Meet a country doctor —one of a dying breed?
By Nancy Jorgensen

Challenge of rural health care is multifaceted.

In 2006, the National Rural Health Association named Missouri’s Dr. Robert David Hill as Rural Doctor of the Year.

Hill appreciates the honor, but earning it didn’t come easy. In the early years of his 27-year career, he struggled to make ends meet.

“The system works against getting anyone to practice in a rural area,” he said bluntly. “There’s no money in it.”

Rural areas often find it difficult to recruit doctors and other medical professionals, even though rural needs are greater.

According to the National Rural Health Association (NRHA), only about 10 percent of physicians practice in rural America despite the fact that nearly one-fourth of the population lives there. More Medicare and Medicaid patients live in rural communities, and doctors are usually paid less for serving these patients than for insured customers. Rural people earn less and carry less health insurance than urban residents. And rural patients tend to experience higher rates of obesity, accidents and other medical problems.

In its report for 2005-2006, the Missouri Office of Rural Health talks about Missouri’s special needs. “The office estimates that 31 percent of Missourians currently lack adequate access to health care. Although 40 percent of Missouri’s population lives in rural areas of the state, only 25 percent of the primary care physicians are located in rural areas.”

Hill becomes a country doctor
Research shows that medical professionals who grew up in rural areas are most likely to go back. Hill is no exception. He was raised in a small town in eastern Oklahoma. When he graduated from medical school at Oklahoma State in 1979, he and his wife, Megan, looked for a small town where he could practice family medicine. “I wanted to put down some roots,” Hill said.

Hill had taken part in the National Health Service (NHS), a federal program that offers tuition reimbursement in return for two years of work in an NHS hospital or in a Primary Health Care Professional Shortage Area. Most counties in Missouri qualify based in part on their ratio of population compared to the number of healthcare providers.
The Hills found a home in Southwest City, Mo., whose 500 residents needed a doctor. As its name implies, the town rests in the southwest corner of the state, in McDonald County. It’s one of Missouri’s lowest-income counties, home to just 21,000 residents.

But McDonald County has its appeal. It lies at the edge of the Ozarks, and Hill and his wife liked its clear-water lakes, rolling hills, limestone bluffs and trees. Before deciding to become a physician, Hill earned his master’s degree in sociology, and his studies and his background drew him to a rural place.

Vicki Plumlee, director of clinics for Hill’s business, called Elk River Health Services, Inc., nominated Hill for the NRHA honor. “The entire town met Dr. Hill and his wife at a community potluck supper and simply won them over,” she said. “The town had cake walks, donkey ball games and rummage sales to raise money for used office and clinical equipment.” Hill could have provided care anywhere, she added. “But he fell in love with a little town that had a need.”

Hill helped community leaders fill out the paperwork to qualify for the NHS program. Once his 2-year commitment to NHS was complete, he bought the local clinic. “We began to feel economic stress,” he said. “Costs were up, but patient revenues were not.”

In earlier years, Hill and his wife, who administered the clinic, worked together to make the practice pay. She took no salary, and he earned extra pay by driving to work in emergency rooms located 20 or more miles away, since McDonald County doesn’t have a hospital. He moonlighted at nursing homes and handicapped facilities. He became a Sexual Abuse Forensic Examiner and medical director of the local ambulance service and the county health department.

Hill provides an example of how rural doctors earn less than their city cousins. Medicare pays doctors in rural nursing homes just $15 per visit, compared to $55 for the same work in a city. The clinic applied to become a federally designated Rural Health Clinic, qualifying Hill to earn more from Medicare and Medicaid. “In private practice, they pay you less than the cost of care,” Hill said.

“Without this program, we would have had to leave.”

One by one, Hill added three more clinics in nearby communities, staffing them with nurse practitioners as required for Rural Health Clinics. Nurse practitioners, who work under a physician’s direction, get paid less than doctors. They also allow Hill to extend care to more patients. “I didn’t know how it would work at first, but it works well for us,” he said.

Hill and his wife weren’t sure if adding a second clinic would make money. “It was a matter of economic survival—we needed to improve our income by treating more people, but we also increased our expense,” Hill said.

In retrospect, adding clinics proved to be brilliant. The county lies just north of Bentonville, Ark., Wal-Mart’s headquarters. As Wal-Mart boomed, the county’s population increased, bringing in more patients. Today, Hill employs 26 people.
“We’re all working as hard as we can,” he said. While competing doctors have arrived, the county remains rural and underserved.

Recruiting a new doctor
Rural communities face challenges in recruiting healthcare workers of all types, not just doctors.
“It’s a big problem,” Hill said. “We’ve been fortunate. The people we’ve recruited have stayed with us and we’ve got a loyal patient base.”

Hill calls on his sociology background to speculate on why healthcare professionals don’t always want to move to rural places. “If you’re married, you’ve got to make your spouse happy,” he said. “There’s a tremendous urban bias that rural schools are inferior. I feel that rural education is quite capable of competing.” After growing up in a small hometown and raising two daughters in Southwest City, he should know.

Keith J. Mueller, director of the Center for Rural Health at the University of Nebraska in Omaha, listed reasons why rural areas may find it tough to attract talent:

1. Fewer medical residents are choosing careers in primary care, especially family care.
2. Rural professionals spend more time on call.
3. Many prefer urban lifestyles.
4. Some don’t want to leave cities for family reasons.
5. Rural areas pay less, which is as much a function of being in primary care as location.
6. Health workers worry that they will experience professional isolation.

