Health of the Heartland

You use, you'll see it a lot on packages as well. One of the most common when it talks about how to use the product. You'll see this character. So this means four, use five. Boys are men. So you might see this on a bathroom door off. Don't you see it all. Good. Okay. From yesterday we talked about the ending soul. What was soul? If we put it, it looks like. Looks like or seems like. Good. They've got some sentences I'd like everybody to look at and see what you can come up with. Maybe some hints with some of the vocabulary you've got enough new stuff in there. I just took a little and then I... She looks very happy. Happy is good. I'm going to take a look at.

Alright. Good. Good. Good. Good. Good. Good. Good. Good. Good. Good. Good. Good. Good. Good. Good. Good. Good. Good. Good. Good. Good. Good. Thank you. Good. Good. Thank you. Good. Good. Good. Good. Good. Good. Good. Good. Good. I really feel like if there would have been a medical center or a hospital here, she would have felt pregnant soon and hopefully delayed the process that fit in for an hour.

The physicians told her when she went to the hospital that she had waited too long and that they would have to amputate her leg. And she refused to have a nut. She signed out AMA against medical advice and leg. Is that foot sore to step on it? 85-year-old Mary Washington won't admit it but she's an extreme pain. She injured her foot when she stepped on a rusty nail while working in her yard. We made it. Since she lives in a community that has no hospital, she waited before seeking treatment. Since then, home health care nurse Anne Capapon has been seeing this Washington twice a day to check on her condition. Residents in this remote Delta region of each central Louisiana have lived without a hospital for more than two years. In addition, the community lost three of its four physicians. In the absence of adequate health care, Mary's minor womb has become a life-threatening problem.

We all know that there is a health care crisis in this country. But what does that really mean? To Ms. Washington, it means deciding whether to live or lose her leg. For those who face critical illness, it means being plunged into a world of playing forms and qualification reviews with no guarantee that their insurance will be there when they really need it. Medical care has changed dramatically over the last 10 years as doctors rely more and more on expensive technology to diagnose and treat disease. While America may provide the best health care in the world to those who can afford it, nearly one out of every seven

people in this country has no health care coverage of any kind, and nearly 65 million citizens will lack coverage at some point this year. As America moved into the 90s, health care, which had been perceived as a problem of the poor and the elderly, became a major concern in the middle class. Candidates for political office at all levels began discussing health care reform. Most of the proposals attacked the problem by improving the way individuals pay for care. But if health care for the rest of the country is a problem, in rural America, it is a crisis. Rural hospitals are closing at a rate three times greater than urban hospitals. Ninety percent of the country's non-metropolitan counties have been designated health care manpower shortage areas by the federal government. Nearly one-fourth of the country's rural physicians are nearing retirement age with few graduating doctors available to replace them. At the same time, rural America's needs are great. Its population is older, poorer, and more ethnically diverse than the rest of the country. Fewer rural Americans

can afford health insurance. Many have to pay for health care services out of pocket, or not pay at all. The health of the heartland is in critical condition. In rural America, the issue is not just about affordable health care. It is about the entire system of doctors, hospitals, nurses, and services, and whether that system can survive. In tensa, parish, like other rural areas in the country, basic services normally provided by hospitals or doctors are in short supply, and simple problems become life-threatening

crises. In the absence of adequate health care services, home health care nurse and cap de pon finds herself doing the work usually handled by a doctor. After visiting with Miss Washington, Andrew of 25 miles to see an 18-year-old woman whose baby nearly died from dehydration. To get her to drink as much as she can. I know that's hard, that's why it's good to feed them every two or three hours. On the initial visit, she wanted to know if she could feed the two-month-old mashed potatoes. She was concerned that it was not going to get enough to eat by only the milk. We did some nurse teaching with her how to care for the baby, when to change the baby, to feed the baby, how much portions to feed the baby, how many bottles, and you notice to proper help. Don't try to feed her anything else right now until the doctor tells you to start on some cereal. I think it's sad. I think it's real sad. I get angry sometimes. I'm frustrated

