Rural hospitals could provide critical help addressing the state’s expected doctor shortage, according to Dr. Douglas Girod, the new executive vice chancellor of the University of Kansas Medical Center.
“This is one of those areas where if you really want to link physicians with where they need to be with funding of the educational enterprise…potentially community hospitals can step into the role,” Girod told KHI News Service.
KU officials also are planning a new $75 million medical education building on the Kansas City, Kan., campus to help train more doctors and are seeking funding help from the Legislature this year.
KU officials estimate Kansas will need 213 new doctors a year by 2030 just to maintain what is now a physician-per-resident ratio that lags the national average. To meet the national average ratio, Kansas would need about 285 new doctors a year by 2030.
Girod said community hospitals could help address doctor shortages in rural areas by funding residency slots through federal Medicare payments.
According to medical center officials, The University of Kansas Hospital pays for 280 residency slots, augmenting its federal funding with money from its clinical operations and with assistance to other hospitals
KU has 511 residency slots in Kansas City and 250 at its Wichita campus.
Kansas has done a good job trying to seed rural communities with more doctors, said Brock Slabach, senior vice president of the National Rural Health Association. He said KU’s campus in Salina was a good example of that.
National medical school accrediting bodies, Slabach said, worry about the training and oversight residents might receive in remote areas so have been reluctant to sign off on training programs outside metropolitan areas.
The federal government has also been slow to implement legislation authorizing rural training tracks, he said. And community hospitals have been reluctant to take on the responsibility because of the added costs of overseeing residents.
Though it can be hard to get them there, once young physicians arrive in smaller towns, they tend to energize the local medical communities.
“It stimulates the physicians in those communities,” he said. “They are challenged a bit in terms of their assumptions and what they have learned. They have someone coming out maybe with some different perspectives on things because of their more recent education.”
KU efforts to construct its new medical building hit a snag in the Legislature last week, when the Senate Ways and Means Committee voted to cut $10 million that Gov. Sam Brownback proposed for the project.
The House Appropriations Committee today approved the $10 million.
In his proposed two-year budget, Gov. Sam Brownback included $3 million in fiscal 2014 and $7 million in fiscal 2015 for KU's effort to build a new $75 million medical education building. The governor also endorsed giving the medical center $35 million in bonding authority for the project.
KU officials say they could train about 25 new doctors a year on the Kansas City campus after the improvements, and need the new facilities anyway or else the school's accreditation could be in peril.
Kathy Damron, a lobbyist for KU, said the facility is needed, in part, to integrate instruction of doctors, nurses and other medical staff, currently trained in separate facilities.
"It will allow the doctor to learn with the nurse, with the anesthesiologist and so on — all in a simulation lab. Right now, we train them all separately and throw them in the hospital and say 'now work together.' And that doesn't really work. That's the modality that schools of medicine are now moving to," Damron said. "The accreditors want to see that we're moving in the right direction to change the modality in which we're teaching our medical students.
Should the state funding come through, Girod said he was confident that KU could raise the $22 million it has pledged toward the building.
He said he would like to have the building ready by 2017, constructed on what is now a parking lot at the northeast corner of northeast corner of Rainbow Boulevard and 39th Street.
“When (donors) think about how they want to invest their funds,” he said, “they want to invest in an area where they are going to see some pretty tangible results. And I think it’s very easy to see a very tangible result from (the building). It will impact generations and that is something that will excite some potential donors.”
Girod also touched on other topics during the interview, including:
• How KU’s recent National Cancer Institute designation helps its education mission: “That creates a culture of clinical, intellectual curiosity that already we are seeing synergies from.”
• The burgeoning relationship between KU and Children’s Mercy Hospitals and Clinics in Kansas City, Mo.: “The potential for that collaboration to grow the research enterprise for both of our organizations is immense and it’s wonderful clinically and it’s great for the kids and it’s great from an education perspective.”
• Status of the proposed School of Public Health: “We have had the work group looking at the combination of feasibility, structure and then financing and we are working down that list. It’s a unique school in that it will involve several campuses…which is a much more dispersed model than a lot of places. It creates challenges but it also creates opportunities because each has different strengths, in part because each sits in a different part of the state.”
Morgan Murray is too young to have any idea who Doogie Howser is, but the 16-year-old from Shawnee is cut from a cloth similar to the prodigy doctor in the '90s TV show.
