Small-Town Doctors Made in a Small Kansas Town

The eight students at the University of Kansas medical school in Salina.
Front, from left, Rany Gilpatrick, Claire Hinrichsen and Sara Ritterling;
second row, Kayla Johnson, Erik Dill and Tyson Wisinger;
back, Jill Corpstein and Daniel Linville.

SALINA, Kan. — 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.

It will be a different experience, one that administrators say will better prepare students for the realities of a rural practice. Lectures on subjects like anatomy will be delivered via streaming video, lab work will be overseen by more practicing generalists and fewer academic specialists, and the problems of patients will tend more to the everyday than to the extraordinary.

And, the thinking goes, spouses picked up along the way are less likely to complain about moving to a small town.

“It just makes sense, and it’s great that it’s been put into practice,” said Alan Morgan, the president of the National Rural Health Association. “From a rural policy perspective, this is big news.”

Increasingly, medical schools across the country have been looking for ways to add to the ranks of physicians in rural areas. Some are using incentives like guaranteeing admission or forgiving loans to students who commit to practicing in small communities.

Others are recruiting students from rural areas and giving their applications preference, in the hope that they will return after graduating. And a number of schools encourage students to spend one year or more training in rural areas.

Kansas has tried each of these approaches in recent years, all of which are being used at the Salina campus. But with more than half the primary care physicians concentrated in the four largest counties, a vast majority of the state is considered medically underserved. And with many rural doctors near retirement age, the shortage could grow more acute.

The medical school program here, which is similar to a program at the Indiana University campus in Terre Haute, emerged as the top recommendation several years ago in a state report on the shortage of rural physicians.

It was supported by research suggesting that students who trained in urban areas faced hurdles in adjusting to the more bare-bones life of a country doctor, said Dr. Heidi Chumley, a senior associate dean at the University of Kansas.

“When they go off to the ritz and the glitz and pick up a spouse from the big city, it’s always hard to get them back to small-town America,” said Micheal Terry, president and chief executive of Salina Regional Health Center, which donated the three-story building being used by the school, as well as enough money to run it for a year. (The school cost $1.1 million to start and $1.1 million in reserve to operate it for the first year.)

Situated at the intersection of two highways, Salina, which has a population of nearly 50,000, serves a crucial role as a regional hub supporting surrounding rural communities; the hospital where the school is based receives patients who travel as many as four hours to get there.

University officials were relieved when one visitor from the Liaison Committee on Medical Education, an accrediting body whose approval was considered a major hurdle, remarked with surprise that the area was not just cornfields.

Barbara Barzansky, co-secretary of the accrediting agency, said there had been concerns about the size of the school: Salina is the smallest city in the country to host a full medical degree program. But she said the committee found the resources to be adequate.

“It’s an interesting model, and if the outcomes are good, it could be a stimulus for other schools to do it,” Ms. Barzansky said.

On Friday, the eight students met for the first time for orientation, sitting nervously alongside one another before breaking into enthusiastic chatter. Dr. William Cathcart-Rake, a longtime physician here who is the director of the school, said that while they were the first class of “something very, very special,” they should not think of themselves as experiments.

Though a couple of students said they would have preferred to attend at the campuses in Kansas City or Wichita — one plans to commute from there — the rest said the smaller school had been their first choice.

Most of them grew up in small towns themselves and have agreed, in exchange for free tuition and monthly stipends, to start their careers in rural areas.

They know the life of a rural physician is not easy. Patients tend to be older, poorer and often uninsured. The job generally pays less than lucrative specialties. And many rural doctors have so little support that they are essentially on call permanently.

But the students also spoke firsthand of the need for doctors — one recalled a half-hour drive to the city, relieved by four Advil and an ice pack, to see a doctor about his broken arm.

“I’m a small-town girl, and I always wanted to be back in a small town,” said Kayla Johnson, 23, who grew up west of here in Odin (population 101) and did not like the idea of living in a city to study medicine. “When I heard that the Salina program was starting, I was so excited.”

Dr. Robert Moser, who had a rural practice before becoming the secretary of the Kansas Department of Health and Environment, said he expected the number of students who go into primary care in rural areas to at least double each year.

And while the number is still small, he said, the impact on communities will be significant.

That would be the case in Jewell County, where the only two doctors have moved away, forcing the county to pay outside physicians to provide services a few days each month and to be on call for emergencies.

“It would be great to have a doctor full time here,” said Angela Murray, the administrator of the County Health Department. “Hopefully that will happen.”

Article courtesy of The New York Times

http://www.nytimes.com/2011/07/23/health/policy/23doctors.html?_r=3

By A. G. SULZBERGER

Published: July 22, 2011

Pharmacies becoming scarce in rural Kansas counties

By Jan Biles

THE CAPITAL-JOURNAL

July 25, 2011

SCOTT CITY — Jena Brunswig understands how important it is for her and her husband, Jonathan, to keep the doors of their pharmacies in Lakin, Leoti and Scott City open.