because nothing is done. I see so much of it because I'm in the patient's home. I see a lot of problems, complications that go on, and it bothers me, but I'm only one person. I can't do everything. I feel like I'm doing the best I can with home health. All right. I'll check on you in a couple days. Bye-bye. You're new. It all boils down. I think to money. The big problem is the money that came. They came to make as much here. They charge as much now. Like I told you a while ago, I lived all those people. The twenty-five, the doctor's not going to do that anymore. It's a different bowl day now. It was a serious illness. 82-year-old Dr. William Chapman is talking about the early days in Tinsaw Parish when he used to charge twenty-five dollars to deliver a baby. Like many doctors of his generation,

he set up a practice in a small town and now, at the end of his career, he can find no one to take his place. I think they look around and they try to find a place where they can make the most money. Not necessarily where they are needed. I believe that's the way it is. Dr. Chapman helped open the first hospital in Tinsaw Parish. He and his partner established their practices here in the late 1940s. They worked aggressively to keep the hospital open, but as they got older, it became more difficult to keep up with the patient load. So he and I kept the hospital up for thirty years, just the two of us. We kept enough patients in there and did enough surgery and obstetrics to keep it going and it was about time for us to turn it over to somebody else. When young doctors would come and they

little while they'd leave. Dr. Chapman closed his office and retired several years ago, but desperate patients still won't leave him alone. That's the farthest thing from my mind. Somebody come and ask me to go and I tell them no. Dr. Chapman says he'll also continue to make host calls as long as he can get around. I know the country. I got my little black bag and I keep all my supplies in there. I just walk in and go to work. Long as this old blue car will run, we'll go. But money alone is not the problem. Rural physicians face significant pressures brought

on by workload, stress and isolation. After Dr. Chapman retired, the pressures were too great for the remaining doctors. James Waddell is currently the only full-time doctor in Tensor Parish. The stress of being constantly on-call forced him to resign these hospital duties. Now he only sees patients through his family practice. Well, I'm working at full capacity. I really can't. I'm really at the stage where I can't handle a lot more, but I've just got so much time in the day. I really don't have enough hours in the day to see any more people than what I'm seeing now. I'm really already I think compromising to some extent. I don't think it's not even people to maybe the attention that they need. Dr. Ron Morgan, who is now practicing in another small community in northern Louisiana, left tensile parish more than four years ago because

of the workload. We were seeing only average 70 patients a day in the flu season. I think the record one day was a hundred patients. We saw between two clinics. In addition to the long days, Dr. Morgan spent many long nights at the hospital delivering babies. It was not unusual to have, you know, babies coming in for a little longer to babies a night in the apartment on dealing with them. Needless to say, the workload was overwhelming. Dr. Morgan, suffering from stress and total burnout, decided it was time to leave. It was more, but it came down to basically an issue of my health or the practice and, you know, I had to leave to get out of the stress of that situation. I couldn't continue physically. Dr. Morgan may no longer see patients in tensile parish, but he hasn't given up on them yet. What we're trying to do initially is establish an outpatient clinic where

we can go and run a clinic two or three days a week and I'll discuss that with my partners here and they're willing to go in a rotation basis in order to treat the patients initially. I see what kind of response we get and hopefully establish a practice good enough that may can stimulate some interest to get the hospital open and go. In many ways, tensile parish is a microcosm for the most troubling problems in rural health today. In a period of 10 years, tensile is reduced from four physicians to one. The hospital closed and now the population, predominantly elderly and overwhelmingly poor, has traveled 65 miles for hospital or emergency room services. For Mary Washington, the lack of available health care led to a choice between losing her leg or her life. She chose

to live. She will soon be fitted for a prosthesis below the knee. Now the major question that gets asked on Capitol Hill is we're investing 67680 billion dollars and that's 1991. 1992, it's projected to be 720 billion dollars in health care. And are the American people any healthier than the people who live in Canada or the people who live in Germany or Japan or elsewhere? And if you're honest, you have to say no. As a matter of fact, we rank 15th in the world and infant mortality. And so it becomes an issue of we're paying lots of money and yet our return on investment, if you think of it from an economic standpoint, is not all that great. I don't know if in this day and age, most small communities can sustain a hospital by

themselves. If you look around and stay in New Mexico, the free-standing community hospital is almost gone. What you have are multi-hospital systems. You have networks of hospitals usually backed up by a tertiary center in a larger community and you find that rural communities increasingly dependent on those systems for their health care. Dr. Richard Cozall has been a practicing physician in Cuban New Mexico for almost 17 years. He came here in 1975 after several years of working in third-world countries and an interest in the organization of rural health services.

