Testimony by KU medicine dean at today's rural health hearing in Hays

HAYS -- Barbara Atkinson, executive dean and vice chancellor for clinical affairs for the University of Kansas School of Medicine, presented the following testimony today at a congressional hearing in Hays on rural health care. David Cook, director of the Health and Technology Outreach department at the KU Medical Center in Kansas City, Kan., also testified.

U.S. Rep. Jerry Moran, R-Kan., and U.S. Rep. Earl Pomeroy, D-N.D., hosted the hearing this morning at the Hays Medical Center. Moran and Pomeroy are co-chairs of the Rural Health Care Coalition. Thomas Scully, administrator of the federal Centers for Medicare and Medicaid, attended the hearing after touring the Rush County Memorial Hospital in LaCrosse.

Also attending the tour and hearing were Jack Fincham, dean of the KU School of Pharmacy; Jon Jackson, senior vice president forÊsystems integration atÊKU Med; and Janet Murguia, KU executive vice chancellor for university relations.

The KU School of Medicine is the primary supplier of physicians and continuing education for physicians for the state of Kansas.

Testimony presented to
Centers for Medicare and Medicaid Services Administrator Tom Scully, Congressman Jerry Moran (R-KS), Congressman Earl Pomeroy (D-ND)
By Barbara Atkinson, M.D., Executive Dean and Vice Chancellor for Clinical Affairs, The University of Kansas School of Medicine
Rural Health Care Forum
Tuesday, May 27, 2003
Hays Medical Center

Thank you for the opportunity to share our School's commitment in support of our mission to serve all Kansans, especially those in the rural communities throughout this state. Educating an ample supply of future physicians and other health professionals who choose to live in rural Kansas is a challenge we take seriously and have met, with more than average success, for more than 50 years. But today in 2003, we are realizing that multiple dynamics are coming together to create tremendous strain on our ability to satisfy Kansas' physician needs in the next 20 years. For this reason, we are extremely grateful that Congressman Moran has assembled this delegation to learn more about rural health in the state of Kansas and we thank him for his leadership in this area.

The KU School of Medicine is the only medical school serving the state of Kansas. We graduated our first class of medical students 98 years ago. Our main campus is located in Kansas City and is part of the KU Medical Center which also includes KU Med, our teaching hospital, the Schools of Nursing and Allied Health. The School of Medicine admits 175 medical students each year and all students take their first two years of basic sciences on the Kansas City campus. Approximately 50 students complete their 3rd and 4th years at our School of Medicine-Wichita campus, a community-based program very strong in the training of primary care. We're very proud of the education, training, and record of service to rural areas by KU including our Wichita campus programs and the Smokey Hill Family Practice Residency program located in Salina, Kansas.

We have 54 physician residency training programs with 650 residents in Kansas City and Wichita. We have one of the nation's top rated master's in public health programs, an MD/PhD program, doctoral degree programs, and a relatively new but excellent master's program in Health Services Administration. To reflect our commitment to Kansas as part of a state supported university, 90% of the students we select each year are from Kansas and 33% of those come from rural Kansas. Following national trends the past few years, we have seen a slight decrease in students' choices for primary care specialties (internal medicine, family practice, pediatrics and OB-GYN), but we are still pleased that 40% of our graduating students choose one of the primary care specialties for their residency training.

EFFORTS TO RECRUIT AND RETAIN KANSAS STUDENTS IN KANSAS

The Kansas Bridging Plan and the Kansas Medical Student Scholarship/Loan Program are programs mandated by the Kansas legislature to encourage Kansas medical students to practice in underserved areas following training. The Kansas Scholarship/Loan program requires loan repayment if the student chooses not to practice in Kansas following residency training. In recent years, a majority of these loan recipients have chosen to stay in Kansas, thus causing a drain on the state's pool of funding. This year fewer scholarships were granted as a result. As the State's own fiscal crisis has worsened, future funding of these programs is in increasing jeopardy.

We do not have adequate private scholarship support to be competitive in recruiting and retaining Kansas students to pursue their medical training in Kansas. Only 33% of our 700 medical students, or 233 students, receive scholarship support. Yet, we have designed several programs that are proving effective in our recruitment and retention of students with interests in returning to rural Kansas to practice medicine.

