Rural Studies

Tanika Taylor, M.D., never intended to practice medicine in rural Kentucky.

In fact, the Louisville native entered the University of Louisville School of Medicine in 2000 with the full intention of ultimately joining an OB/GYN practice in her hometown, surrounded by the comforts and convenience of Kentucky's largest city.

But in her second year of medical school, Taylor heard about a rural medicine program that allowed UofL's Louisville-based students to complete their third and fourth years of training at the school's Madisonville, Ky., regional medical campus.

Taylor was intrigued by the prospect of practicing medicine in a rural setting, so she attended a presentation to learn more -- and hasn't looked back. The presentation and a subsequent tour of the regional campus had such an impact on her that she moved to Madisonville full time to finish her undergraduate medical studies. Now an OB/GYN resident at Cincinnati's Good Samaritan Hospital, she plans a return to Madisonville to join the faculty at UofL's western medical school branch in 2008.

"I never thought I wanted to practice in a rural setting, but after my experiences in Madisonville, I fell in love with community medicine and the pace of small-town life," Taylor says.

"The people were wonderful and really appreciated what we were trying to do for them as medical providers. They also were willing to participate in our education and seemed genuinely glad that we were there. I haven't gotten that feeling from patients in big towns very often."

It also didn't hurt that the Madisonville campus offers excellent clinical training, Taylor says.

"Students have a one-on-one relationship with their faculty and attendings, so they have an incredible opportunity to participate in all aspects of patient care. You don't just watch procedures being performed -- you get to do them yourself.

"I think I came out of my experience in Madisonville with the experience of an intern who's been on the job for six months or a year. My surgical skills were far ahead of graduates from other programs because I got to do so much there."

An academic partnership

Operated in partnership with the Hopkins County-based Trover Health System and officially known as the University of Louisville School of Medicine Trover Campus, the Madisonville operation grew from modest beginnings starting in 1994. That's when Gov. Brereton Jones issued a proclamation creating of an off-campus teaching center jointly operated by UofL and Trover.

Summer classes were offered initially, but in 1998 each partner contributed $220,000 to hire an associate dean and kick-start the programs necessary to offer full-time clinical instruction for third- and fourth-year medical students. The program has been funded by the state with coal severance taxes ever since, says Robert W. Brooks, vice president of Trover's Education and Research Foundation.

One of the campus' primary missions is to recruit more physicians like Taylor to practice in rural parts of the state, according to associate dean William J. Crump, M.D., UofL's top administrator in Madisonville (population: 19,273).

Nearly 61 percent of the state's 120 counties have too few primary-care doctors to adequately treat their patient populations, Crump says, and the figures are expected to get worse as aging baby boomers require more care from an overburdened rural health-care network.

To address this need, UofL established the Trover Campus and programs like a rural medicine rotation to expose students to alternate career possibilities.

"The published literature clearly shows that doctors tend to set up practice in towns like those in which they train," Crump notes. "In UofL's case, this meant that the majority of the school's graduates were staying in urban areas, so we needed to find a way to get some of the students into a rural setting on a regional campus."

But the Tanika Taylors of the world -- students who grow up in the city and decide to practice in the country -- are only a small part of the potential solution, Crump says.

"If you really want to fix the problem, you have to admit more students from small towns and you have to train those students in small towns," Crump says. "Those students are much more likely to choose small-town practice -- if you can get them away from the urban disruption of the big city during their last two years of medical school."

In other words, UofL's Trover Campus needs recruits like Sara Huss, a third-year medical student from small-town Maysville, Ky., who moved from Louisville to Madisonville in 2006 to complete her M.D.

Huss says she'd always planned to return to a smaller town to practice medicine after graduation and residency, but that would place her in the minority of students. And two more years in Louisville might have changed her mind.

Either way, she is grateful for the opportunity to study in Madisonville and learn medicine in the more intimate setting offered by Trover.

"I'm from a small town, and Louisville always felt a little too big for me," Huss says. "I just feel more comfortable down here."

Like Taylor, Huss appreciates the one-on-one relationships she has with faculty and the opportunity to get hands-on experience with even the most difficult cases.

"My first rotation here was obstetrics, and I got to serve as a first-assistant surgeon on several C-sections almost immediately. I even delivered a baby within a few weeks of starting the program. That was pretty cool for a third-year medical student who had very little hospital experience."

Other students agree that Trover offers superb educational opportunities -- even those who have no intention of practicing rural medicine but who nonetheless queue up each year for a limited number of eight-week surgical rotations offered in Madisonville for Louisville-based students.