Even while finishing high school and getting a jump on college, Murray finds time to be flown across the country several times a year to help teach doctors twice her age how to perform challenging tracheal intubations, a procedure to get oxygen to patients with blocked airways.
"It's a very high-stress, very time-oriented procedure," said Murray. "I am helping teach the doctors how to intubate using high-fidelity simulators. I act as their nurse, getting them anything they need. Then I help debrief and tell them what they can do better."
Murray came into the teaching opportunity while sitting in on classes, which were taught by her mother. Two years ago, the instructor in the nurse role was out sick, and Murray seized the opportunity to fill in.
Now Murray is seizing another opportunity to get a jump on her career at the Kansas Academy of Mathematics and Science.
The two-year program is a sort of fast-track boarding school at Fort Hays State University. Each year, up to 40 high school juniors from across the state move into a campus dorm and complete their last two years of high school coursework while also taking college math and science courses.
Murray said that the academy — often called KAMS by students — provides an environment where staff and other students drive each other to set goals high.
"I've been wanting to pursue medicine since I was in third grade," Murray said. "KAMS has pushed me to do even more than I thought I could. I've done more in this semester than I thought was even possible."
Plugging the brain drain
Murray is one of 68 students currently enrolled in the academy. Another 53 students have graduated from KAMS since the first class in 2009.
The Kansas Legislature founded KAMS in 2006, in part to give students like Murray a learning opportunity in Kansas that would challenge the state's most talented students, said director Ron Keller.
"The academy was formed to keep the students here in the state — to keep intellectual capital from leaving Kansas, to keep from losing our best and brightest kids," Keller said.
The people who run the state’s only medical school say its national accreditation falls in jeopardy or is lost, if money isn’t raised for a new, $75 million structure at its Kansas City campus.
“If you're not an accredited medical school, your students can't take board examinations. Your graduates cannot get into residency programs that are accredited. And in most jurisdictions if you can't sit for your boards and you don't graduate from an accredited residency program you can't practice (medicine), you can't get a license. So accreditation is a huge deal,” said Dr. Glen Cox, the dean in charge of keeping the school OK with the Liaison Committee on Medical Education, the national group that certifies medical schools.
The current education building on the school’s Kansas City campus was built in 1976 and officials here say if it isn’t obsolete it is nearly so, especially given the changes happening in the ways doctors and other health professionals are trained.
“A building built in the 1970s just can't fit the technology needs of today,” said Dr. Steven Stites, acting executive vice chancellor of the University of Kansas Medical Center, which includes the medical school. “We have a structural problem and we can’t renovate it. It would cost more to fix it up than it would to replace it.”
Lecture halls, even in the first year of study, now are considered less important to learning than small practice rooms that allow for simulations that mimic the conditions students — as doctors — will face when they encounter real patients. Also, with growing emphasis on coordinated care within the health care industry, schooling now focuses increasingly on teamwork, not just among fellow medical students but also drawing in nursing students and other health-care trainees.
The school has some spaces for that sort of teaching by doing in small groups, but not enough, according to the people in charge. The accreditation process is so meticulous, as described by Cox, that it even dictates how much private space and storage must be allowed for each resident.
Cox said he is among the few people at the medical school to remember the accreditation problems it experienced in the 1990s, a years-long ordeal he said he would prefer not to live again. And that was before he was the administrator tasked with keeping those things in order.
Need for more docs
Besides warding off accreditation woes, a new school would allow for training more doctors, KU officials said. Experts across the country for years have warned of doctor shortages that have since arrived and are growing and of the need to expand medical schools to slow or reverse that trend.
KU between 1998 and 2007, according to medical school statistics, graduated an average of about 165 medical students per year and 41 percent (an average of about 67 graduates per year) stayed in the state.
The new building would allow the school to have 25 more students per class year in Kansas City and — after counting graduates from expanded satellite campuses in Wichita and Salina — the state should see 96 new KU-trained doctors a year practicing in the state by 2016, according to projections prepared by KU. That would be a net gain of almost 30 doctors a year.
With a generation of baby-boom doctors retiring or soon to retire, many Kansas towns struggle to recruit new doctors. A disproportionate number of the doctors working in the state’s rural and underserved areas are KU graduates.
There are about 259 doctors per 100,000 U.S. residents. In Kansas, however, there are only about 213 doctors per 100,000 residents. The state also is below the national average when it comes to primary care doctors.
According to KU estimates, the state will need 213 new doctors a year by 2030 just to maintain the state’s current below-average ratio. To match the national average, it would need about 285 new doctors a year by 2030.
