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Rural West Virginia Winning Over Health Care Workers

By: Francis X. Clines
The New York Times, June 21, 2001

PINEVILLE, W.Va. When the coal company doctors took down their shingles as the mining camps died off, the people of Appalachia settled in for long years of what they do well, stoic suffering amid the neighborliness of the hills as the level of health care spiraled further toward the bottom nationally.

"Coal-mining care they used to call it around here," said Angela Privett, as she presented her 11-year-old daughter, Kristen, who has cerebral palsy, to the ministrations of Hank Shrewsberry, a physician's assistant who represents the new order of Appalachian medicine.

"I always thought I'd go to a larger place to work," said Mr. Shrewsberry, one of nine children who returned to his roots here in the hills to practice medicine as a certified assistant under a doctor's direction, after a career in the Navy. "I never thought I'd come back to southern West Virginia, but I decided this was the place to make a difference."

In a reversal of fortune, this state is attracting scores of professionals like Mr. Shrewsberry to restock its most rural outposts with health workers. In the last decade, 92 doctors have been recruited and groomed as primary-care practitioners in what has become the state's evolving academic specialty of rural medicine. In this, doctors often must make a broader range of on-the-spot decisions than their urban counterparts. At their sides are 51 accredited physicians' assistants like Mr. Shrewsberry and an increasing array of other health professionals.

And, most significantly for the goal of recruiting a fresh generation, at Mr. Shrewsberry's side these days as he makes his rounds is Karen Russell, a medical student fulfilling the field training in the back hills that the state now requires of all students in West Virginia's medical schools, whether they have big-city career plans or not.

"Out here it's much more fulfilling," said Ms. Russell, already resolved to stay in rural practice after her studies. "You're helping small- town people who otherwise have to drive hours to get care they desperately need."

That mandate of some rural residency for medical students, enacted under public pressure on the Legislature, is proving to be the key to the steady improvement in the state's rural health care. More of these students required to get a taste of life in the mountain hollow communities are later choosing to root their careers among rural patients.

"Those who stay are usually either mavericks or missionaries, and I'm grateful for both," said Hilda R. Heady, the executive director of the state's Rural Health Education Partnerships. Primed by research money from the Kellogg Foundation, this decade-old program was designed to solve the paradox that the state, which has three booming medical schools and no shortage of health care education, was losing many of its best and brightest to other states.

"They were defaulting on their social contract," said Dr. Robert Walker, the associate dean of the Marshall University School of Medicine who maintains a country practice and includes program students on his rounds. "At the universities, all the textbooks are about urban medicine and urban case examples. So people would say, `You can't go to Pineville to learn medicine.' Well, now you can. We're putting doctors out here because they want to serve."

The program rotates 130 students a month through 295 training sites in the state where local practitioners with typically heavy caseloads volunteer to offer first-hand teaching and gain sorely needed help. The program, financed by the state at an annual cost of $7.5 million, had 31 medical school graduates complete their residencies last year and choose to practice primary care in the state. Almost two out of three of them began their medical studies in West Virginia and decided to stay.

More than 650 community leaders volunteer in arranging free housing and shepherd the students through a minimum of three months' training in the country. The enforced sharing in the powerful community strength of Appalachia's residents can make a student's heart grow fonder when he or she chooses a place to serve.

"When you work in a rural community, you kind of never leave your patients without hugging them," said Kirsten Bradford, a graduate of the program. She is now a physician's assistant teaching the next generation in the program in field rounds that branch out from a woodsy coal town called Left Hand. "They're learning our patients aren't strangers and that we deeply depend on other disciplines for help," Ms. Bradford said, referring to the program's growing network of specialists who can be called on statewide.

Visitors to hamlets where the program operates can sense a healthy contagion about it. For example, Ms. Privett, encouraged by Hank Shrewsberry's home visits, plans to begin training this summer to be a registered nurse. And up in Summersville, Jamie Flare, 18, has broken through the cultural resistance to college studies that has long plagued Appalachia. Ms. Flare plans to study forensic science at the University of West Virginia.

"Now, I'm the role model," said Ms. Flare, looking back to her high school colleagues. Her breakout from her coal-town roots came through a second state program, the Health Sciences Technology Academy. It helps high school students in 22 poor, rural counties to discover distant campuses and to master math and science courses as the first step toward health care careers in West Virginia.

The program has required unusual cooperation on field studies from Marshall, the University of West Virginia and the West Virginia School of Osteopathic Medicine, which was already pioneering its own specialty in rural areas. The program's mission is far from accomplished; the list of physician openings totals 74 and is growing, state officials say.

"Ten years ago, we heard clearly from political leaders that the university was in isolation and not addressing the health needs of the state," said Dr. Robert M. D'Alessandri, dean of the University of West Virginia's Health Sciences Center. "But now I'd say the program has become the exemplar for the rest of the university on how to deal with our communities."

Program graduates talk of a certain seed of yearning planted during their rural service that flowers best in the old coal towns of Appalachia.

"My fellow doctors called me hillbilly," said Dr. Paul Conley, a program alumnus who completed his residency a year ago at a hospital outside Philadelphia and returned without a pause to practice in the green hill country of Summersville. "I wanted to sample the big city atmosphere, and I did. And after that hillbilly won the graduation honors up there, he decided there's a bigger challenge to practicing rural medicine down here."