Their Health Mart franchises are the only pharmacies in Kearny, Wichita and Scott counties, respectively. If they were to close, customers — many of them elderly — would have to drive 45 minutes to an hour to have their prescriptions filled and, of course, drive the same distance home.

Six Kansas counties are without a pharmacy, while 30 counties have only one.

"We originally opened a pharmacy in the Wichita County Health Center in Leoti about 15 years ago," Brunswig, who has a doctorate degree in pharmacy from The University of Kansas, said.

Thirteen years ago, the couple opened J&J Pharmacy in the Kearny County Health Center, and in 2003 they purchased the Scott City business.

Her husband, who also has a doctorate degree in pharmacy from KU, serves as a consultant for rural hospitals and nursing homes in Kearny, Finney, Lane, Scott and Wichita counties.

Brunswig said their pharmacies employ 20 to 25 full-time workers and about 20 to 25 part-time employees during the summer and holiday season.

"With the declining population, it's difficult to have enough people to run a business," she said.

Even more difficult is finding pharmacists who want to work and live in small western Kansas towns. So, the Brunswigs rely on "growing our own" through the KU School of Pharmacy curriculum that places students in communities for a one-month rotation. The curriculum allows community pharmacists to mentor students as they gain real-world experience.

"All the pharmacists we've hired have grown up here," she said.

Brunswig said she and her husband recently hired KU pharmacy students from Scott City and Leoti who wanted to return to their hometowns to begin their careers.

"They'll typically stay five years and then move on, although some marry and stay here," she said. "The KU perceptorship has increased our ability to find staff."

Abby Amick, director of Wabaunsee County Economic Development, said that county has been without a pharmacy since 1988, when its owner retired.

"When I started working here, it was one of my biggest concerns," Amick said.

Talks about establishing a satellite office through a pharmacy in a neighboring county was aborted when it became apparent it would be too costly to staff the pharmacy and pay overhead, she said.

"It's all the regulations that caused people not to be interested," she said, explaining how the satellite office would be required to have a full-time pharmacist to dispense and monitor the medications.

Amick said Alma residents can drive 16 miles to Wamego to pick up medications, while Alta Vista residents can travel to Council Grove, about 15 miles away, to fill prescriptions. A Rossville pharmacy makes deliveries to the Lake Wabaunsee and Eskridge areas, and a Topeka pharmacy also delivers to Lake Wabaunsee.

In addition, several area pharmacies offer mail-order services.

Brunswig said mail-order pharmacy services are a growing threat to brick-and-mortar pharmacies because they can provide medications more cheaply and be delivered to a person's mailbox.

"Schools, hospitals and the county have gone to mail-order prescriptions," she said. "It's cheaper for them to provide health insurance if they have this mail-order rider."

However, Brunswig said, mail-order pharmacies can't provide medications the day a person becomes ill or runs out of medication.

"Waiting three days for an antibiotic from mail order is not quality care," she said.

Consequently, the Brunswigs' pharmacies fill and deliver prescriptions to elderly residents who live in town and sometimes to rural areas.

"I hope that the population sustains our business, and the health insurance legislation will not inhibit our health care service," she said. "There are a lot of unknowns, and so many things are out of our control. The future of hospitals, clinics and pharmacies is unknown."

Article courtesy of The Topeka Capital-Journal.  View article at: 

http://cjonline.com/news/2011-07-25/pharmacies-becoming-scarce-rural-kansas-counties#.Ti6mheamMy4

2011 Rural Kansas Photography Contest

Once again it is time for the Rural Kansas Photography contest, presented by Rural Health Education and Services.

Photos submitted should depict Kansas as a great place to live, work, and play. Winning photos will be published and prizes will be awarded.

Photographs are due by September 19, 2011.

For more information, contest rules, and entry forms please go to http://ruralhealth.kumc.edu/photocontest/index_info.html

Rural Health Welcomes Jenifer Yuza

Rural Health Education and Services welcomes Jenifer Yuza as the new Marketing and Communications Coordinator. In this role she will be coordinating the production of Kansas Connections and all marketing activities of RHES.  You can contact Jenifer directly at jyuza@kumc.edu . Welcome to RHES, Jenifer!

Switch to electronic records improves patients' health

July 01, 2011

By Cori Ast

As Jennifer Brull, MD, enters an exam room, her hands are free to greet her patient with a warm handshake. That's because, unlike many doctors, Brull isn't holding a clipboard with the patient's chart. Paper charts are a thing of the past at Plainville Medical Clinic, which documents patient visits with electronic health records (EHRs) that Brull can call up on a password-protected, networked computer in the exam room.