At the time I came, we really didn't have a hospital in place here. When we had it was a network of medical and dental clinics and attend bed holding facility, which we really just used for overnight observation until we could transfer patients out to more sophisticated health care. Our direction over the five years after I arrived was really to get the facility accredited as an acute care hospital. We were able to achieve a federal program certification so we could be reimbursed under Medicare and Medicaid. That was a major accomplishment for staff of the health system at that time. The hospital was self-sufficient for two reasons. It had a source of contract support from the Indian Health Services and it was integrated into the outpatient clinic network, allowing the hospital to share staff and other resources with the outpatient program. But the hospital did not stay open for long. Several things happened. First of all, the Indian Health Service built some new facilities

and their need for contract hospital care diminished after 1985 or so. Secondly, technology, even in the 10 years of that facility, had changed to the point where doing obstetrics and a few other things was very difficult in a nine bed facility, 85 miles from the nearest center. We began feeling the pinch of technology and what made sense for us in Cuba. In much of rural America, factors of poverty and isolation combined to widen the gap between the quality of care that is available to rural populations and to the rest of the country. Here the problem is one of diseconomies of scale. That is, what to do when the community must have a service, and yet cannot afford it. People has become very complex and technologically intensive institution that is difficult for a lot of small towns to cope with, I think.

The only standing medical facility in Cuba today is this outpatient clinic next to the old hospital. Recently, its contract with the Indian Health Services was renewed for another year, but in the midst of the good news, other problems such as geographical boundaries, physician shortage, reimbursement and aging emergency units continue to plague the small facility. We have worked with some people from Washington, D.C. that came through the Council on Social Security and they are trying to give us some research projects that we might be able to help our dilemma with and see if we can write for those in different types of grants. But the problem with grants, they run out. What happens next year? And we are looking at a long term versus just a short term. For now, the clinic is looking to improve its emergency service. Their newest ambulance, a 1988 model recently blew its engine. While the mechanics try to repair it, the community has to rely on an ambulance service from Farmington more than 85 miles away. It seems unfortunate that this is the best we can do for people. It seems like we ought to have something better. If we have all of the technological advancement, 80 or 100 miles

away in Albuquerque, it seems we could do better than that for people in Cuba. But we could come up with a system that would allow for more than that. We do get a lot of community support in terms of verbal support or political support, but unfortunately we don't get a lot in financial support. Most of the problems that we have in this area without having a real tax base here of any kind. There is no industry in Cuba to speak of. The major employers in town here are the school district and the health center here. Since their service oriented services, they don't really generate a tax base of any kind. I take Indian patients. In fact, I have a contract with the Indian Health Service to provide emergency care to Indian patients in the Cuba area as there is no other mechanism for their emergency care.

She thinks it's because somebody stepped on her foot? Yeah, cotton. When we're Castillo and her daughter traveled more than 60 miles to visit Dr. Cozal today. They live west of Cuba on a remote Indian reservation. Their visit to the doctor today was not an emergency, but if it had been, access to immediate health care would have been impossible. A trip to the doctor can take anywhere from an hour to three hours depending on the road conditions. Well, we've got a very difficult problem. For patients who have more elective medical problems, it's not a major problem to get them to a hospital 80 or 100 miles per year. But we've got the emergency situations where stabilization and transport is difficult. We also have an ambulance service that really has only one crew, so if the ambulance is out either with a transport or to the city of an accident, where without emergency transport services, so that can be a really difficult situation. It's very critical.

One patient overwhelms our system. One critical patient is all we can handle at a time. If anything happens while we're transporting some minor injuries somewhere because we don't have any facilities here to take care of them, something major happens that person's probably going to die. It's an hour and a half for another ambulance to get here from anywhere else. We do the best we can. If there was lots of funding available, we could do lots more, but there isn't. And it's a problem, I guess, across the whole nation, with rural health care seems to be in trouble everywhere. That one guy was standing out. He was screaming about his leg or something. And the other guy was just looking like he's unconscious. It took him entirely too long. We got here about five after 12 and it was 25 till one before the ambulance got in. You don't know where we're going to be at when we get a call. You don't know where the ambulance may be stationed at when they get a call. They may be 25, 30 minutes away from

you. It doesn't get more rural than the hills of Pineville, West Virginia. This is the heart of coal country or what used to be coal country before most of the mines shut down. It is an area of undeniable medical and economic need where the nearest hospital is 30 miles away and the nearest full service hospitals are a two and a half to four hour drive. Well, let's say that we had a hospital here in Pineville. Let's say we had an accident at the bar end of even one of the cameras. This is sort of simply located. You still have a 20 to 30 minutes response time. So if you did all the pants, you know, you can't have a hospital in their area. It's true. You can have a hospital in every area. But as desperate as the situation sounds, there's talk of hospital closures in several rural areas of West Virginia. In

