doctors

BEATTYVILLE, Ky. Carl Wade knew he needed regular checkups for his diabetes or he could go blind, lose a leg or even die.

But as one of some 8,000 residents in a county with just three doctors, Wade also knew he would have to make appointments weeks in advance and then wait in the office for hours to be seen.

"I never did go to doctors until I got in the shape I'm in right now," said Wade, who travels 75 miles to Lexington almost weekly to see a doctor. "Part of it is we just don't have enough doctors in these mountains."

Last year, he lost his left leg below the knee and now suffers from partial blindness as a result of the disease.

Lee County's doctor shortage is fairly typical in rural Kentucky, where most counties face a critical shortage of primary care physicians, according to a recent study by the University of Kentucky Center for Rural Health.

The lack of doctors translates to a lack of health care and unhealthy lifestyles, experts say.

"If you have trouble getting in to see a doctor, before long you find more women coming in to deliver who haven't had the prenatal care they should, you start seeing the percentage of kids with all their shots declining, and you set yourself up for epidemics," said Wayne Myers, president of the National Rural Health Association.

About two-thirds of Kentucky's 120 counties, most of them rural, are designated as health professional shortage areas for primary care by the U.S. Health Resources and Services Administration, the study said. This designation is based on primary care doctor-to-patient ratios of one doctor for every 3,000 to 3,500 residents. And many of the doctors are close to retirement age.

According to the Kentucky Medical Association, of the 1,273 physicians who left Kentucky between January 2000 and December 2002, 31percent went to neighboring states, including Indiana, Ohio and Tennessee, which have cheaper medical malpractice insurance rates, the UK study said. The American Medical Association lists Kentucky as one of 19 "crisis" states regarding increases in malpractice insurance.

Typically in urban areas there is one doctor for every 900 people, said Dr. John Strosnider, the dean of Pikeville College's School of Osteopathic Medicine.

"When you don't have many primary care physicians to begin with, the ones who do go to rural areas get burned out or retire, and there's no one to replace them," Strosnider said. "Primary care doctors are the gatekeepers who help people decide how to lead healthy lifestyles."

The doctors say the shortage also forces them to labor under difficult, frustrating conditions. For Dr. James Hurm, being one of only four doctors for Lee County means working 15-hour days and still feeling as if he is failing to keep up.

In addition to the doctor shortage, Kentucky consistently ranks at the top of lists for health risks.

A recent UK study showed that Kentucky leads the nation in the percentage of people who smoke and lead sedentary lifestyles and ranked in the top 10 states for obesity.

An urgent need to recruit doctors

Rural Ballard County in far Western Kentucky has just one general practitioner to treat its 8,000 residents.

To meet the standards for primary care and family practice medical personnel recommended by the U.S. Council on Graduate Medical Education, Kentucky needs approximately 600 additional family medicine practitioners, according to the UK study.

About 400 of Kentucky's family physicians are 60 or older, the study said, emphasizing the urgency of the problem.

According to the UK study, the reasons for the shortage of doctors in rural Kentucky include that medical schools have failed to select and prepare students for such service, rural communities have been unable to effectively recruit physicians, and doctors have been unable to adapt to non-urban practice and life.

Some improvement has been made in these areas, however, the study said.

Finding solutions to doctor crisis

In July, the first graduates at the Pikeville School of Osteopathic Medicine are set to finish their residencies, and many plan to stay in underserved Eastern Kentucky to start general practices, Strosnider said. If you want physicians who do primary care, you have to mentor them," Strosnider said. "If you want people to go to a rural area, you have to
pick them from that area."

Hurm, whose missionary zeal brought him to Lee County eight years ago, said he recognizes he made a rare choice. "I love it here, but most people tend to practice in cities near where they went to medical school," Hurm said.

The lure for some of international doctors who have completed residencies at prestigious American medical schools is that they can earn a green card by agreeing to practice in underserved areas.

The difference in availability of medical care between urban and rural Kentucky is startling, but not entirely surprising, considering that few rural Kentucky counties have major hospitals, Myers said.

Perry County, an Eastern Kentucky county that does have a regional medical center, has one doctor per 334 people, a ratio that rivals urban areas. But the lack of doctors in most rural Kentucky counties has contributed to a culture in which people seek medical care only in emergencies, Myers said.

In Eastern Kentucky, where the terrain is rugged, travel times between county seats are often longer and poverty is persistent, the situation is more problematic

For Michael Fox, 27, a Beattyville resident, the emergency room is his doctor's office. "I wait until the last minute before I go to the doctor," Fox said. "I wait it out until something happens."

As for his children, Fox said he is not sure whether his 5-year-old son is up to date on his shots.

Carl Wade and his wife, Shirley, who is also diabetic, can no longer wait for doctors to come to Lee County, and they find themselves on the road to Lexington at least once a week.

He supports himself and his wife on $840 a month in disability payments, but he said his weekly trips to Lexington cost him more than $100 a month in gas and food.

With the help of a primary care doctor, complications from diabetes such as foot ulcers can be detected early, decreasing the potential for serious consequences including amputation, Myers said.

"It's the diabetic with high blood pressure who is overweight that most needs to be able to pick up the phone and talk to a doctor when something's worrying them," Myers said.