The Primary Care Summer Mentor Program exposes college premedical students to primary care medicine in Kansas by pairing them with Kansas primary care physicians during a six-week period of mentoring in the summer. A variety of experiences, including community health opportunities, working with various members of the health care team, and writing patient case summaries are required. Students are matched with physicians in, or near, their hometowns.

The Scholars in Primary Care Program is especially designed to attract Kansas premedical students to service in primary care settings in underserved areas of Kansas. Six premedical students are selected each year. Those selected must be from a Kansas rural community with a population of less than 30,000. They must have demonstrated intellectual promise; have attained sophomore standing in a Kansas university, college or junior college; have completed required course work; demonstrated a commitment to service, and to practicing primary care medicine in rural Kansas. Scholars who meet the program's requirements during the two years of working with a primary care mentor are guaranteed admission into the next entering class of the KU School of Medicine. The first group of Scholars just graduated and all chose primary care residencies. The fifth group will enter medical school in August.

We have implemented a statewide Medical Education Network to better facilitate our rural medical education efforts. All efforts in each of the six regions are coordinated by a local physician who serves as medical education network site director, helping to assure that the School of Medicine is attuned to the needs of the local communities while utilizing the resources of the rural physicians and hospitals most effectively.

We have had a deep commitment to rural Kansas for over half a century. The KU School of Medicine is one of the first medical schools in the U.S. to establish a Rural Preceptorship Program. Since 1951, all fourth year medical students at KU School of Medicine spend a month or more in a rural Kansas community, being mentored by a primary care physician in a clinical setting. Today 1,200 physicians in rural communities throughout Kansas serve as clinical preceptors to our students in their fourth year rural preceptorship rotation and in a growing number of clerkships throughout the 4-year medical curriculum. This model program is the foundation of all our efforts to connect with Kansas physicians. It helps to assure that all our students understand and appreciate the unique dynamics of rural health, and demonstrates first-hand the opportunities and challenges for primary care physicians in rural Kansas.

One way the KU School of Medicine is working to find solutions to these rural health problems is to expand our educational and research opportunities for students to train in rural underserved health. An example is the Practice-Based Research Network developed in 1992 through the department of family medicine. This rural educational network includes over 35 practices that precept 35-45 medical students each year. This program is supported by the Kansas Academy of Family Physicians, the Kansas Association for the Medically Underserved, the Kansas Health Foundation, and the Baker Trust just a few miles from here in Lacrosse, Kansas. Medical students between their first and second years of medical school are placed with rural family practitioners for a clinical internship, following a competitive application process. These students receive a stipend for their internship that requires not only clinical work and full participation in practice activities, but also involvement in research projects which entail collection of data about practices or patients in the rural setting. A number of these students have gone on to practice in rural locales throughout the state and currently 5 to 7 of the active host physicians participated as students in the early years of its existence.

We are constantly looking for ways to improve our medical curriculum to assure that our graduates have the critical thinking skills and vision to help bring about positive changes in the delivery of health care in the future. Health of the Public is one such course that is proving to be effective. Students work as members of interdisciplinary teams on population based issues such as reducing lower-extremity amputations in diabetics, improving immunization rates in an outpatient clinic, or financing medical care for the working poor. Many of these projects focus on a population in a rural community.

In addition, faculty in the Department of Preventive Medicine now teach a course incorporating practice management, medicare/Medicaid and financial issues, quality of care, disease management, systems of care, and practice-based learning and improvement. The Department of Health Services Administration is expanding its teaching to residents and discussions are underway to expand teaching to medical students.

A physician who chooses to practice in a rural Kansas community faces formidable obstacles: professional isolation, difficult access to specialists and specialty services when needed, long hours with limited back-up relief. We strive to serve these practicing physicians so that their ability to practice in these isolated communities is enhanced.