The tricky part
It’s been known since Coronado traipsed the Plains that gold doesn’t always turn up in Kansas. And, unfortunately, Dr. Glen Cox did not win the Lottery last week (he said), so KU is struggling to come up with a way to pay for the school building that KU and other higher education officials say it must have and that the state needs.
Members of the governance committee for the Kansas Board of Regents have agreed that the full board should hear the pros and cons of a proposal to train mid-level dental practitioners.
Regents' officials said this week that discussion among board members likely would happen before the Legislature convenes in January, perhaps when the board that oversees state universities, junior colleges and technical schools next meets in November.
Bills authorizing the licensing of "registered dental practitioners" as a way of improving access to dental care for Kansans in rural and other underserved areas were considered by lawmakers in each of the past two sessions of the Legislature but were not advanced because of stiff opposition from the Kansas Dental Association, which represents about 75 percent of the state's dentists, of which there are fewer than 1,500.
Had the proposals become law, the mid-level practitioners would have been allowed to perform about 30 routine services and procedures — such as extracting loose baby teeth, taking X-rays and administering local anesthetic — that currently are limited to dentists. The practitioners, similar to a nurse practitioner, would be required to work under a dentist's "general" supervision, though the dentist would not be required at the technician's side.
Spokespersons for the dental association have argued that routine procedures quickly can turn dangerous and that allowing lesser-trained practitioners to do what dentists now do could put patients at risk.
But supporters of the measure, including a coalition that includes the state's safety-net clinics, argue that some people in Kansas, including children, have died due to lack of dental care and that putting more oral health workers into the field is essential for meeting the state's needs. They also cite studies from countries and states where the practitioners are licensed showing they provide good quality, cost-effective care.
Not enough dentists
According to the Kansas Department of Health and Environment the state's dental workforce is below the national average and shrinking. More than a dozen of the state's 105 counties have no dentist and many more than that have too few.
A proposal to create the new class of dental technician is expected to be before the Legislature again in the 2013 session, which begins in January.
Practicing medicine on the frontier in Kansas doesn't have a whole lot in common with big city medicine — so why would small town hospitals use big city physician recruiters?
Kiley Floyd said it's clear to her now that they shouldn't, but the chief executive of Osborne County Memorial Hospital learned the hard way.
"Small rural hospitals are not the same as large tertiary hospitals. Requirements of docs are different, the relationship with staff is different, the patients are different. When you're using a large recruiting firm, I learned the hard way that they don't get that. They're in it to make money," Floyd said. "We needed a good match."
The last time she used a national recruiting firm, it took two years to fill a family practice physician vacancy — and that's all the longer the doctor stayed at her north-central Kansas critical access hospital.
"The doc was not a match at all. He looked good on paper, he was a great interview, but he was not a match. He lasted a couple years," Floyd said. "He was a city guy. He'd never lived in a rural community. He thought he wanted to, but when it came down to it, he did not."
Overall her experience recruiting has been time-consuming and expensive.
"We've hired recruiters, we've done contingency firms, we tried it on our own. We've kind of run the gamut," she said. "My experience was terrible previous to Sunflower."
Things are different now.
To fill the last two openings at her hospital, Floyd has enlisted the physician recruiter from the Sunflower Health Network.
The network — one of a dozen in Kansas — consists of 15 critical access hospitals that share services, pool resources and refer patients to a common hub, Salina Regional Health Center. Salina Regional first began contracting out its internal recruiter to network members in 2009.
Floyd decided to give the new recruiting service a shot, and said that in about three months she had filled the position at a third of the cost of the previous, failed effort.
"And it was a good match," Floyd said of the recruit, Dr. Dorothy Breault.
In February, the recruiter began working full time for the Sunflower network. In the last three years, eight openings at member hospitals have been filled and three more are in contract negotiations to start in 2013, said the network's executive director, Heather Fuller.
"This is a service our members wanted," Fuller said. "It's just so expensive for hospitals, especially critical access hospitals, to do on their own. It made sense to look at it from a group standpoint. It's something they all need at one point or another."
Faced with the formidable task of recruiting and training enough doctors to replace a retiring generation, Kansas education leaders would like to find more medical students like David Le, who are willing to work in the state’s rural and underserved areas.
Le’s from western Kansas and sees himself going back there some day to practice.
The third-year student at the University of Kansas Medical Center said his thinking on the matter crystallized during a recent rural surgery preceptorship with Dr. Tyler Hughes in McPherson.