Brull, a family physician, can enter her diagnosis, treatment and other health information into the computer during the visit. Then she can print up a summary -- for the patient, not for her files.

"Each patient encounter is much more comprehensive. I no longer have to remember things about visits that might have been six months ago or more -- the computer remembers for me," Brull says.

The EHR system at Plainville Medical Clinic improves patient care and physician efficiency, but it also qualifies Brull for up to $63,750 in Medicare incentive payments. The payments are given to registered physicians and hospitals who engage in ""meaningful use"" of EHRs, which requires physicians to use the technology to improve patient care in a measurable manner. Some of these measurements include tracking preventive health screenings and behavioral information, such as tobacco use, that often influence patient health.

As of mid-May, only 1,026 providers in the nation had registered for the payments, out of a possible 56,599 that have demonstrated ""meaningful use."" Brull was one of the earliest adopters -- and the first certified ""meaningful use"" physician in Kansas.

"It's cool to be the first doctor in Kansas, but the best part of meaningful use is that, in the process, I improved the way I take care of my patients," Brull says. "And that's what''s key -- my patients get better care."

That better care has saved lives, too, according to Brull, who graduated from the KU School of Medicine in 1998.

For example, Brull thought she was doing a great job of talking to her patients about colon cancer prevention. However, when Plainville Medical Clinic implemented an EHR system, Brull realized her baseline measures for colon cancer screening were a paltry 43 percent.

"Anecdotally, I thought I was doing a great job of screening my patients for colon cancer. In reality, I wasn't," Brull says. In the two years she has been using EHRs, the percentage of her patients who are screened regularly for colon cancer has jumped to 85 percent. Brull has also caught three cases of colon cancer so early that the patients did not need chemotherapy. Those cases, she says, might have been missed if she was still screening fewer than half of her patients.

In fact, improved quality of care is why Brull and the physicians at Plainville Medical Clinic paid the hefty start-up costs to implement their EHR system, which went live in 2008. Despite the substantial investment, the EHR system at Plainville Medical Center has already paid for itself in increased physician productivity.
"It's just easier to see patients in the electronic world," Brull explains.

The financial incentives for EHRs extend beyond increased productivity. Brull has already received her first $18,000 Medicare incentive payment. The payments, which are authorized under the American Recovery and Reinvestment Act of 2009, will continue through 2016 for Medicare-based payments and through 2021 for Medicaid-based payments.

In 2015, however, punitive measures will go into effect for physicians and hospitals choosing not to comply with "meaningful use" of EHRs. Those providers will receive less money from Medicare reimbursement for providing the same services as certified "meaningful use" providers.

Karl Koob, chair of health information management at the University of Kansas School of Allied Health, says that the Center for Medicare and Medicaid Service''s carrot-and-stick approach is necessary because collecting the data on a national scale is critical for improving the U.S. health care system.

Although physicians benefit from the government''s push to adopt EHRs, many practices still haven't switched to electronic records. Anna Johnson, MET, clinical assistant professor of health information management at KU School of Allied Health, believes the hesitation, particularly among rural physicians, is due to in large part to the high start-up costs and the drastic changes EHRs can have on a physician's work day.

"Small physician practices don''t have as many resources," Johnson says. Because implementing an electronic health record system is resource-intensive, the uncertainty of success can leave doctors waiting on the sidelines.

Brull believes that cost isn't the largest barrier. Instead, she says, it's a lack of support.

"I think when doctors say they're not financially able to implement an EHR, it has to do a lot more with the culture that is in place in the office. If you have people who believe it won't work, then it won''t," Brull says.
Brull and the physicians at Plainville Medical Clinic believed an EHR system could work for their practice -- and it does. Today, Plainville's patients can access their health records online, email their physicians with questions and receive overall better care thanks to the EHR system. Brull and the other physicians spend less time on paperwork and more with patients. The EHR system has also reduced the number of late nights in the office, leaving more time for family. A meaningful change indeed.

To view this article visit:  http://www.kumc.edu/news-listing-page/electronic-records-improve-patients-health.html

New Salina med school campus unique in U.S.

By Dave Ranney
KHI News Service
July 5, 2011

 

SALINA — Next month, the University of Kansas School of Medicine will open a four-year, fully accredited school – officials prefer to call it a campus – next door to the Salina Regional Health Center.

“This will be the smallest medical school campus in the country and Salina will be the smallest city in the country - outside of a few major suburbs - to have a medical school campus,” said Dr. Heidi Chumley, senior associate dean for medical education at KU Medical Center.

The first class will have eight students, seven of whom are from Kansas.

KU Medical Center officials said they plan to add eight students a year at the campus in each of the next four years.