Our Continuing Education program is the largest accredited provider of continuing medical education in Kansas. We have three Area Health Education Centers (AHECS) to cover the areas of rural Kansas. The AHECS are an integral part of our mission to implement rural health initiatives throughout the state of Kansas. The Network Sites work closely with the Health Policy Institute, State Data Board, Department of Health Services, Office of Rural Health, and all health profession schools at KU and other Regents institutions. The AHECS assist with locum tenens services for a variety of health professions, help to coordinate the telemedicine system for clinic consultations, education, and administrative functions, assist with continuing education, serve as an information clearinghouse for communities to easily access KU resources, assist communities in recruiting health care providers, and help to coordinate local student and resident education programs.

Beginning July 1, the new Kansas Recruitment Center at the KU School of Medicine-Wichita campus will help rural towns find physicians. This much needed initiative is sponsored by the Kansas Department of Health and Environment, Office of Local and Rural Health, the Kansas Hospital Association, the Kansas Board Emergency Medical Services and the Kansas Medical Society.

OUTCOMES

All of these efforts pay off for Kansas in that we have one of the region's highest percentages of graduates going into primary care specialties and choosing to stay in Kansas.

The Balanced Budget Act of 1997 has negatively impacted the hospitals of Kansas as well as the KU School of Medicine. The hospital experts here today can speak to these concerns much better than I. But, we know that many of these hospitals are in rural, isolated areas where the quality of life and the economic viability of the entire region depend on the citizens having access to convenient health care. Many of the citizens are older with greater health problems or they are members of the rapidly growing segment of underrepresented and uninsured also with high health risks. Many of these hospitals are critical access hospitals and worth saving. Few, if any, are part of managed care networks.

Cuts to these hospitals and cuts to our graduate medical education program are intertwined and cause a huge ripple effect to present and future health care in the state of Kansas. Hospitals in Hays and Olathe that previously sponsored family medicine residency programs were forced to close these programs resulting in a loss of eighteen residency positions in family medicine. Another twelve positions that were sponsored by the Kansas Medical Education Foundation were lost in Topeka bringing a total of thirty family medicine residency positions lost in Kansas in the last few years due to funding issues.

Our primary mission is to educate future physicians and health care professionals for the state of Kansas. To accomplish this, we need a viable network of hospitals with adequate health care professionals in rural communities to serve as outposts for our educational programs. Without this hospital network it will be extremely difficult to recruit and retain physicians to live and work in these communities.

The GME cuts have limited our ability to recruit additional residents into several of our specialty training programs, including those in primary care. This has happened at the same time that the LCGME is mandating a maximum resident physician workload of 80 hours per week. The net effect of fewer resident positions and less resident physician work time is:

 • resident candidates will go elsewhere and Kansas will lose them as potential future physicians
 • less time for faculty to conduct continuing medical education programs
 • loss of residency training programs and sites throughout the state
 • less care for uninsured and indigent patients
 • negative effects on local and state economies (fewer residents in Kansas City and Wichita, and their dependents)

In addition, to other CME cuts, our state's funding of disproportionate share payments through Medicaid has been severely cut in the last year, which has the direct effect of restricting medical education opportunities, most specifically at the KU School of Medicine-Wichita. I realize that this is a state issue, but it represents the type of difficult choice that states need to make. I support the states' governors in asking that their federal match be increased so that they can take care of increasing numbers of Medicaid enrollees. At present Kansas match is 60%.

The seriousness of these cuts to the School of Medicine, to Kansas hospitals, and the state can best be understood when you take a look at the disturbing trends occurring in the U.S. physician workforce market. Our state needs primary care physicians, as well as other specialists and subspecialists in a variety of areas. We currently have major shortages in anesthesiologists, radiologists, pathologists, surgeons, cardiologists, pulmonary and GI internists and emergency medicine doctors, in addition to primary care doctors. There is strong evidence that the U.S. health system is heading toward major shortages in physician supply, as indicated by these alarming predictions:

