This rural Iowa hospital is creating a pipeline to train and retain doctors
Wayne County Hospital's fellowship program equips doctors for rural medicine
'If our plan works, we will have long-lasting career doctors in these communities'
CORYDON — No matter what a patient needs, each one uses the same door at Wayne County Hospital and Clinic System.
A Critical Access Hospital since 2004, the facility not only is the sole hospital in Wayne County but also the only labor and delivery unit in an eight-county area.
For physicians such as Dr. Joel Wells, no day is ever the same. One moment he is determining whether an elderly patient had pneumonia, and the next is examining a woman in labor with her fifth child.
For years, the family practice physician was the only doctor on-call at the independent clinic he owned in Corydon. When he merged his practice with the hospital, he joined the medical staff, alleviating the day-to-day schedule doctors in rural health care settings must take on.
However, Wayne County Hospital — as with many other small community hospitals — struggles to recruit and retain an adequate physician workforce to meet its needs.
As Wells and Dr. Dave Kermode, a general surgeon and another longtime practitioner at the facility, drew closer to retirement each year, they grappled with how to continue the care they provide in light of these challenges.
They asked themselves: When we retire in the next decade, what kind of skill set would their successors need in order to function well in this environment?
Creating a rural-based fellowship program was their solution, Wells recalled.
“This is career building,” Wells said. “If our plan works, we will have long-lasting career doctors in these communities.”
For the past year, Wells and other officials at Wayne County Hospital have been undertaking this plan through a fellowship program that trains family medicine physicians in certain surgical and obstetric skills.
These capabilities are beyond the typical skill set of a family practice doctor that has a certification in obstetrics and gynecology, hospital officials said.
Future doctors passing through the rural fellowship program not only will need to handle a broad scope of care through a day, but they need to be willing to offer these skills to patients in a small community for the rest of their careers.
“The people we train going forward are going to have to be smarter than the average doctor, harder working than the average doctor and they will have to be nicer than the average doctor,” Wells said.
A rural fellowship
In August 2018, Dr. Tara Blalock Burgher became the hospital’s first fellow.
Called the Obstetric Rural Expanded Surgical Skills Track, it will be offered as an additional year of training to family medicine physicians upon completion of their residency.
Fellows recruited to the hospital for the program undergo surgical and obstetric training that include C-sections, upper and lower endoscopies, and postpartum tubal ligations, among others. They also gain an understanding of obstetric and surgical ultrasounds throughout the yearlong program.
Wayne County Hospital is taking on the expenses needed to operate this fellowship, and program directors plan to select another fellow in August.
To start, hospital officials plan to only hire one fellow per year. The long-term goal of the program is to increase the graduating size to six to eight fellows by including other Critical Access Hospitals into this initiative.
The program is based in Corydon, directed by Wells and Kermode. Kermode, who first had the idea for the fellowship, said it was modeled after a similar program in Canada.
Burgher also traveled to other hospitals for additional education.
In the midst of her training, Burgher works as a doctor on staff, seeing patients in clinic, caring for individuals admitted to the hospital and managing the emergency department a number of days a month.
Burgher “can technically, if she didn’t want to do the fellowship, go out and start working as a physician, so we tried to balance that,” said Kara Urlis-Comer, director of clinical support at Wayne County Hospital. “As a doctor, she’s able to see patients, which creates revenue. That helps cover some of the cost when she’s not in the clinic and we’re sending her off to learn these different things” at other hospitals.
'You're always thinking ahead'
Like Wells, Burgher found herself switching her focus throughout the day as she cared for patients across the board. She could be working with a hypoxic 80-year-old while thinking ahead to a woman who is likely to deliver her baby later that day.
“You’re not just thinking about what you’re doing right then, you’re always thinking about what else is in the hospital and what could be coming up,” Burgher said. “You’re always thinking ahead.
“It definitely stretches you, but in the end, I can just tell from residency to the end of this year that my skill set is so much larger and I’m a better doctor.”
Burgher joined as the fourth family practitioner in the county hospital, which currently maintains 25 in-patient beds and an emergency department, in addition to its labor and delivery unit.
Corydon has a population of about 1,600. It’s located within the fifth-least populated county in Iowa, which has fewer than 6,500 people, according to the 2010 U.S. Census.