Hill commented on the latter concern. When the Hills moved to Southwest City, his Tulsa friends speculated that they wouldn’t have enough to do. “Once we got here, we were so busy!” Hill said. “Small towns keep you occupied. It’s very fulfilling.”

Working in a small town can come with benefits. “I remember working 96-hour shifts in the city,” Hill said. “Here, we don’t mind working hard, but we want people to have a personal life.”

About 2 years ago, Hill recruited another doctor, Coral Couchenour, also a participant in National Health Service. Having grown up in a small town in Iowa, she fits the model of a successful rural recruit. On top of that, Hill noted proudly that Couchenour earned top honors at her med school in Kansas City.

“I knew Kansas City had plenty of physicians, and at times I dreamed of going to a place where I was really needed,” Couchenour said. She contacted Hill in her search for a location where her fiancé could start an organic farm and live close to friends in nearby Arkansas.

“Doc,” as she calls him, didn’t spend much time promoting his practice. Instead, he hauled her to his farm in his pickup and walked her, high heels and all, through the barn, showing off his Appaloosa horses. “Eddy and I thought if anyone would take care of us, Doc would,” she said.

Hill’s clinic applied for the NHS loan program for Couchenour’s benefit. Today, medical school can cost up to $36,000 annually in Kansas City; rates have jumped since she graduated.

Now married, the couple recently purchased 12 acres of land, and plan to stay. As Couchenour examines patients in the clinic where she works in Anderson, she can take time to listen to them talk about vegetable gardens, volunteer work and quilt making.

Back at the ranch
Throughout the years, Hill has always invited medical and nurse practitioner students to work under him. Beyond working with students, he performs his share of community service. He provides free sports physicals and volunteers at local fairs. For several years, he spearheaded an annual trail ride benefiting the American Cancer Society.

Rosemary J. Coillot, a nurse with New Visions Group Homes, Inc., said Hill continues to provide care to her group home for disabled people. “These types of patients resist strangers. I have seen him sit on the floor with a young lady with Down Syndrome and autism, screaming her lungs out. Dr. Hill gently made eye contact, talked quietly to gain her confidence and proceeded with the examination.”

Plumlee added her endorsement of Hill’s bedside manner. “Money or lack of it has never gotten in the way,” she said. One time she went to Hill with a concern about the high cost of flu vaccine. “He looked at me and said, ‘We don’t have an option. Our patients need to get their flu shots here.’”

Megan no longer works, and Hill is slowing down a bit. Both now devote more time to their ranch. They practice yoga and meditate each day—Hill finds it relieves frustration he feels with patients who don’t listen to his advice.

And get this—he still makes house calls. He visits one patient with advanced Alzheimer’s who remains at home, and another who can’t get around anymore. The extra level of care may not always be possible, but he’ll continue as long as he maintains his business at its current size.

“I’m not a big businessman,” he said. “My dream is to continue to serve and survive in our rural communities.”

Alan Morgan, executive director of NRHA, doesn’t offer much hope that the rural healthcare shortage will improve, or that communities will find replacements for physicians like Hill as they retire. “It’s getting harder to find a rural sole practitioner,” he says. “That model of care is disappearing. We need to increase federal and state funding of rural healthcare.”

Hill went further, outlining his vision for the nation. “I don’t think you’ll find a young doctor in the U.S. willing to start in a rural area today,” he said. “I’d like to see our government start programs to encourage private practice. We need to reverse the prejudice against rural areas by the government, insurance companies and HMOs.”

Tuition reimbursement available for those who work in rural health

Rural states like Missouri face special problems recruiting healthcare workers. But the problems can turn into opportunities for young people who want to enter the field.

“We’re trying to educate high school students in rural areas on the tuition reimbursement programs available,” said Barry Backer, coordinator for the Missouri Office of Rural Health in Jefferson City.

In Milan, Mo., in the northern part of the state, Martha Gragg knows firsthand about recruiting medical workers. As CEO of Sullivan County Memorial Hospital, her struggles prompted her to chair the Missouri Hospital Association (MHA) Workforce Advisory Committee. The association provides grants to nursing and lab technician schools to build capacity. “It’s not just that we don’t have enough people to fill our positions,” she said. “But also we don’t have enough capacity in schools.”

A nurse with a master’s degree, Gragg contended that hospitals feel the nursing shortage most since they must maintain 24-hour nursing coverage. “RNs can go anywhere to get a job,” she said.

As a local who returned home, she feels that “growing your own” makes for the best way to attract healthcare professionals to rural areas. Her hospital works with local schools to interest youth in healthcare careers, hoping they’ll return home after graduation. They also tell students about state and federal programs that reimburse tuition for students who go on to work in areas of need.

The Missouri Office of Rural Health works with several such programs, including the Primary Care Office and the Primary Care Resource Initiative for Missouri (PRIMO). During 2004 and 2005, the office placed 52 physicians, dentists and nurse practitioners in underserved communities, and of those 52, half went to rural counties. In addition, the program helped 70 nurses earn forgiveness, and 31 of them went to rural counties.

The state also helps recruit medical workers. Partnering with the Missouri Provider Recruitment Services and the National Health Service, the state helped place 256 health professionals in 2004-2005, with 68 percent going to rural areas. In the same period, through another program, the state health office recruited more than 30 foreign med school graduates to practice in rural underserved areas.

For more information on healthcare tuition and recruitment programs, call the Missouri Office of Rural Health at (800) 891-7415, or visit www.dhss.mo.gov/PrimaryCareRuralHealth.  

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