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April 30, 2012
McPHERSON 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."
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.
Photo by Michael Kennedy.
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."
To that end, Hughes also fostered an online community on the American College of Surgeons website in 2009.
The online portal exemplifies the kind of creativity that is needed to address the rural workforce shortage, said Brock Slabach, senior vice president of the rural health association.
"The surgery portal he's created helps connect isolated surgeons to each other so they can be of mutual support," Slabach said. "Through the portal they can address issues specific to rural surgery."
Hughes sees the portal as a small first step toward better connecting far-flung rural surgeons. He said professional isolation is one of the obstacles to recruiting more doctors to remote areas.
"A really strong telemedicine program for surgery is not present yet. But it's going to be a need and we need to develop it," Hughes said.
Now, rural surgeons have to be careful about the patients they choose to operate on instead of refer to a larger hospital that has surgical specialists.
"Rural surgeons are still doing it all," Hughes said. "There are no subspecialists immediately at your elbow to help you out. It's daunting to know that at any time you could get hit with any kind of subspecialty emergency and you need to be able to recognize it."
Establishing a statewide video network of specialists would immediately improve patient care and efficiency of delivery, he said.
"But in the current health care tumult, trying to get rural telemedicine funded and activated is not on everybody's top priority list. There are a lot of alligators in the swamp right now. There's no money for anything."
Another pressing need, particularly when it comes to selling new medical school graduates on rural practice, is a support system for covering on-call shifts.
"It's incredibly expensive for the system to keep highly trained surgeons on call constantly. And it makes recruitment difficult if a surgeon with a young family is coming in and he's realizing he's going to miss birthday parties every year — that's not very attractive. So we've got to figure out a way around that," Hughes said. "Kansas is still in beginning stages of addressing workforce needs.”
Hughes is at the vanguard of the effort, said Dr. Michael Kennedy, associate dean for rural health education at the KU School of Medicine.
Hughes and his partner, Dr. Clayton Fetsch, are the only surgeons in KU's rural preceptorship program. Since they began in 2000, they've mentored about 72 students, Kennedy said.
"It's insanely popular. Students love it," Kennedy said. "We've had to lottery the position as long as I've been here, which is seven years. We are using his success to encourage other surgeons. We recently had a surgeon in Salina pilot this, and that went over well. Now we're looking at potential other sites throughout the state.”
Increasing student demand in the last five years is driving the search for more surgery preceptorships, Kennedy said.
"The popularity of rural surgery has really increased as a good career pathway for young students," he said. "It offers a good income and it offers a pretty good lifestyle. A general surgeon in the city is working night and day. In a rural area, you're still busy, but not as busy so the lifestyle is better."
"And the obvious: Surgeons make more than family doctors. Students have loan debt that is astronomical. The last average I heard was $165,000," Kennedy said. "Family med income average is $165,000 (a year) to start. General surgery is about $275,000 to $300,000 first year." (View a recent report on physician compensation from MedScape News.)
The shortage of rural surgeons is about equal to that of family medicine doctors, Kennedy said.
"Primary care is talked about a lot and is a severe crisis, but surgery is equally severe," he said.
"That's why in the Salina model, they do not consider it a failure if someone chooses surgery and goes back to a rural area," Kennedy said, referring to KU's new medical school campus in Salina.
KU officials have said they aim for 75 percent of the Salina graduates to choose rural or primary care.
"The emphasis has to be on primary care because that's where the greatest ability to change overall access to care is," Kennedy said. "But you won't find a family doc in Kansas that says we don't need more general surgeons. The trick is to get students back into rural practice."
Most of Kansas’ 105 counties have at least one federally designated Health Professional Shortage Area and about 25 rural counties are entirely designated as shortage areas.
Recruiting students from small towns and training them closer to where it is hoped they will set up practice were among the recommendations of a KU task force that five years ago studied ways to expand the state’s primary care workforce.
As a result of the study, the KU medical school expanded to include the Salina campus and allow for increased enrollment at the Wichita campus, which last year grew from 55 to 75 students.
Also among the recommendations made in the 2007 report by KU's Primary Care Education Enhancement Task Force were loan repayment programs to help lure medical professionals to underserved areas.
For example, providers in the National Health Service Corps typically receive up to $60,000 in loan assistance in exchange for two years of service but can receive up to $170,000 in loan repayments by agreeing to serve in underserved areas for five years.
The number of Kansas medical providers enrolled in that program has more than doubled in the past year or so, to a total of 125.
The federal health reform law now before the U.S. Supreme Court included about $1.5 billion for the program to be spent over five years. A major goal was to lure more primary care providers, including dentists and mental health workers, into underserved areas in anticipation of the law’s scheduled expansion of Medicaid in 2014.
Under the Affordable Care Act, states are required to expand Medicaid eligibility to include all adults with income at or below 138 percent of federal poverty guidelines. That means an estimated 16 million more Americans would come into the program, including an estimated 130,000 in Kansas.
There are comparable efforts emerging in other rural states where the workforce shortage is particularly acute, said Slabach of the rural health association.
In Mississippi, for example, a program will pay $30,000 a year — no loan needed — for a medical student from a rural area to go to school. For each year of payment, the student agrees to work a year in an underserved area.
"That's the kind of grow-your-own (doctor) program that we monitor and make sure everybody's aware of so they can be replicated nationwide," Slabach said. "It's going to require creativity to address these workforce issues."
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