The hospital has maintained a steady profit in recent years, in part driven by an equally steady increase in patient volume, according to data from the Iowa Hospital Association. Total out-patient visits climbed to nearly 29,000 in 2017, and total admissions for acute in-patient beds reached 480 that same year.
However, total births at Wayne County Hospital between 2015 and 2017 did not see much growth, reaching 144 in that last year.
The need to do more
The shortage of physicians has intensified across the United States, in part because of an aging population and the increased prevalence of comorbidities — experiencing multiple chronic conditions simultaneously — among patients. The Association of American Medical Colleges predicts the United States will see a shortage of up to 122,000 doctors by 2032.
But this shortage is felt more intensely by rural-based hospitals and clinics, which struggle to recruit and retain doctors away from urban-based health centers, said Kermode, the general surgeon.
Despite this, Wayne County Hospital officials are still hopeful. They plan to entice doctors like Burgher, who want to work in rural medical settings, to join their fellowship.
“Family practice in a rural area is very much different from family practice an urban area,” said Dr. Stephanie Perkins Mahan, family medicine doctor at Wayne County Hospital with an obstetrics-gynecology specialty. “In urban areas, they’re much more limited to clinic work. Whereas here, we are doing hospital work and obstetrics and emergency and procedures.
“Exposing students to that increases their likelihood of wanting to go to that type of environment.”
Burgher grew up in North Carolina in a town similar in size to Corydon and knew she wanted to practice rural medicine, she said. Burgher, who completed residency training in Des Moines, found she enjoyed working in the delivery room and performing surgical procedures.
“Family medicine really lends itself to a lot of different things as long as you’re willing to get trained in it,” she said.
By training fellows in this skills specifically within a rural health care setting, they hope it will guarantee success for fellowship graduates as they work in some of the least populous parts of the country.
Burgher will remain on staff at Wayne County Hospital after she completes the program in November. However, future doctors recruited to the fellowship likely will move onto jobs in other rural hospitals after completing their yearlong training.
“But wherever (fellows) go in a rural setting, you have to have an expanded knowledge outside of just general family practice because you will need to do more things than just check somebody for a sore throat or pneumonia or roll out a stroke,” Urlis-Comer said.
Because Wayne County Hospital has a minimal workforce, a challenge facing the rural fellowship program is that it is dependent on very few people, Kermode said.
“The bench is not very deep,” Kermode said. “You have to play offense and defense. Any loss of a critical individual can kill the program at this point.”
'There just isn't enough physician access'
This challenge, coupled with declining patient volume and low reimbursement rates, have led some rural hospitals in Iowa to reduce services or shut them down all together.
Maternity services have been the subject of these cuts in recent years. Thirty-four of Iowa’s 118 community hospitals have closed their obstetric units since 2000, according to the Iowa Hospital Association.
The most recent closure occurred in September at the hospital in Marshalltown, in central Iowa.
It comes down to the amount of time a young doctor is willing to be on-call, or the time a physician must be available to care for patients outside typical office hours, Wells said.
Younger doctors are seeking a better balance between work and personal life, and do not want to be on-call for a majority of their time.
It’s not something Wells holds against medical professionals just entering the field. When Wells, a Plano native first moved to Wayne County to practice in 1989, he said he was the only family medicine doctor for his clinic — meaning a significant amount of his time was dedicated to its patients.
“The patients I was responsible for, I was responsible for them every day,” he said. “Now we’ve come to a point where physicians don’t want to do that.”
Mahan, the family medicine doctor at Wayne County Hospital, said since she joined the hospital in July 2017, she’s already had patients tell her it’s hard to get an appointment on her schedule.
“There just isn’t enough physician access,” she said. “I mean, that’s a good problem to have, but also a bad problem to have. So anything that you can do to open up access is important.”
Other organizations and policy makers have taken note of the challenges facing rural health care as well. Medical schools have created rural-specific training tracks for students and state officials have created loan forgiveness initiatives for doctors who practice in rural hospital settings.
The creation of a pipeline to get doctors into rural health care settings, while on its way, is not there yet for rural health care providers, Wells said.
“Part of why doing this (fellowship) where I am and where I’ve been practicing for 30 years is because no one came to us, a Critical Access Hospital, and asked us what we need for solutions,” he said. “ ... We’re the star of some of these research projects, but getting us involved in our own solutions is not very common.
“Most of us,” he added, “are just trying to keep our head above water.”
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