical and psychological) from that care for as long as necessary, lost wages, etc. Even the ‘pain and suffering’ of $250K makes sense. It makes no sense to pay those things and then add the $20M for pain and suffering, which is our current system. Truthfully, it is an insult to the patient’s (or her/his decedents’) pain and suffering to say that so many millions will compensate for it. It is ironic to me that our politicians fiercely defend the unlimited caps on non-economic damages (the term for ‘pain and suffering’) in malpractice while all docs who are insured by the government (health centers, military, Indian Health Service, VA, etc.) have a $250K cap on those very non-economic damages.
Montanan makes great comments. Your right that pa’s and np’s often do cost the system more, but they are easier to get trained and deployed because of less school. For 19/20 patients that won’t matter. Occasionally there is a patient who would have done better under an md or do’s care. In this age of resentment over doctor’s salaries, even as they decline, I suppose you get what you pay for and society wants to lower physician pay and work conditions.
There does need to be a way to compensate injured people in an orderly and efficient manner, in a way that recognizes that every dollar removed from the health system for compensation is a dollar not available for patient care. The current tort system is costly, unreliable and creates an atmosphere of fear where errors are covered up rather than discussed and corrected.
The cousin was Dr. Richard (Dick) Cram. He was in the Larned-St. Francis area. His son and I were friendly rivals while son was at West Point and I was at Annapolis. Also typical of many small-town docs, Dick spent some time in the Kansaa legislature.
Yes, NP’s and PA’s are a real helps to doctors and can multiply the care done. I saw this in the Army with my beloved corpsmen. However, they should not be sent off by themselves to play doctor. In fact, today no physician should go off to a rural isolated area by themselves. The technology and infrastructure is so complex to practice today. The doctor practicing out of his black bag in someones kitchen is not pheasable. Especially with the legal and government hassel.
But we need to also ask, why do s o few people live in rural areas? Ther are no Starbucks, Baskin Robbinson, TV repairman or probalby no movie theater. One doctor can burn himself out caring for a small poputation group when in a more densely populated area he would do many times more good and maybe survive.
An interesting experiment. The students individual instruction will be fantastic. However, the students are limiting themselves. Will they be able to manage a patient in an ICU? There probably isn’t an ICU for three hours and all the really sick patients get shipped out.
However, the experience at large urban medical schools, the medical students training is becoming more and more worthless for actually managing a patient. They can’t write orders. They can’t screw up. They walk around in a herd, with hands in their pockets. After finishing medical school, they aren’t real doctors. The point when the become real doctors is getting pushed back more and more. Now they are getting out of residency still not being real doctors.
Also, when these students are looking for a job, there will be NP’s and PA’s willing to take the same rural position for a half the salary. A cash strapped community will say the physician is “over-qualified.” I would use the same argument for any physician going into primary care but the rural setting seems even worse.