Webster County, the community can no longer support this hospital. Downstairs, you're going to see it closed. You can see pediatric range closed. The OB wing is closed. The only thing is running now is patient area on second floor, which is 35 beds. In the early 60s during the mining bloom, the Webster County Hospital Prosper. Occupancy was high and the hospital expanded to more than 100 bits. When the mines shut down, 45% of their regular patients left Webster County to find jobs. The migration further eroded the hospital's financial base, making it more difficult to cover costs, let alone purchase new technology or expand services that would help retain patients and recruit physicians. I think there's not one single factor is caused our demise. There's several factors. One, I think regulations has been one of the great things. It's really hurt us. I think it's heard all hospitals, small hospitals in particular. I think reimbursement has been a

really a stickler. We just haven't been reimbursed at the point where you can actually survive. The major problem that we faced in the past is that the same physician providing the same service for the same type of patient using the same resources on the same type of problem gets reimbursed differently if that physician's in an urban area versus a rural area. And that is an inherent inequity that shouldn't exist. Both Medicaid, which covers the very poor and Medicare, which provides for the elderly, pay considerably less than the hospital charges. As a result, rural hospitals are extremely sensitive to state and federal reimbursement policies. But rural hospitals face enormous financial problems. In addition to the high percentage of Medicare patients, many of the working poor do not qualify for Medicaid and therefore have no way to pay for services.

Medicare has had a devastating impact on health care in rural America. There's been either by choice or chance, clear discrimination in the payments made to rural hospitals and rural physicians. When the Medicare perspective payment system, the so-called DRG system, where people are paid a fixed sum by the diagnosis of the discharge. When that program was instituted in the early 1980s, urban hospitals right from the start were paid a bonus of about 40 percent for doing exactly the same work. Medicare seems to feel that we have to practice under more difficult situations, but they pay our hospital less than in order to see Medicare patients. That we see a much higher percentage of Medicare and Medicaid patients than other hospitals, but we get paid less by Medicare, get paid the same by Medicaid. But we don't have the other patients to make up that. The cost difference with.

I think that those are the changes that need to be made. Changes are already occurring at the hospital. In fact, many rural hospitals on the verge of extinction are being forced to adapt in order to survive. Currently, the hospital operates 35 beds under what's called the each peach program. The hospital with the help of federal grants will downsize to a 10 to 12 bed hospital and become part of a regional health care system. For many hospitals, the each peach model seems to offer the possibility of maintaining essential support and reorganizing the local health care services in a more effective model. I personally think it's one of the most innovative, helpful ideas we can come up with. That is recognize flat out that there are some places that simply cannot sustain a full service hospital. But they can sustain something else which is important medically beneficial for the community, something that I have thought of as a medical

holding center. That is a place that can provide short-term inpatient care up to three days on a limited bed basis, where after the individual will either go back to the home because they have been stabilized efficiently to not require hospitalization or they'll be transferred to a center either the essential access or some other center not too far away in order to receive further health care. Well, the thing we look at were 82 miles from the next level of care. If somebody has pneumonia, for example, you come in and we start a treatment and you start to respond at the end of 72 hours, why ship lodging an ambulance in ship 82 miles one way when you might be discharged on the next couple of days? I think we need some slack in that. I believe a much sounder approach is to work with a community and give it the authority and responsibility to define a set of health services that

