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Wanted: doctors and nurses for rural health care facilities

Solo doctors in rural areas are overworked and in need of assistance
Sunday, October 22, 2006 | 12:00 a.m. CDT; updated 12:05 a.m. CDT, Saturday, July 12, 2008

It is past 3 p.m. and Alan Weaver is more than an hour late. A few cars sit in the gravel parking lot at the Tri-County Medical Clinic in Sturgeon, their occupants waiting for a staff member to unlock the white front door. Finally, a woman comes from the inside and opens it, signaling that the doctor is finally in.

Once inside the waiting room, Bob Newland fills out medical forms while he waits another 45 minutes for his turn with Weaver. Newland drove almost 100 miles south from Lancaster for his appointment instead of visiting a closer, larger hospital, such as the Northeast Regional Medical Center in Kirksville.

“Everybody feels that bigger is better, but bigger is not always better,” Newland said. “The small clinics are more personalized.”

Some regular patients come from all over the state for health care at Weaver’s office. But many of Weaver’s 7,000 patients are from Sturgeon — residents at the local nursing home and nearby Amish families — because his one-doctor practice is the only available health care in town.

[photo]

Alan Weaver takes time to get to know Bob Newland, who drove nearly 100 miles to Tri-County Medical Clinic in Sturgeon on Oct. 10. A shortage of health professionals in rural areas means that doctors like Weaver are often overworked.

(ROBIN HOECKER/Missourian)

Joy Winkler, from Huntsville, waits with her granddaughter, Natasha, who drove more than an hour from Linn to see Weaver.

“I just feel more comfortable with him,” she said.

Most of Winkler’s grandchildren are Weaver’s patients.

“When you come to see Dr. Weaver, you can expect to wait, but it’s worth the wait,” said Winkler.

On the other side of the waiting room wall, beyond the patient bathroom and down a short, carpeted hallway lined with a few examination rooms on either side, Weaver has just returned to his office.

He’s late because he tried to fit in both a house call and a meal over his lunch break. Although he’s already behind schedule, he will make no effort to rush his patients in the examination rooms to get back on track. He will listen to their ailments and explain procedures and diseases until his patients are comfortable. He will simply work until he’s done seeing everyone.

“Then, when I’m done, I either go to the nursing home or hospital and see people,” said Weaver. “I try to fit in house calls either early or late so that we don’t interfere with the office unless there’s an emergency I have to leave for. I finish with paperwork anywhere from 10 p.m. to midnight, get to bed by 2 a.m. almost every night, and get up at 6 or 7 a.m. and start again.”

As the only doctor in Sturgeon, Weaver is used to working 80 to 100 hours a week. His wife and four children, who all work at the clinic when they are able, understand the pressures of his job.

“We get kind of used to missing him at the (dinner) table,” said Nathan, Weaver’s youngest child. Nathan, 15, works in the clinic after school. He calls patients in from the waiting room and helps behind the desk.

“When I didn’t work here, I didn’t see him as much,” he said.

Weaver has been the only physician in Sturgeon for 19 years. He and his family haven’t taken a vacation since he bought the practice five years ago.

“The stress of being a solo doctor is frustrating because you’re on call 24/7,” said Weaver.

Back in the waiting room, Nathan opens the door and calls Newland back to an examination room. Other patients read, sew or watch the television in the corner of the room as they wait well beyond their scheduled appointment time. The secretary answers a call from a woman who accidentally missed her appointment the day before. Weaver is booked solid and the woman has no choice but to wait almost two weeks for the next available time.

The scene in the Tri-County Medical Clinic waiting room is common across the nation.

Approximately 50 million people live in communities without access to primary health care, according to the National Health Service Corps, a program of the U.S. Public Health System. These communities are referred to as health professional shortage areas. The number of primary care health profession shortage areas in the United States totals 4,577 as of 2005, and many of these areas are in rural settings. The number of shortage areas in Missouri is 146. The NHSC says 27,000 primary care professionals are needed to adequately serve people living in health professional shortage areas.

Physician assistants, or PAs, provide valuable care in many health professional shortage areas in Missouri. In 1997, PAs began seeing patients without on-site physician supervision for a portion of time. In 1999, the rule was modified and PAs in non-shortage areas are now required to have 100 percent supervision, while PAs in shortage areas can still practice without a physician on site but are supervised via telecommunication.

"If I were a PA in a rural area and I had a supervising physician that was seeing patients in a hospital or nursing home, I could still see patients if he was available by phone," says Erin Hutton, a physician assistant in Jefferson City.

However, this law is being debated and new legislation could be introduced. The Missouri Academy of Physicians Assistants is lobbying for more flexibility to see patients without as much on-site supervision, while the Board of Healing Arts wants to implement complete on-site supervision for all PAs, regardless of location.

Although Hutton is not directly affected by the possible change in procedure, she knows many colleagues who have patients in rural areas who depend on them for health care. This could make access to health care in rural areas even scarcer and the demand on family physicians like Weaver even larger.

To encourage medical students to practice in non-metropolitan areas, MU's School of Medicine Area Health Education Center offers a program called the Rural Track Program. The MU-AHEC program offers rural experiences to medical students after their first year and during their third year.

During the third year of medical school, students can spend up to six months learning from a community-based physician at rural sites the School of Medicine and the MU-AHEC have established across the state, according to Kathleen Quinn, director of the MU-AHEC.

"Thirty percent of the third-year students are currently completing clerkships in rural rotations," said Quinn.

The program has had success in the past encouraging students to practice in more rural areas.

"Forty-two percent of those students who participated in third-year rural clerkships are now practicing in rural Missouri," says Quinn.

But the numbers are still small: only 170 students have participated in the program and not all have finished a residency, according to the MU-AHEC.

"Nationwide, about 50 percent of students who participate in rural rotations are now practicing in rural areas," Quinn said. "We're hoping to surpass this."

The NHSC also has established programs to help reduce the health professional shortages. Created in 1970, the NHSC pairs underserved areas with health professionals. Its scholarship and loan repayment programs place recent medical school graduates in health professional shortage areas. Graduates agree to a term of service and the NHSC assists with medical school fees and loan repayment. The NHSC currently has 4,000 health care professionals serving around the country, caring for 74 million people. Sixty percent of NHSC health care professionals are working in rural settings.

While programs such as the NHSC are beneficial for health professional shortage areas, there are downfalls. Newland said it is hard when young doctors come and go from small clinics.

"They work four or five years, then go to a bigger city so they can make a lot of money," he said. "It's hard to stay with one doctor. You get comfortable with one, then they leave and you have to start over with another doctor."

This is one of the reasons why Weaver's patients are so loyal.

"I've been coming here since 1994," said Melanie Estes of Mendon, as she waited in the Tri-County Medical Clinic for a routine pregnancy check-up. "Now I live an hour and a half away, and I still come here."

"People drive from all around this area to come to him," said Winkler, who drove 30 minutes to reach Sturgeon. "If Dr. Weaver refers us, we go elsewhere, but he's our first stop."

Several times over the last 10 years, Weaver has had to stop taking new patients because of his current patient list demand.

"Then somebody always talks us into taking a few more," he said as he prepared to see Newland for the first time.

However, Weaver doesn't mind being so busy if it means fulfilling a current need in rural area health care shortages.

"I don't consider my job work, I consider it a mission," he said. "People need help. There are still a lot of patients out there that need doctors."


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