These rotations actually predate UofL's Trover campus by more than 20 years, having been created in 1973 by UofL's then-surgery department chair, Hiram C. Polk, M.D., to take advantage of the excellent learning environment at Trover.

"The typical teaching team at a university medical center -- and I'm a product of it -- consists of four or five medical students, a couple of residents, a fellow and a faculty member," Crump explains. "As a third-year surgery student, you're usually in the back of the room trying to determine if something is an appendix or not.

"Here at Trover, the teaching team consists of a faculty member and a student. That's it. So the student is scrubbed in on every case, and they get to do procedures -- not just watch procedures."

Many, many procedures.

Patient-care logs show that Madisonville students see two to four times as many patients as their counterparts in Louisville and perform up to 10 times as many procedures.

Zach Hoy, a Louisville-based third-year student, recently completed what he described as an "intense" surgical rotation at Trover.

"In Madisonville, you get to be part of surgery every day," Hoy says. "We helped suture wounds, put in catheters, intubate for general anesthesia, change wound dressings, evaluate trauma patients and drive scopes for colonoscopies. It was difficult at first to adjust to the fast pace, but it was a great experience."

Building a system

It would be difficult for UofL to have picked a better partner with which to build a regional medical campus than the Trover Health System.

The system traces its roots 1957, when two UofL medical school graduates, Loman C. Trover, M.D., and Faull Trover, M.D., decided to set up practice in Western Kentucky. It wasn't long before the two physicians realized that patient demand was unexpectedly strong -- so strong they couldn't come close to meeting it without help. So the Trovers considered two options: close their office and move back to Louisville, where they could build their own individual specialty practices without being inundated by patients; or they could begin developing a multi-specialty group practice in the rural setting they loved.

After touring the Ochsner Clinic, a well-known multi-disciplinary facility in New Orleans, the Trovers decided to attempt the latter. Curiously, their decision was met with resistance by some members of the established medical community, who viewed multi-specialty clinics as "the corporate practice of medicine," Brooks says.

"Their approach, although common today, was cutting-edge at that time because most doctors outside the big cities were just rural physicians, general practitioners or surgeons," he says. "They referred all of their patients who needed specialty care to tertiary centers in the larger cities like Nashville or Louisville.

"So setting up a multi-specialty practice in a small town -- at that time, Madisonville's population was probably about 8,000 people -- was really unheard of."

The Trovers knew their task would be challenging -- officials at the Ochsner Clinic had said as much. But those officials also gave the Trovers some good advice, Brooks says.

"They told the Trovers that it would be difficult to recruit many medical professionals to a rural setting like Madisonville, and that we would need to add an educational component so we could grow our own staff."

And for 54 years, that's exactly what the Trover Health System has done, beginning in 1953 with the establishment of a five-physician, multi-specialty Trover Clinic and, in 1957, the creation of an educational development unit, The Trover Foundation.

By slowly adding programs through the years, the Trover System has grown to an $88 million health-care powerhouse, offering care in 42 specialties at eight area clinics that saw nearly 350,000 patient visits in 2006.

The system, which draws patients from 101 Kentucky counties, also includes a Center for Women's Health, the Merle M. Mahr Cancer Center and Trover's Regional Medical Center, a 415-bed hospital with state-of-the-art facilities for such advanced care as open-heart surgery. More than 7,000 surgeries were performed there last year, Brooks says, and 11,186 patients were admitted.

Supporting these operations are more than 1,000 licensed health professionals, including 66 board-certified physicians and 500 registered nurses. Clinical equipment includes the kinds of gear typically only found in much larger cites, like linear accelerators for use in radiation oncology and diagnostic tools such as PET and MRI scanners.

"I think we are unique in the state of Kentucky because we are technologically second to nobody, we have an excellent staff in place, and we do all that in a rural setting," says Berton Whitaker, president and CEO of Trover Health Systems.

"That means our patients don't have to drive to Louisville or Nashville to receive the highest standard of care."

Trover's educational efforts are equally impressive, with initiatives in 12 areas, including community and continuing education, a Center for Rural Health operated jointly with the University of Kentucky College of Medicine, and training programs to produce badly needed nurses and medical technologists in partnership with Madisonville Community College.

Trover also started the state's first Family Medicine Residency Program in 1971, producing 120 graduates that have set up rural practices in more than 30 Kentucky counties from the Appalachian Mountains to the Mississippi River basin.

"We've populated the state from east to west with that program," Brooks says of the effort, which now is run cooperatively with UofL.

