COLUMBIA — Gravel roads, small towns and rows of corn that go on for miles — these are images of rural Missouri.
More often than not, doctors are missing from that picture.
Gov. Jay Nixon's budget proposal for the Missouri Area Health Education Center, which helps support the Rural Track Pipeline Program, is at zero dollars for fiscal year 2011.
The budget won't be finalized, though, until May 2010.
"Anything could change between now and then," said Michael French, co-director of Area Health Education Center at Kirksville College of Osteopathic Medicine.
Weldon Webb, associate dean for rural health at the MU School of Medicine, said that it's going to be a difficult budget year for all programs.
When asked what will happen to the program if it is not state-funded next year, Webb answered, "That's a bridge we'll have to cross when we get to it."
Eighty percent of Missouri's counties don't have enough physicians. Many of those counties are rural, according to the Missouri Department of Health and Senior Services.
One of the ways MU's School of Medicine has sought to draw more physicians to rural areas is through the Rural Track Pipeline Program. It began in 1995 and continues to educate medical students about the importance of practicing in rural areas.
A big factor in the shortage of health care providers is the retirement of baby boomers, said David Oliver, assistant director of the MU Interdisciplinary Center on Aging.
Approximately 78 million people born between 1946 and 1964 make up the baby boom population. In 2011, the first baby boomer will turn 65 years old.
According to the Office of Social and Economic Data Analysis, the population of people age 65 to 74 has increased in many rural counties in Missouri. Webster County, just east of Springfield, grew 15.3 percent between 2000 and 2004 in people ages 65 to 74. The current population of Webster County is just over 36,000.
That means that over the next 20 years, there will be an extreme need for physicians, especially in rural areas, to better serve the aging population.
“The impact will be dramatic,” Oliver said. “Our health care system is not prepared.”
MU's Rural Track Pipeline Program
Despite cuts to the Missouri Area Health Education Center budget, which assists the Rural Track Pipeline Program, it continues to give medical students firsthand experience in rural medicine by sending them to rural areas to live and learn.
“The goal of our program is to address the maldistribution of physicians in Missouri by getting more physicians to understand health access and disparity issues by rural training,” said Kathleen Quinn, program director of MU Area Health Education Center.
Quinn sees success in the numbers: More students in the program enter primary care residencies in Missouri than out of state, and 28 percent of them go on to practice in towns of 50,000 or less, she said.
Nationally, only about 10 percent of physicians practice in rural areas, according to National Rural Health Association.
“The pipeline is renewing in the sense that we have students who were part of the program in the mid-'90s that now teach students participating in the Rural Track Pipeline Program,” Quinn said.
Rural doctor experiences close-knit community
Karlynn Sievers, 36, graduated from MU's School of Medicine in 2001 and was a student in the program during its first few years. She now teaches medical students in the program.
For four years, Sievers has taught in Rolla — a town of about 18,000 — the importance of practicing in rural areas.
"I think it's really important to give students a feel of what a rural area is like," Sievers said.
In her view, the program also gives students more experience than studying in a larger city would do.
"You get a lot more intense experience," she said. "You see more patients and aren't competing with other students. It's a lot of one-on-one time."
Sievers knows of the shortage in rural areas and says that is the most important thing she teaches them.
"We need docs," Sievers said. "There's just a huge demand."
The problem will just escalate if the final health care reform bill includes a public option, Sievers said.
"We have this huge uninsured population that doesn't have access to the services they need right now," she said. "If we suddenly insure these people, and they can get access to the health care they need, we're going to need so much more manpower."
In St. John's Clinic, where Sievers works as a family physician, a receptionist greets every patient. Within minutes, one of the five doctors in the practice appears and welcomes the patient to an examination room.
Although Sievers sees about 25 patients a day, she said she's on a first-name basis with all of her patients. The babies she has delivered since she arrived in Rolla five years ago have grown into toddlers, and she does their annual checkups.
Sievers, who did her residency in Kansas City, said it's harder to develop such a bond with patients when working in a larger city where there are so many doctors and specialists. For example, if a patient came to a family physician in a large city with a heart problem, he or she would be sent to a cardiologist. In a smaller town, the patient might remain with the family physician, depending upon the problem.
Sievers deals with a little bit of everything and with patients of all ages, she said.
"We always say we work from cradle to grave," she said.
Sievers knows her patients so well that she anticipates spending extra time in the grocery store because she knows she'll bump into patients and wind up having 12 conversations.
"I shop at Country Mart to get groceries, and I swear every one of my patients shops at Country Mart," she said. "I thought it would be an awkward thing, but it's not. It's kind of a neat experience."
Her 5-year-old son played T-ball on the same team as many of her patients' children.
"You get to feel like you're a piece of the community," she said. "I think a lot of why we go into medicine is because you want to feel like you're making a difference for people and you want to feel like you're helping their lives. And when you're in a big city, you may not ever really get feedback about that."
"But when you're in a small community, you see these people and you think, 'Wow, look at all these people I know I got to take care of.'," she said. "So it's constant feedback on why your job is important."
A student's involvement with the program
Lincoln Sheets, 46, a third-year medical student in the in the Rural Track Pipeline Program, is currently studying in Joplin, a rural city in the southwestern corner of Missouri with a population of less than 50,000.
“It’s a little different culture,” Sheets said.
His hometown is Springfield — only 70 miles from Joplin — but the two cities are very different, especially in terms of medicine, he said.
“Doctors in a small town get a chance to build a better relationship with their patients,” Sheets said.
And the small-town feeling is growing on him. It started on his first day.
On his way to orientation in Joplin, Sheets got a flat tire. When he arrived, he made small talk with a doctor. When Sheets mentioned he was driving on a spare, the doctor immediately handed him a card with the name of the best guy for tire repair in Joplin.
“It’s really wonderful how they look after me,” Sheets said. “You wouldn’t get that in a large city.”
Sheets said he plans to practice in southwest Missouri, possibly Joplin, after he graduates in 2011.
Michael Rothermich completed the program and graduated from MU in 2000. He now works in Montgomery City — a city of fewer than 3,000 people — about 50 miles east of Columbia.
He's originally from south St. Louis City. He said the program led him to where he is now.
“This program not only helped me become a better physician but directly contributed to my decision to settle in an underserved area,” he said in a letter in support of funding for the Area Health Education Center earlier this year.
He's made a commitment to serving the underinsured, accepting all insurance and providing a sliding fee based on income, he said.
“Many of our patients without insurance pay less than $10 per visit,” he said.
He thinks that physicians are simply unaware of how badly they're needed in rural areas — or how comfortably they can live in smaller towns. For example, in family practice, doctors can make more in a rural area than in a larger town because there are not as many specialists to send patients to.
Rural health is hard work
The downside is the stress that comes from being so needed.
"We're the front line for everything," Sievers said.
Although there are many benefits to practicing in a small town, such as minimal traffic and a close-knit community, there are many downsides as well.
Sheets has learned that when there are only a few doctors per town, it can be stressful for the doctors.
“When there is such a need for doctors, it makes it hard for a doctor to leave, or even go on vacation,” Sheets said.
Oliver also recognizes the stress many physicians may face in a rural area.
“You’re always on call. There’s not a lot of backup,” he said. “The doctors who do commit to rural areas are the angels of medicine.”