seem appropriate for that community. I understand that communities that lose a hospital feel that it is not only the medical care that is no longer available, but that it is somehow a statement about the economic viability and development of the community and therefore communities tend to fight very hard to keep open hospitals that may not be viable. Of course, the hospital administrator would like to sustain a full-service hospital, but at this point he feels he has no choice but the downsides in order to qualify for grant money. We don't see the conditions getting any better unless each piece might be the saving grace if we get on cost reimbursement. We're a little bit afraid of the thing and I'll tell you why one of the big reasons we're afraid of it, one of the reasons they're saying that they would reimburse us for the first two years on cost reimbursement. I'm not sure what their definition of it is, but anyway, at the end of the second year they're

going to take a look at it. Now what happens after the end of the second year, if you build up a base and get started to run and they jerk their rug out, then it might well annihilate you in one foul sweep, so we're a little skittish, be honest with you. It's difficult when you find yourself always having the fight for that little bit extra. Dr. Bowers, on the other hand, believes that each peach model is the only way Webster County Hospital can provide the emergency care that is necessary. I've spent thousands of dollars in patients that have come in here in the hospital's and reimbursed $17. You just cannot continue the function without having some money coming in and hopefully under each peach, if we're paid at least for a portion of our patients at cost, we'll be able to continue to maintain this hospital. As it is, we've been operating at a deficit for years and that's because we take care of everyone who comes in regardless of their ability to pay in this area. Most of the patients can't pay. We still have an awful lot of challenges, but there's an increasing number of people who

are doing exciting work and are making a difference in their communities. We hear a lot about the closures. We don't hear enough about the success stories. The Prairie Dishine Wisconsin Prairie Dishine Memorial Hospital has worked hard and creatively to recover from difficult times. Using a strategy opposite to the each peach program, the hospital has diversified in order to survive. They've been very inventive and finding other sources of revenue to support a dwindling patient hospital population. At the same time, they've increased their outpatient services as most hospitals have. Prairie Dishine Memorial is a non-profit 49-bed acute care hospital serving residents with southwestern Wisconsin and northeastern Iowa. It has been nationally recognized as a progressive community health care center ranking among the most effective patient care facilities in the United States. Many attribute the success to the strong decisive management of their

chief executive officer, Harold Brown. I think that you have to take a certain degree of risk and I think they should do that. And I think that all rural hospitals should be community health centers. And in order to do that, you have to take a certain degree of risk. Good morning, Mr. Burr. 18 years ago, Prairie Dishine Memorial averaged 60 acute care patients staying in the hospital. Now only 32 beds are available for acute patients. 15 are used on an average day. To compensate, Prairie Dishine Memorial leases unused space to an urban hospital that operates a hemodialysis unit there. Kidney disease outpatients no longer face a lengthy commute to their dialysis treatments. In addition, the hospital's cafeteria and dietary services were increasingly less utilized as the hospital closed beds. When the city needed a source of subsidized meals for the elderly, the hospital stepped in and filled the need.

At first, when the current meal site previously was in a school basement and the school no longer wanted to be a resource and for that utilization. So the bid came up and again, this is where an opportunity came to, we had the facilities, we had the staff, so the congregate meal site was bid on and we received the bid. Opening the cafeteria to the public had unanticipated benefits. The hospital now hosted a significant number of citizens every day for the Heart Lunch program. It only took a month and I think probably 50 or 60 people daily come here for meals and the camaraderie again is just great. They like being able to visit with one another. The meal actually served, I think, at 11 and by 10-30, they're already coming.

They enjoy it very much. We enjoy having them here. They're coming here because they want to come here for something other than being sick. That's great. It was not a great leap then for the hospital to also use the cafeteria services to support the meals on wheels program for the elderly. Then the laundry found itself providing a diaper service and the vans bought to deliver the meals were also used for diaper deliveries. Later when the need for more elderly housing grew apparent, the hospital stepped in and developed both independent and supported living programs for the elderly in the community. Basically what we do is that the employees work a little longer and we're using all the same resources that we have and just spreading them further and that goes through the whole gamut of all the various diversified services that we have. As the hospital diversified and expanded its base, it became obvious that prairie-dishine memorial was no longer merely a hospital. It was a Center for Health Services for the entire

community. Everybody always likes to show off something that's good and it's your own. We enjoy it and I enjoy it and more than anything, I think it's good for our people that work here and really do the work. I really don't do the work but it's good for the people who are working here and I think if you give them credit then they make them do a better job. The hospital now gets visitors from all over the country wanting to learn the strategy. They use to succeed. They think that we do an awful lot with the your the employees that we have. I think probably what impresses them more than anything is the fact that some of our employees have five or six different jobs and also that they've taken over the years of taking on additional responsibility and additional job in most cases for not much more pay. It takes people. It takes people that want to make an organization strong and good. Now those people start with certainly your leadership, your board of directors that is willing to let you

