Hello everybody welcome to The County Seat
today I'm your host Chad Booth. Johnny breaks
a finger and you have to make a decision? Do
we go to the doctor or not? Seem obvious
doesn't it, but when you live in rural Utah and
you are a 2-hour drive away from any medical
treatment you think differently. That is the
subject today the shortage of medical care in
rural Utah and we will start with the Basics.
My dad was a country doctor, who moved from
a small Illinois town where he grew up, to an
even smaller one to practice medicine. It was
hard work, but he loved it, and so did all of my
brothers and sisters.
Growing up in a town of 800 people on a farm,
we had horses, jeeps, motorcycles, room to run,
fish to catch and trees to climb. There was so
much to do, we didn't have time to get in
trouble. It paid off because 5 of my 6 brothers
became rural doctors and surgeons themselves,
and most of my sisters have made careers in
rural medicine as well.
So why is it so hard to get and keep rural
doctors today?
Well here
are five things to consider: In The Basics.
1.The very culture of rural communities
tends to play down the advantages of rural
life and instead focuses on the challenges.
I'm sure you've heard it, I did ..."You don't
want to stay here, there is no future, go off
to the city and find your fortune" and so
kids do. Because we don't talk about the
positive things that make us want to live
rurally, our children place little value on the
good things of rural life,
In fact, rural communities often have
better luck recruiting people from the city
who want to escape the urban pressure
they felt growing up.
2.Number 2 is also cultural, but it is the one
students discover in medical schools. Most
all schools tend to celebrate and elevate
the specialty practice, it is like joining the
ranks of the elite. Few medical school
graduates find any prestige in "family
medicine" and often they are lured or
forced toward the higher earnings, not
realizing that there are costs that go with it.
3.Another obstacle to the hometown hero
returning to set up a rural practice is the
spouse factor. A student from Panguitch
gets into a mentoring program at SUU,
learns how to be a good medical student,
crosses the hurdle into med school and
comes out ready to practice. But in the 8
years of living in the city they likely have
gotten married and grown accustomed to
the perks of city life, while not having a
clear idea of the blessings found in rural
living. Nothing like an unhappy spouse to
put the kybosh on plans for a rural practice.
Which is exactly what happened to my one
brother, who now practices in the big city.
4.Another factor graduates face when
seeking the practice of rural medicine is
simply how to practice it. Doctoring in a
small town is very different than in the big
city, and they don't teach that at med
school.
5.But the single biggest obstacle to retaining
a rural doctor in Utah's remote
communities is the debt! Currently,
doctors entering a family practice for the
first time, are carrying an average of
$300,000 of educational debt, limiting
where a person can choose to practice
medicine
When my dad graduated, his entire
education cost $50,000, and the GI bill paid
all of it.
This one fact alone explains why urban areas
have about 90 doctors for every 100,000
patients, but in rural America it barely tops 65.
And specifically, there are communities right
here in Utah where if you need to see a doctor,
you have a 2 hour drive in front of you, not just
a two hour wait. That means that a lot of sick
people, don't get proper medical attention.
To help staff rural clinics there are state and
federal programs which will agree to pay a
significant part of a student's loan balance in
exchange for a commitment to practice for at
least two years in a rural setting. Generally it
amounts to about 20% of their student loans. It
does not however help the practitioner
understand the nuances of a rural practice
That is why there is an effort to also create
mentoring programs to expose medical
students early on to the unique nature of rural
medicine.
None of these programs will solve the shortage
of rural practitioners overnight, but that is
where our discussion will begin today, when
Chad comes back. For the County Seat, I'm Ria
Rossi Booth
Welcome back to The County Seat we are
talking today about the challenges today of
rural medicine shortage of doctors and what we
can do about it. The discussion today is about
what we can do about it and what we are doing
about it. Joining us for our conversation are
people who certainly know if the programs are
working we have Rebecca Powell who is a
senior medical student at the Univ of Utah
School of Medicine and we also have the Dean
of the School of Medicine Dr. Wayne
Samuelson. Doctor and Doctor do you like that
are in place right now to try and steer students
rurally to a medical practice and then back to
the rural community and I guess you have been
involved in 3 of them.