 • the American College of Surgeons predicts that by 2005 only 4.8% of US graduating medical students will be interested in general surgery compared to approximately 8% in 1995 and that by 2005, only 76.6% of general surgery residency slots will be filled.
 • a recent study by the American College of Cardiology determined that the demand for cardiologists will increase 66% by 2030 ad 93% by 2050 but the actual number of cardiologists will only increase by 1% per year.
 • currently there is a shortage of 1,200 Ð 3,800 anesthesiologists and by 2005 the shortage is expected to rise by 4,500.
 • the demand for intensivists will outpace supply 22% by 2020 and 35% by 2030. Demand for pulmonologists will outpace supply 35% by 2020 and 46% by 2030.
 • spurred by declines in specialty residencies, demand for select specialists are expected to rise. Between 1994 and 1999 orthopedic residents declined 9%, radiology residents declined 13% and oncology residents declined 63%.
 • physician shortages have caused the use of locum tenens to rise dramatically. Currently, nearly $2 billion per year is spent in the U.S. for temporary physicians. The top temp specialties include primary care, hospitalists, dermatology and emergency medicine.

Colwill and Cultice (2003) have plotted the national trends in the numbers of family medicine/general practice physicians from 1997 to 2020. Using the Bureau of Health Physicians' Physician Supply Model, the researchers made the following predictions:

 • by 2020 there will be approximately 20,000 fewer physicians in these specialties. This alarming prediction is based on the current trend of 4,015 graduates per year in these specialties. The reduced trend assumes a decrease to 2,602 graduates per year over five years.
 • by 2020 the number of practicing family/general practitioners per 100,000 population will decrease from approximately 34 to 29.
 • the greatest shortages of practicing family/general practitioners, general obstetricians, general pediatricians, and general internists will be felt in counties with less than 50,000 to 199,000 population.

I must add that here in Kansas, the growing physician shortage co-exists with a severe shortage of nursing and allied health personnel. This is acutely felt in Kansas' rural communities.

SOLUTIONS

We believe a reversal of these disturbing trends will occur only when we implement effective strategies on several levels, including:

 • design the curriculum to produce the desired outcomes. We want to document students' demonstration of knowledge, skills, attitudes and behaviors. We want to produce graduates that are self-directed, self-motivated and capable of self-evaluation.
 • modify or build the necessary educational infrastructure
 • maintain and expand opportunities for internship and residency training in the state. We need to assure a strong traditional medical center base for specialists. At the same time, we must increase training opportunities in community-based and ambulatory primary care settings, and expand rural consortia for practice in underserved areas. This training needs to occur in communities similar to where these students intend to practice in the future.
 • maintain and expand scholarships, grants and debt forgiveness in exchange for service.

We believe the following measures, if enacted, would cause extremely negative outcomes for Kansas:

 • reduction of medical school size would cause a decrease in the future size of the workforce. Cost savings would be non-existent because educational costs are largely fixed.
 • reduced funding for graduate medical education would further exacerbate the developing shortage of physicians. The competitiveness of Kansas programs would be weakened and resident trainees would incur more debt as funding support decreased.
 • cutting or reallocating residency positions will drive students out of state to pursue their desired training. It is a well-documented fact that the majority of residents establish their careers within 150 miles of their training.

We know from experience that local attempts to address shortages or maldistribution of physician workforce fail in the absence of strong regional or national initiatives. Trainees will simply move to regions where their options are less restricted. Therefore, we are eager to partner with you, other regional and national leaders to design and implement initiatives that will assure the long-term health of our nation's rural communities.

Recently, we received word that a Title VII funded grant to the department of family medicine has been funded to develop the Patients in Diverse Communities Program. This practice-based program will expose medical students and their precepting physicians to research addressing health disparities in rural settings. The program will contain a long-term patient research registry and community/environmental assessment capabilities. The goal is to provide a statewide þlaboratoryú to study areas of underserved health, and associated community features. This endeavor is creating a unique and novel environment for the conduct of high quality primary care research while simultaneously exposing students and junior faculty to the unique role primary care will play in the elimination of health disparities for our nation's poorest and underserved. Ultimately, we believe projects such as this will contribute to the solutions for the looming workforce disparities by exposing students to these practice settings very early in their training and with elective opportunities throughout their medical school years.

Thank you for the opportunity to present these concerns to you today. The KU School of Medicine looks forward to opportunities to work with you to find solutions for the long-term health of Kansans and our rural communities.