take those risks. Be they visionary or not. All those in favor signify by saying aye. Aye. Opposed by no. Carry. The change in reformation has not come easily. And as the hospital board ponders the future of other programs they are still faced with some very real problems grounded in federal Medicare policy towards rural hospitals. Like many small community hospitals more than 50% of its admissions are Medicare patients. Brown says that underfunding for Medicare reimbursement would have closed the hospital long ago if it hadn't been diversified. We were receiving about 65% of our charges and so why should not the government share in all the other things that you have to do because you have to certainly get more than your cost if you expect to buy new equipment, the latest tech if you expect to renovate all the projects we've done in the last two or three years. I mean you have to have more

than what you would consider your cost at least from a federal cost basis and why shouldn't they share in that? There's been a real recognition that rural hospitals have been hurting. I think we understand that in the health care financing administration. The Congress has understood that very well. As of last year there was a formalized move to close the gap in the standardized payment rates for rural and urban hospitals and what that means is by 1995 the basic payment for taking care of somebody with a certain diagnosis will be the same for rural and for urban hospitals. What we're doing is we're increasing the amount that we pay for rural hospitals at a faster rate to close this gap that had existed. If rural hospitals are to survive they need the help and support of their communities. They need local tech support. They need rural physicians who refer their patients to them not to urban hospitals. They need mayors and county

councilmen and local leaders and young people who are willing to be patients in those rural hospitals as well as give them their verbal support. They need a better deal in Medicare reimbursement and they need more help from states and from state Medicaid programs as well. But even if rural hospitals can reorganize or diversify their services they cannot survive without physicians to admit and treat patients. Almost 90% of the medical school graduates go on to train in specialties which they can practice only in large population centers. Even among those graduates that choose primary care specialties few choose to establish their practices in rural areas. I think the biggest and most difficult thing right now is the frustration in trying to recruit people to this area and this is shared by all small towns. I think the situation is very critical it's been getting worse. We have data for example that shows looking at America's medical schools that 9% of all of those who graduated from medical school

in the early 1980s have gone out to serve in rural areas but with 25% of the population out there that isn't enough and it suggests the problem will get worse. The physician supply problem in rural America exists for many reasons. Higher workloads and lower incomes are only part of the picture. To understand the physician shortage it is important to understand the medical education system and the culture of the academic health center in which tomorrow's doctors are trained. Medical schools are by nature specially oriented. Academic health centers exist for research, teaching and patient care in which state-of-the-art is emphasized. Since medical training requires a high volume and variety of patients almost all teaching hospitals and medical schools are in large urban population centers. As a result medical students enter a high tech urban specially oriented environment. The fact matter is that most medical schools don't do a very good job of

training primary care physicians. You don't take a family doc, put them in a 600-bit hospital, put them in a primary care program where they have every specialist they can ever imagine being on call 24 hours a day, have them use the MR scan etc and then expect them to go out into a rural area and practice family practice. It's not the way to go about training those kind of providers. In response to this problem many medical schools have developed programs which move some of the students training out of the urban setting and into the rural areas. One such program has been developed by the Louisiana State University Schools of Medicine. Beth and Joe Danford are completing their first and second years in medical school. By the time they are midway through their third year it is likely they will have decided what type of medicine they will practice. That decision will rest on many factors including the range of their experiences

in medical school. I have really had my decide. I think that once I become a junior medical student and begin to do the rotations then perhaps I'm hoping that one of those rotations will suit me better than the others. Basically I think that the primary care physicians are the frontline type physicians. They get to see the first, the patients at first with the materialist is and they can decide if they can treat it they do, if not they can refer it on. And they get to work more one-on-one with the patients which is what I want to do. The Area Health Education Center or the AHEC program has been started in several areas in the state of Louisiana to allow medical students to get into rural areas and see what that lifestyle is like. The student lives in the rural community frequently at the hospital or nearby the preceptor when the doctors on call the students on call. The student has to get up in the middle of the night