Yes, in my college years I went to Southern Utah
University I am originally from Utah a little town
called Ivan's outside of St. George for those
who are familiar with Washington County and I
went to SUU and there they have a program
called the rural health scholars program this
program is a framework for undergraduate
students who want to pursue graduate health
related education whether it be dental,
optometry nursing and in my case medical
school to become a physician and so that is
what I joined and being at Southern Utah
University which is a regional school in southern
Utah a lot of my volunteer experience was in
communities even smaller than where I grew up
example of an opportunity I had through rural
health scholars during college. My goal and
number one choice was to come to University
of Utah medical school for my medical degree I
was accepted and I achieved it and a few
months from graduating I graduate in May
after 4 years at the school and one of my goals
once I was there was to make sure I could
maximize my time in rural settings to maximize
my learning and maximize what I want to do
which is eventually a rural practice for myself
and so one of those ways I did that is during my
third year of med school which we call our
clinical they take us from the classroom and
start rotating us to the different departments of
the hospital during my family medicine rotation
I actually requested to go to Blanding Utah and
This is a program that U Med is involved in is
getting students specifically into rural settings
in the rotations as part of their practicum so to
speak.
Yes, that is correct. The family medicine
rotation is it mostly takes place now and one of
the things we are working on now we are trying
to broaden that experience to more
communities in other primary care specialties.
Some not just family medicine but also internal
medicine, pediatrics wherever we can find spots
for them to have that experience in
underserved or rural community.
working to solve that rift of people going to
medical school and ending up practicing in a
rural community?
We think it's a start but only a start and one of
the good things about the rural healthy scholars
program at SUU is that it recognizes that there
is more than just physician care that is
important to rural and underserved areas and
so that experience prepares students for a wide
variety of positions and healthcare not just to
be physicians but also to practice another
ancillary areas and some people start in that
program and think they want to become a
physician and decide they want to be
something else which is also very valuable. But
of Utah where we can make some end roads
and so we are actively seeking now to bring
physicians or with hospital administrators or
people from other parts of the state in
participation on our admissions committee to
help us identify students in different parts of
the state who really belong in medical school
and have them participate in the decision.
How young can you start figuring that out? Do
you start that at High School level do you start
at college level? When did you figure it out?
that I belonged to as a medical student at the
Univ. of Utah is called URAP, that stands for
Utah rural outreach program and what that
organization does it that it organizes medical
students generally 1st and 2nd years who have
the time in between their courses to go during
their winter and spring breaks and they actually
travel to rural high schools in Utah and they talk
not just medical school but just any sort of
medical training beyond high school talking to
these kids who maybe have never considered
that I'm going to be the first student in my
family to graduate high school never even
considered college but if I want to be a
physician or a nurse I'm going to have to go to
college and here are some kids UROP takes any
programs where they tutor and they call them
these pipeline programs they tutor in the
underserved and under developed schools in
the Salt Lake areas and beyond the idea being
that you really can't compete to go to medical
school unless you can do well in college. You
cannot perform well in college unless you have
some basic skills that get your through high
school. A lot of young people don't dare to
dream that they can do this and we are trying
Historically do you think there has been or is
there any anecdotal evidence of this actually
working where if you are pooling people from
Ivans and pulling them into a program that they
are more likely to actually return to a rural
practice even after the lure of the spouse affect
and all the glitter and glamour of specialty
practice and all that there appear to be a couple
influences on the eventual choices for
physicians where they want to live and work. A
big drive is where you actually did your
residency program and so residency is what you
do after medical school that is called training
and that is what gets you your license we get
the degree here but they all have to go on and
train to some specialty usually for a period of 3-
5-7 years that is a big draw where you finish
that up because you have been working with
physicians and that community and that area
and they tend to like you and offer you
positions. The other big draw is if you had a
conversation and you both are more than
welcome to answer is that this is all well and
good but how many residencies can you do at
Panguitch hospital.
Yes, that is exactly the point, you cannot. Utah
has a shortage of residencies and as we bring
more and more people into medical school we
are pretty much guaranteeing that they are all
going to leave and not come back unless we
give them a reason to come back. We are not
going to be able to get the number of
residencies in Utah and certainly not one in
Panguitch just for population reasons that will
leave those graduates wanting to stay there so
we have to create other reasons for them to
come back to Utah and that is what we are
trying to do.