“His practice is very alluring,” Le said. "I could see making a career out of serving in a rural community, a community hospital, sort of the same feel as McPherson where everybody knows one another."
"There were a few times (Hughes) said, 'Well, you can. Rural surgeons are highly sought after.' He really was encouraging of it," he said.
"That's something I'd want to do after I've received more of my training in a larger setting."
In that respect, he could follow Hughes’ lead.
After working 15 years at a large hospital in his native Dallas, Hughes picked up his family and moved 400 miles north to a Kansas town where he could be a “real surgeon,” averting the administrative track he was on, he said.
"I wanted to take care of patients and I felt there was a need out in the rural environment," Hughes said.
That was 17 years ago. Since then, he has trained some 80 students, most of them through KU’s program. But he also has let younger area youngsters interested in medicine shadow him on the job, sometimes with pay.
"When I was 17, going on 18, I wanted to be a surgeon. An orthopedic surgeon from my town named Dave Selby heard about it, and he invited me to do it and he paid me a small amount,” Hughes said. “I thought that was incredibly wonderful and I promised myself that I would always teach, even if I had to pay the students myself."
Currently Hughes’ practice in McPherson offers KU’s only rural surgery preceptorship in the state.
Hughes’ drive to extend his formative experiences to others was recognized this month at the National Rural Health Association’s annual conference, where he was named 2012 Rural Health Practitioner of the Year, a national honor.
The distinction comes on the heels of Hughes’ appointment in February to a six-year term as at-large director of the American Board of Surgery.
Le said that Hughes was clearly surprised by the recent accolades.
"He said he's not done anything different the last 30 years, but it kind of seems overnight he's become this huge sensation," Le said. "I think he embraces it fully because he likes the ability to give input to the profession. He likes teaching."
Dr. Beth Loney graduated from the University of Kansas School of Medicine’s Wichita campus in June and then went into practice in Stockton, a town of about 1,300 people in Rooks County, north of Hays.
When she started medical school, she had no plans to become a rural doctor.
"I knew I wanted to do family medicine, but I wouldn't have said I wanted to do rural. I didn't have family that was rural, I didn't grow up going to a rural area, so I didn't know a lot about rural medicine," Loney said.
That changed thanks to an exposure to rural medicine during her second year of medical school. She participated in a "rural health weekend" at Dr. Jennifer Brull's practice in Plainville. That led to a third-year rotation in Plainville.
"That's what made me decide to do rural by the time I went to residency," Loney said. "Early exposure is so important if you're actually going to get people to consider it as an option."
There are others like Loney.
More graduates from the KU Wichita campus chose to practice in rural areas of the state in 2011 than in any of the previous five years.
The KU Wichita campus was expanded last year to include a full four-year program, and a new four-year program was started at KU Salina with hopes that more students would focus on primary care and work in rural or other underserved areas of the state upon graduation.
If last year’s graduating class is any indication, the strategy already may be paying off.
Dr. Brad Poss, professor of pediatrics and associate dean for graduate medical education at the KU Wichita campus, said interest in working in rural Kansas is closely tied to growing interest in primary care among students.
"And having a connection to Kansas is important,” he said. “That's one of the reasons for the opening of the new four-year campus here. Families get established, they get to know the area and they begin to make a life here. So, they then like to do their residency here as well and they become established in Kansas and subsequently have practices here."
Currently there about 776 residents in KU’s medical school — 499 in Kansas City, 264 in Wichita and 13 in Salina. Last year, 121 graduated from KC, 66 from Wichita and four from Salina. Graduating class sizes vary from year to year because residencies last from three to seven years.
Poss said in recent years, about 50 percent of KU Wichita’s students chose to practice in Kansas following their residencies and about 30 percent chose to leave the state. The remaining 20 percent went on to advanced training in fields such as cardiology or neurosurgery, and about half of those specialists stay in Kansas afterward.
In 2011, 32 residents graduated from KU Wichita and set up practice in Kansas. Of those, 18 chose to practice in rural communities, or 56 percent. That's up from 19 percent in 2010 and an average of 35 percent the previous five years, Poss said.
Comparable numbers from the other two KU medical campuses weren't immediately available.
Allure of rural medicine
Loney said part of the allure of rural medicine was the broad range of work involved.
"You're going to work in the ER, you're going to admit your own patients to the hospital, you're going to deliver babies, you're going to do your own procedures — things that in the big city you don't do," Loney said.
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