and go to the emergency room if his preceptors called out to do that. We want them to understand the type of lifestyle that's available in the small community. We also want them to have a good understanding of what a rural practice is like and the AHEC program lets them do that. They get a few spotters on their stomach and someone there extremities. Do you see very much of that here? The Danford spent the summer with doctors Brian and Marguerite Piku who practiced family medicine in the small community in north central Louisiana. During their stay, Joe and Beth worked side by side with either Marguerite in the office or with Brian on hospital rounds and visits to the local community clinic. I think the most one thing that has impressed me about rural doctors is the tremendous amount of hours that they had to put in per day. It's 12, 13, 14 hour days, six or seven days a week. There's an incredible amount of dedication that you have to have to want to come to rural environment because there's not always

someone that can take your place. It's hard to take a vacation. I had an illusion in my own mind at how many hours I thought the physicians were working. It was, I really had a underestimated. They work an average of 60 plus hours a week. They had to do rounds every day seven days a week so that was my big eye opener right there. It was just a number of things that they look at. For Joe and Beth who grew up in small towns, the rewards of working in a rural setting are evident. I love knackered. I really, really do. This would be, I think, a perfect location to write family. It's beautiful. You can't replace the hospitality. It was small. It's just not fair. The town's just, you know, for Joe and I, just don't have it. They're missing something and

thanks to hospitality as a big part of that. I believe the medical school, especially the state medical schools, have to take primary responsibility for the male distribution and the male proportion of specialties for rural communities. Nobody else has the resources. Nobody has been given the responsibility for physician training and the proportion of specialties trained. And my perspective is that not just the rural communities, but the rural professional groups and the rural legislatures need to say to medical schools, it's not enough for you to do work on this problem. You need to take responsibility for solving this problem. Well, I need to push it a little bit more. Programs like this are very good, but a lot of physicians, like an internal medicine physician, which you primarily see a lot at some medical schools, they don't really tend to push away from family practice, but they'll tend to say the only real doctors are whatever they might be. But attracting physicians to rural primary care

practices is only one part of the problem. Many experts in the field believe that our system of medical education has become too focused on the urban practice of medicine and does not adequately prepare doctors for the rigorous demands of rural practice. At any time, you have to be able to handle anything that walks through that door. And in a university setting, you have other people around all the time that you can count on, that you can call their right there. If anything comes in and you don't know how to handle it out here in a rural area, it's you. And if you can't get them to a major city within time, you have to deal with it. And if you're not trained well enough, you're going to panic and you're getting nervous and patients see that. Medical student Lisa Desbian is taking an elective fourth year clerkship with Dr. John

Haynes in Vivian, Louisiana, a small town on the Louisiana Arkansas border. She will start her residency training next fall. But Dr. Haynes doubts whether it alone can give her the skill she needs for this type of work. These people have worked for me on emergency rooms and I work for me as a resident. And I think they're it's not their fault, but I think they're inadequately trying. I'm trying to read elective cardiograms properly, diagnose they read me as that may occur, cardiac arrhythmias. I've never been trying to put a chest tube in. They've never been trying to take care of severe trauma. Dr. Haynes greatest satisfaction comes from practicing medicine the way he was trained. He believes a good well-trained physician can take care of 90 to 95% of most problems in rural practice. He emphasizes the ability of the primary care physician to both diagnose and treat the patient whenever possible. Dr. Haynes also believes family medicine

residents today are often trained to do a little more than make an initial diagnosis and then refer to a specialist. The situation is critical. The situation is nearing the point of no return. Because there will be a time when there will be no longer any family practitioners available that have been trained adequately to have trained these guys. I think now's the time to turn this around. And I didn't realize that in eight o'clock you just don't go home just because you feel like you're finished with your workers always, you know, emergency comes in. He's here all the time and his patients in this whole town really depend on him. Being here and expect him to be here when something goes wrong and if he's not they really get upset and that impressed me probably more than anything else. The fact that he's got this big responsibility to all these people. In a large specialty oriented medical center, Elisa would never be exposed

to the realities of rural practice. Just being here for two weeks, I felt more comfortable doing things that I'll shoot you. I wouldn't feel comfortable doing just because I get to do them. But in some model programs, a new approach is being tried which integrates a greater exposure to rural practice in family medicine residency training. Dr. Katie Sherman is about to complete her residency and family medicine based in Colville, Washington, a small community of 3,000 people in the northeast corner of the state. She is one of about six medical students in Washington who spends the majority of the residency training in rural areas. The program called the Rural Residency Training Track, or RTT, is innovative in that the final two years are based in a rural community. Okay, great. Nice to see you. Okay, all right. Most residency programs are based in urban settings and which they work out of the large tertiary care hospital. Our residents see is basically incorporated into a busy rural family practice, a group practice setting.