The way we do that is during my four years of
medical school education there are certain
rotations that are set I will rotate through
surgery I will rotate through family medicine
and pediatrics so then I can decide can I see
myself as Pediatrician, can I see myself as a
Surgeon. But there is another question, can you
see yourself as a rural physician and if you have
never had any experiences as a rural physician
having preceptors or making those connections
or actually being there on the ground boots on
the ground learning from those practitioners
how can you comfortably say this is something
or someplace I want to go.
That is really it. One of the attractions of
practicing medicine in an urban center you have
ancillary help you your pharmacists your
dietician your physical therapist your
occupational therapist people just down the
hall that is not always the case and so another
big part of our initiative is creating the same
sort of training opportunities or learning
opportunities in the other health professions so
reimbursement program that I believe is state,
federal and the hospitals chip in that will pay
like $60,000 for a 2 year contract to go back and
spend 2 years filling that gap rurally, so if you go
and you fill that gap how much culture shock is
there at the end without some of these other
trainings to get them to think about to stay.
more than just forcing people back with the
incentive of getting your debts paid because
they just started the clock what we are hoping
to do is create relationships, good feelings and
hopefully bring the other health care
professions along with us so someone can go
practice in a rural community or an
underserved community feel like they are
practicing state of art medicine with colleagues
who will help them do that delivering care to a
community that is very appreciative and the
impact of that is that is a great place to live and
I want my family to come here I want to stay
there that is what we are hoping for we have
seen it work in other states.
Do the communities need to pay more
attention to the kids that are coming though on
their rotations?
They really try one of the problems is that we at
the medical school have not facilitated that and
we are trying to change that right now working
more with the communities and like I say
getting the right students into the medical
school that is why we are actively soliciting
people from the communities that we are trying
to put students to participate with the medical
admissions committee and DR. Chan has been
very inviting and worked very hard to get those
kind of people in and it makes things difficult
because you have to do things over Skype or
teleconference but he has done that I think the
committee the admissions process and the
school are all benefiting from that.
I would imagine if you were in Fillmore and
somebody brought you cookies while on a
rotation you might be tempted to say this is not
a bad gig.
Anecdotally I worked very hard when I was
down in Blanding in my family medicine
rotation not only because I wanted to learn but
because I wanted to prove myself on that
rotation because it was something I was looking
at doing and they said as I left we love you and
if some day you want to return to our
community we would love to have you and in
whatever capacity it is because at that time I
had not decided on my program. Along those
lines most people their favorite genre of music
is whatever they had when they were teenagers
during those formative years growing up and
learning who you are I feel like during my
formative years during my medical training
which is when I was in medical school and prior
to that in college I definitely was influenced by
those people who had a passion for rural
medicine and that was instilled in me and I'm
going to continue that forward and be very
happy with that.
My own anecdote as a subspecialist
moonlighting in the ER one weekend a month in
a very small rural community at the end of that
time when I finished my fellowship and
accepted a faculty position at Duke Univ my
dream of dreams the people in that community
gave me a going way party and they said if you
ever change your mind about being a specialists
you want to come back here and be our
internists we would love to have you. That was
a very tough decision to make.
movie the Color Purple it was filmed in that
town and did not change anything for the movie
it was really a small and underserved
community they really struggled in a lot ways
but beautiful wonderful people. Even touched
the heart of a hard core subspecialists myself.
Thank you both so much for being part of this
conversation when we come back we will take a
look at a doctor that is starting a program that
is called Direct Care that actually fits a model of
filling in the gaps in some of these small rural
communities. We will be right back with The
County Seat.
Welcome back to The County Seat as we are
looking at the problem of rural health care we
will have to look outside the box because we
haven't found any answers inside the box. We
recently had an opportunity to interview and
Doctor in Kansas City who practices his entire
practice of medicine outside the box and its
working for him and he believes it will work for
rural medicine as well.
Doug Nunamaker:
if it takes 11 years to train someone and two
years to make quit. You can't keep up with that.
There's no system that can keep up with that
kind of mass exodus the previous mentality of
physicians was medicine was everything. And
you know nothing else superseded that.
