Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: MONDAY, April 4, 1994 TAG: 9404040201
SECTION: VIRGINIA PAGE: A1 EDITION: METRO
SOURCE: LAURA WILLIAMSON STAFF WRITER
DATELINE: MONETA LENGTH: Long
\ Christine Burrows unbuttoned the 71-year-old man's shirt, placed the stethoscope against his back and listened to his lungs as William Sumner tried to breathe without the help of his oxygen tank.
"Take a deep breath and blow out really hard," she coaxed.
Sumner's lungs, damaged by years of smoking cigarettes and working with asbestos, produced a long, raspy wheeze.
"You're an expert at getting a wheeze out," his family doctor told him.
Burrows, a second-year University of Virginia medical student, smiled. Her part in Sumner's medical exam last month was purely academic. She was there to learn from Dr. Kitty Bono, a rural family physician, a rare breed.
The National Association of Community Health Centers estimates there are 43 million Americans living in medically underserved areas - 640,000 of them in Virginia. There are fewer than 250 doctors to care for those people.
Burrows could be one more.
With two more years of medical school to finish before her residency, she's still not sure which area of medicine she will pursue. But UVa's hoping that students like Burrows will go where the research says they will - into whatever field their medical schools have exposed them to.
"Research shows students are swayed by whatever experience is right in front of their faces," said Dr. Claudette Dalton, UVa's assistant dean for medical education.
That's why students in the past have wanted to work in hospitals and to specialize - it's what the medical schools have been teaching them. Now, UVa will require all students to also spend time shadowing primary care physicians before they graduate, preferably in rural or inner-city areas where medical care is hard to find.
The change in curriculum follows a promise by UVa and the state's two other medical schools - Virginia Commonwealth University's Medical College of Virginia and the Medical College of Hampton Roads - to boost the number of general physicians they're producing from one-third to one-half of the graduates by the end of this decade.
To help them keep that promise, state legislators agreed this year to kick in $3.4 million over the next two years. The money will help the schools recruit and train students of general internal medicine, general pediatrics, family practice and obstetrics and gynecology. Private grants and donations - primarily from the Robert Wood Johnson Foundation - will add another $3.8 million.
At the same time, the General Assembly expanded the Southwest Virginia Medical Scholarship fund to allow students who live outside Southwest Virginia - but inside the state - to qualify. The program awards medical scholarships to students who agree to enter a family practice in Southwest Virginia after they graduate.
In addition, legislators created a loan repayment program - more flexible than a similar, federal program - that helps doctors pay back their medical school loans in exchange for several years of service in a medically underserved part of the state. State lawmakers established the program but failed to come up with any money for it this year. Officials at the Joint Commission on Health Care, which writes most of the state's health care legislation, said they expect to receive funding for the program next year.
Congressional efforts to reform the nation's health care system also may help. Included in President Clinton's comprehensive reform package is a request for substantially more money for the National Health Service Corps - the federal loan repayment program that inspired the CBS television show "Northern Exposure." Clinton wants to boost the agency's budget from $130 million to $950 million per year.
But whether Congress can or will come up with that money remains to be seen.
Some see programs such as the state and federal medical school repayment plans as critical to any discussion of health care reform. If there are no doctors in rural areas, what good does it do to promise universal insurance coverage? asked John Gorman, associate policy director for the National Association of Community Health Centers.
"An insurance card, it wouldn't be worth the plastic that it's on unless these people have somebody who's willing to care for them," he said.
They will, said House Majority Leader Richard Gephardt, D-Mo., in a recent coast-to-coast satellite interview on health care reform. Gephardt said he believes doctors will be more willing to work in poor or rural areas once they know all of their patients can afford to pay for their services.
"If you put the insurance out there, the doctors will follow," he said.
But there are other deterrents.
Some doctors feel isolated in the country, Dalton said. They are out of touch with their colleagues, with the sophisticated lifestyle of a big city and often find it tough to keep current with what's happening in their field.
Even if the country atmosphere appeals to them, she said, it might not appeal to their spouses. Or the couple may worry whether there are adequate school and sports facilities for their children.
"A lot of people who might enjoy it don't do it because they're worried about their family," Dalton said.
Not to mention the money.
Rural family physicians earn what many would consider a decent living - roughly $60,000 to $75,000 per year. But that's nothing compared to the $200,000 and $300,000 annual salaries earned by specialists in more populated areas, said Dr. David Marsland, chairman of MCV's department of family practice.
What's worse, he said, Medicaid and Medicare - the federal health insurance plans for the poor and elderly - reimburse rural doctors at a lower rate than urban doctors. Yet, country practices often are overloaded with these patients.
The state's best hope for attracting doctors to rural areas is to go after the students who grew up in those areas, said May Fox, a consultant for the joint commission. She said some of the medical schools' recruitment money will be directed at high school students who live in underserved parts of the state.
"If you can attract people who have grown up in a rural area, they're much more likely to return," she said.
Doctors who didn't grow up in the country are reluctant to go there now - even with the federal government offering to help them pay back thousands of dollars in student loans each year, said Dr. Bruce Hagadorn, medical director of Lewis-Gale Clinic in Salem.
Hagadorn said he has been trying to recruit somebody to work in the clinic's satellite office in New Castle for the past year and a half. He sent letters to more than 20 doctors on a list compiled by the National Health Service Corps. Not one responded.
He can't understand why doctors don't jump at the chance to pay off their loans.
"There's lots of them out there," he said. "There's lots of debt to be paid back."
Bono doesn't understand, either.
Until recently, Moneta was considered medically underserved. Begun with a federal grant, Village Family Physicians has grown over the years to include five doctors - three of them sisters - and one nurse practitioner. Two other practices - each staffed by one doctor - also have opened recently near the lake.
Bono's practice sees about 100 patients a day, plus those who show up for a Saturday clinic. Bono said she gets to know all of her patients personally, something she considers a benefit of the job. But she admits it has its drawbacks, as well.
"It's a bit more confining to be a doctor in a rural area," she said. "You're a doctor at the grocery store. And at the YMCA. It's a profession, not a job."
Much of the satisfaction comes from taking care of the whole patient, she said. She treats people from cradle to grave - and she knows enough about what's going on in each patient's life to know what might or might not be affecting his or her health.
If it doesn't pay as well as other specialties, so be it, she said. It's what she wants.
"I'm not saying that it's not a good living," Bono said. "But it's definitely not golf on Wednesday afternoons and Porsches."
by CNB