Rich educational environment

It was in this rich educational environment that UofL came to establish the University of Louisville School of Medicine Trover Campus in 1998, drawing on the skills of Trover staff to provide adjunct faculty for students seeking clinical experience in a rural setting.

Two kinds of students train at Trover: Louisville-based trainees who simply want to complete a handful of four-week or eight-week clinical electives in Madisonville before returning to the big city; and students who decide they want to complete their entire third and fourth years of education at Trover.

Students who elect to move to Madisonville for two years continue to attend lectures as though they were in Louisville, thanks to a live, interactive TV link between classrooms at Trover and lecture halls on the main campus.

The rest of their training, however, is firmly grounded in the clinical care offered at Trover's state-of-the-art facilities.

These include a student-staffed free clinic that cares for economically disadvantaged patients under the watchful eyes of faculty preceptors.

"We always have a licensed practitioner present, but the students pretty much run the show with advice from faculty," Crump says.

Students also are exposed to a full gamut of rotations at Trover, including OB/GYN, gastroenterology, endocrinology and specialty surgery.

To date, the campus has produced 41 graduates, starting with three in 2000 and growing to eight last year. About 78 percent of those graduates are practicing in a rural area somewhere in the region, Crump says, and most have remained in Kentucky.

Wherever they go, they are highly prized for their skills as clinicians.

UofL surveys the directors of residency programs at hospitals where its graduates continue to train after earning M.D.s, and the feedback is uniformly excellent, Crump says.

"Those residency directors are calling and saying, 'Have you got any more?' Because our students have so much experience, they're already the equivalent of house officers when they graduate from here. And so by the time they get to their internship, they already know how to write notes, take care of difficult families and do procedures with minimal supervision."

Clearly, the health-care system has a need for more graduates from the Trover campus, Crump says, and UofL would like to recruit more than eight students per year (the program is designed to handle 12 and up).

But the school remains limited by the relatively low numbers of rural students who elect to pursue medical degrees anywhere, much less at a regional campus like Trover.

And that brings up the second primary mission of the UofL-Trover partnership: getting more small-town high school students into medical school in the first place.

"Studies have shown that most rural kids who could go to medical school simply don't apply," Crump says. "Part of the reason is that small-town high schools across the country just don't do a good enough job of preparing kids to be medical students. So they get into pre-med classes in college, and the science courses eat them alive."

To address that issue, Trover and UofL have partnered to create the Pathways Program, a series of initiatives to interest rural youth in medical careers and then give them the tools they need to succeed. These include:

• The High School Rural Scholars Program, which coordinates health-care shadowing opportunities for rural youth in their home towns during the summer between their junior and senior years of high school. Students work 30 hours each week during the four-week program and receive a $650 stipend to cover expenses. The idea is to interest students in small-town medicine before they attend college in a larger city and experience "urban disruption" -- the process through which students become accustomed to big-city amenities and form personal relationships that keep them in urban areas to practice after graduation.
• The Trover Rural Scholars Program, which provides college students from 23 rural western Kentucky counties with academic enrichment, shadowing opportunities and a series of activities that lead to a certificate in rural health studies. The students participate in the program, held in Madisonville, for four weeks each summer during the last three years of their undergraduate educations. The goal is to provide additional training in the basic sciences, facilitate academic success and provide tangible evidence to medical school admissions committees that the students have invested time to understand the practical details of rural medicine.
• The Trover Rural Health Interim Session, which is targeted at college upper-classmen and provides one week of rural health overviews, case studies and shadowing opportunities in Madisonville.
• The Trover Prematriculation Program, which offers four weeks of classes to college graduates from rural Kentucky prior to the start of the first year of medical school. It gives students a variety of opportunities to explore multiple facets of community medicine and rural health care.

The success of the various Pathways programs can be found in their many graduates who are pursuing medical careers across the region right now, Crump says. One of those, Chris Sperry, has successfully navigated the arduous first two years of medical school in Louisville and will be entering his third-year as a student on the Trover Campus this fall.

"The Pathways program has expanded my awareness of the many different aspects of practicing medicine in a rural setting," notes Sperry, who's from Providence, Ky.

Students like Sperry, Huss and Taylor prove the efficacy of the UofL Trover Campus program, Crump says, and they're helping make a tremendous impact on health care in rural areas across the state.

"I feel really good about what we're doing here at the University of Louisville Trover Campus," he says. "Nobody offers a better educational experience than we do, and our numbers show that we're making a real impact on placing more physicians in small towns all over Kentucky."