Josh Umbehr:
we like to say in a lot of ways we haven't
changed anything. The practice of family
medicine is the same but in other ways. We've
changed everything by changing the business
model where an insurance free practice that
charges a monthly membership for full access to
care. But by doing that we remove 90% of the
headache. The hassle the inefficiency so that
the patient's now can get quality, affordable care
the doctors can focus on the patient's and
provide procedures and medicines and lab tests.
The discount it truly makes medicine, affordable
and accessible again.
What we gain in efficiency. We also gain in profit
by being able to cut 90% of our overhead we
can charge the patient's a fair amount and still
retain more of that are doctors on average make
30% more than the local family physicians in this
area, so it's actually more profitable for a doctor
to be in this model, providing very affordable
very accessible care and I think that's what
business does well competing things that don't
make sense but we get a better, faster, cheaper
product and higher-quality through good
business in all sorts of areas of our lives.
Doug Nunamaker:
I can't imagine going back to seeing more
patients a day then you're able it's akin to
making a mechanic fix 10 too many cars per day
somebody's going to get in a wreck. That's what
it is and in medicine, you can only truly take care
of so many people today. And if you do more
than that, then some of those people aren't
getting the care.
Josh Umbehr:
if it's bad for the patient's it's bad for the doctors
and that is what is driving doctors away from
rural medicine. They feel like they need to be
part of a giant system to play this giant
paperwork game this model streamlines that
whole process. I think that we've tried to do
higher and higher volumes and we've got less
and less value in return. The standard Dr. will
have 3000 patients and see 30 or 40 a day and
in our model the doctors are limited to about 600
patients and see five or six a day. So that we
can do same-day appointments. Almost all the
time and we can do hour-long appointments if
need be but we can also be available for phone
text e-mail to make health care accessible
without the patient needing to come to the office
we have more time to focus on the patient. So
I'd like to think we make fewer mistakes we have
less paperwork less distraction depending on
the study. You can look a doctor spending
between 22 and 65% of their day on the
computer doing paperwork or electronic filing.
That's just a whole chunk of time the doctor isn't
focused on the patient.
Doug Nunamaker:
I certainly enjoy this allot better than what the
alternative is. We even have people in
residencies or graduating medical students and
they spend time with us and they say do I really
have to do three years of an insurance type
practice you know, learning that?
Josh Umbehr:
the rural doctor has patient's who need care. I
grew up in a town of 900 and myself. One doctor
can manage that whole town very well in a direct
care model just with a simple redesign the same
medicine the same labs the same doctors
different payment model to make these things fit.
Gives you a lot to think about doesn't it? Let's
take stock of the things we have covered. We
have identified the basics at the beginning of
the show about what the shortages were
caused by in medicine. We have looked at the
things the schools and government have done
to improve it as far as the subsides and
programs and we looked at one Doctor who has
thought outside the box and come up with a
different way to approach medicine that might
work in rural Utah. Sounds promising but there
are still things that we may want to consider,
and we will get to that in my 2 cents worth in
just a minute.
Welcome back to The County Seat we have
looked at the issues of shortage of medical care
in rural Utah today here is my 2 cents worth on
that subject. The sad truth is that we have
allowed medical culture to cost too much to
work in a dispersed population base. It costs
too much to get an education you have to do
too much to avoid being sued. Our culture
makes you need too much because success is
measured by how much you make not by how
well you serve. And finally, we as consumers
expect too much of the insurance medical
complex and no longer ask how much we are
being charged for a drug or a service, yet we are
still paying for it with our premiums and our
taxes. I once asked my doctor how much it
would costs to get a procedure done that he
was recommending he could not answer the
question. By removing that direct link between
doctor and patient as to the costs of treatment
it becomes far too easy for prices to sky rocket
because the person paying premiums as well as
the doctor prescribing are disconnected from
knowing the cost of treatment. We have to
move back to a place where patient and doctor
are aware of and talking about how much care
costs. I believe that awareness along with the
things that we talked about today will start to
bring things back in line again and provide the
long-term fix to access to care. Thanks for
watching today you can see the extended
discussion with our guests on our YouTube
channel along with a full interview with Dr.
Umber we invite you to follow our social media
for midweek updates and we will see you next
week on The County Seat.
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