More primary-care docs

“The goal is to develop more primary care doctors for rural Kansas,” Chumley said. “We’re shooting for 75 percent (of the new school’s eventual graduates) choosing primary care, and 75 percent rural.”

Much of the new school’s curriculum will be tied to the classroom offerings at the KU Medical Center’s campuses in Kansas City and Wichita.

“We completely redid our curriculum about six years ago. It’s very computerized now,” said KU Medical Center Executive Vice Chancellor Barbara Atkinson. “All the lectures are podcasts. They’re all going to be teleconferenced (in Salina), though some will be generated on-site.”

The cost of remodeling the three-story building has been picked up by Salina Regional Health Center. And the hospital’s foundation and several private donors are covering many of the operational costs and scholarship offers.

“So far, we’ve not asked the state for any money for this because we understand the financial situation the state is in,” Atkinson said. “But we have asked donors to support it and they’ve been very, very generous. Incredibly generous.”

Salina-area benefactors, she said, hope to raise $2.5 million over the next four years. They’ve already raised $1.5 million with $1 million coming from the salina hospital.

Salina Regional Health Center has hosted a residency program for KU Medical School graduates for about 30 years.

Most of its residents went on to start or join rural practices.

Model for other states

“What the University of Kansas is doing, I think, will be a template for having a positive impact on the number of medical practitioners in rural communities,” said Brock Slabach, senior vice president at the National Rural Health Association. “Other universities will be watching because, really, for a major medical school to commit itself to meeting rural-community needs like this is truly novel. It shouldn’t be, but it is.”

Slabach said he’s long been baffled by the fact that medical school officials in many rural states’ fail to see the connection between their states' shortages of health care providers and their students leaving for big cities in other states.

“I wouldn’t include Kansas in that group,” he said.

Last year, a national survey of how well medical schools were fulfilling their “social mission to train doctors…” ranked KU School of Medicine fifth in the nation.

The school was ranked eighth for its percentage of graduates (44 percent) practicing in underserved areas.
Earlier this year, a Kansas Department of Health and Environment survey found that 51 of the state’s 105 counties had less than one physician per 2,695 residents and were considered medically underserved.

Looming retirements

“The shortage of health care professionals has been a critical issue for a long time,” said Dr. William Cathcart-Rake, a Salina oncologist and director at the KU-Salina campus. “It’s not new, but what is new is that now we have a number of physicians who are nearing retirement age, and a good number of them are practicing in the rural communities.”

Generating enough new doctors to replace those who are retiring – especially in rural areas - will be difficult, he said.

“We have to do something,” Cathcart-Rake said. “We can’t keep doing what we’ve always done. It’s not enough.”

The Salina campus, he said, will be geared toward allowing students from small towns to complete their studies and residencies in a small-town environment.

“There is evidence that shows that if someone is trained in a rural area they are more likely to stay in a rural area,” he said. “So the idea is that from day one we’ll be training our students in in non-metropolitan settings and exposing them to all the good and the bad that comes with life in rural Kansas. After that, we’ll hope for the best.”

Cathcart-Rake, who grew up in small town in Orange County, Calif. (“…back when there was still a small town in Orange County”), has been practicing medicine in Salina for 32 years.

“The perception is that if you go to a small town you’ll work yourself to death, you’ll never get a vacation and you won’t get to spend time with your family,” he said. “The way to get around that is to be with a group of physicians so you can cover for each other so you don’t have to do everything for yourself.

“The days of there being a doc in every little town are gone. That’s not the model anymore,” Cathcart-Rake said, noting that in Clay Center, for example, the local clinic has eight physicians and four mid-level practitioners serving a large catchment area.

Similar models are in place in Tribune, Quinter, and Beloit.

Enjoying small-town life

Earlier this year, Aneisa Slack, 25, completed her second year of study at KU Medical School in Kansas City. She’s starting her third year on the school’s Wichita campus.

“I’ll be here for six months,” she said. “Then, in January I’ll go to Salina. I’ll be there for 18 months.”
Slack, who grew up on the family farm south of Oxford in Sumner County, said she wants to be a primary-care physician in a small town.

“I like the small-town lifestyle,” she said. “I know that a lot of people don’t. But that, I think, is because they’re not from a small town. I’ve had some classes with students from Wichita and Kansas City who’ve never been to a small town. They’ve driven through them, but they’ve never spent any time in one.”

Slack last year was president of the KU Rural Medicine Interest Group, which is a student organization. She said she was leaning toward joining an existing practice or going to work for a small-town hospital.

Most of her fellow students, she said, are not interested in opening their own practices.

“The ones I know aren’t really interested in starting a business,” she said. “They don’t want to have to put up with all the paperwork. They just want to be a doctor.”

Article courtesy of Kansas Health Institute.  View article at:  http://www.khi.org/news/2011/jul/05/salina-medical-school-campus-be-no-other/#