And our residents are basically treated like a member of our practice like we would an associate incorporating their curriculum and their educational needs into a longitudinal experience here. After spending the first year in Spokane where they concentrate on the type of training usually provided in a large medical setting, the residents are placed with a group of family physicians in a rural community, but returned to Spokane periodically for rotations in specialized training areas. The importance of that is that not only does it have more time in the rural area, but now the the mentor, the faculty becomes family physicians and the residents live in a rural area so that they get not only the flavor of what it's like to practice and learn from family physicians in rural America, but they also get the opportunity to live in that community

and experience what it's like to be a family physician during the residency. And I think we have more clinical hours and we're balancing all of the aspects of general practice within this residency, the clinical responsibilities, the the meetings that go along with with planning long-term and short range for the clinic for operative procedures as well as hospital requirements. And then we carry our own obstetrics patients and we deliver those people and care for them and their children which is actually one of the big benefits. By the time that our residents are have done two years here in Colville, they're they're basically my peer. They're very sophisticated practitioners. They have a wide range of skills. They have excellent interpersonal skills in dealing with the public. They're already part of the community.

The choice to train in Colville was easy for Kate because this is her home. This is where she was born. She says the rural training track offered her the best of both worlds. The benefits are obvious you know and that I'm already starting to build my practice while I'm in training. And then the other thing that may not be so obvious is that I wanted to be living in a rural area and what better way to train than in a rural community. I think that if you compare our statistics with where our people end up after they graduate that we are better than the national average of getting people to practice in rural areas and to to stay in our part of the of the country the Pacific Northwest. Basically I'm from the northwest and I wanted to return to the northwest practice medicine. I thought it was important that I do my training up in this area so I get to know

the area and the people. Also the rural training track is offered up here where it's not offered anywhere else in the United States and that was important to me also because I plan on practicing a small town. Sam graduated from medical school at the top of his class while there he was encouraged to specialize but he wanted a broad-based practice. He decided to go into family medicine. I was actually kind of angry at the medical school that I went to because out of the 118 we graduated I think only four when in family practice we were pretty much discouraged from doing family practice. The core problem is that our health care system is set up to serve the health care provider and not the patients out there. So we have a system in which we reward people who go into specialty careers and tend to stay in large cities and we make it very difficult for people who want to be generalists who want to be primary care doctors and who may want to live in rural areas and everything we do is structured in that way and so it's not any particular surprise when the

students that finish our medical schools and our training institutions end up going into large cities and becoming narrowly based specialists. For Sam and Katie the choice to become rural practitioners was made easy by the fact that there was a program whose education objective is to train physicians for rural practice. This is home. My husband and I have built a very nice home. We're comfortable here. We like it here. And we like small towns. This is how we want to spend in Thailand. I guess my belief is that there is an appropriate role for rural America, but it's going to change and it might be different than the role that we want to custom to over the preceding century. And that's the struggle that all of us have to face

as we try to figure out how we can respond to the many changes that are occurring that are really outstripping our capability sometimes for the coming century. Those who have been involved in rural health care are beginning to recognize that it takes a lot more than just keeping hospitals and physicians applied for rural areas. I think that we always think too simplistically about issues. A rural town needs a doctor. It's the usual way it occurs. And so we go out and try to recruit a doctor. That's not the way it can do. I mean that's a sham. That's an embarrassment to all others. If you're going to build a system that's stable and that lasts over time, you have to look at both the community and the providers and it's the linkages that are the important thing. Whether a national health care plan or a series of innovative programs helps ease the rural health care crisis, the goal of people working in these

small communities is to get a reasonable fighting chance so that in the future access to health care services becomes a fundamental right for all Americans regardless of who they are, what they earn, or where they live. Dr. Cravitz, you have a visitor in the main model. Dr. Cravitz, a visitor in the main model. Please, Dr. Forrest, please dial 1118.