LEXINGTON, Ky. — Long before the COVID-19 pandemic took an unprecedented toll on health care in America, rural areas were already facing the threat of closing hospitals. With a nationwide shortage of doctors, it may become increasingly more difficult to access quality care in less populated parts of Kentucky. 

Doctors in rural areas are retiring and not being replaced fast enough. According to Dr. Jacqueline Fincher, president of the American College of Physicians, 21% of the population of the United States lives in rural areas, but just 10% of physicians practice there. Those statistics are more concerning when coupled with numbers from a 2019 report in the Health Affairs Journal that shows patients in rural areas have a 40% higher rate of preventable hospitalizations and a 23% higher death rate than their urban counterparts. By 2033, there's expected to be a shortage of up to 139,000 physicians in the United States, potentially costing more than 7,000 lives a year, according to a 2020 report from the Association of American Medical Colleges.

A report published in The Journal of Rural Health shows, “immediate action must be taken,” or the shortage could have “severe consequences on the health status of rural communities.”

Almost two-thirds of Kentucky’s counties are considered health professional shortage areas, meaning they have far too few primary care physicians. The University of Louisville became focused on the predicted shortage in 1998 by establishing the Trover Campus at Baptist Health in Madisonville, a town of about 20,000 people located 150 miles southwest of Louisville in the western Kentucky coalfields of Hopkins County. 

Dr. William J. Crump is associate dean of the University of Louisville School of Medicine for the Trover Campus at Baptist Health in Madisonville and oversees the program that allows medical students to study their last two years of medical school in a rural setting; it is the second of its kind in the United States.

Crump believes training students in a small town setting would more likely produce physicians for those areas, and he has been working to increase the number of physicians in rural communities by training doctors at Trover Campus for the past 23 years. Crump and his colleagues Steve Fricker, Craig Zeigler and David Wiegman wrote an article in 2015 to show their efforts are paying off.

Dr. William J. Crump is associate dean of the University of Louisville School of Medicine for the Trover Campus at Baptist Health in Madisonville and oversees the program that allows medical students to study their last two years of medical school in a rural setting. (Courtesy William J. Crump)

The article was published by The Journal of Rural Health and reveals 45% of the physicians who completed medical school at the campus now practice in rural areas, compared with only 7% of graduates who remained on the campus in Louisville.

The authors examined data for 1,120 physicians who graduated from the UofL School of Medicine between 2001 and 2008, including those who completed training at the traditional urban setting and Trover Campus. They used statistical methods to control for the percentage of graduates who had a rural upbringing and chose family medicine, factors that previously were shown to predispose a physician to rural practice and were able to demonstrate the rural campus itself added to the likelihood a physician would choose rural practice.

Crump’s efforts are ongoing.

“This is my professional life,” he said. “I've spent the past 23 years here in Madisonville studying the question of, ‘How do we fix this?’ and publishing a lot. It's a huge problem, and probably worse in Kentucky than most states because we’re so rural. If you go into a medical school class anywhere in the country and ask the students to raise their hand if they’re going to go to small-town practice, about 5% will raise their hand. About 43% of our graduates are in small-town practice, which ranks us No. 2 in the country.”

If Crump could use one person as an example of his efforts, it could likely be Dr. Samantha Hays. Hays is a medical doctor and native of Jackson County, a rural county with a population of about 14,000, located 70 miles southeast of Lexington. Its county seat is McKee (pop. 800), and the Daniel Boone National Forest covers one-fourth of the county (56,0000 acres).

Hays is a 2017 graduate of the University of Louisville School of Medicine and completed her residency in 2020 at Trover Campus. She is currently practicing family medicine at the Annville and McKee medical centers in Jackson County, the Burning Springs Medical Clinic in rural Clay County and the East Bernstadt medical clinic in rural Laurel County. Her plan since starting medical school was to return to Jackson County.

“It was important for me to be able to practice medicine where I’m from and where I was raised,” Hays said. “Most of my family is here and my husband's family is here. My goal from day one was to come back home. I was very glad I was able to do that.”

Hays said growing up in Jackson County gave her a keen awareness of the need for medical professionals in rural areas.

Dr. Samantha Hays is a 2017 graduate of the University of Louisville School of Medicine and completed her residency in 2020 at Trover Campus. She is currently practicing family medicine at the Annville and McKee medical centers in Jackson County, the Burning Springs Medical Clinic in rural Clay County and the East Bernstadt medical clinic in rural Laurel County. Her plan since starting medical school was to return to Jackson County. (Courtesy Samantha Hays)

“The best way to get doctors to small towns is to get medical students from small towns and train them in small towns. It's that simple,” Crump said. “The article we wrote in 2015 and we got all that praise for, that's all it says. If most of your students come from the big city, they're going back to the big city because they grew up having lots of restaurants and lots of entertainment opportunities. They're going to fall in love with somebody from the city – you're just swimming upstream. Those doctors practicing medicine in a rural area is just not going to happen. You have to get students from small towns.” 

To try to recruit medical students, Hays said she would tell them working in rural areas is never dull.    

“If you're someone who needs a lot of different things because you get bored with the same thing day-in and day-out, family medicine in particular, or primary care in a rural area, requires you to wear a lot of hats,” she said. “You can kind of run the gamut in the same day, from OB-GYN in some cases, to taking care of nursing home patients and then there are the emergencies that come in. So, you might be taking care of chest pain in one room and taking care of a sinus infection in the back and be doing someone’s well-child visit in another room. You never know what's going to walk through the door.” 

The feeling of being appreciated is also a plus to practicing in rural areas as well, Hays said, especially if it happens to be your hometown. 

“It's not easy to get to hospitals and places for more advanced care, so people really express their appreciation here for what you do, they’re glad there’s someone who can take care of them here in town, and take care of all of their needs,” she said. “They really like coming to see you and you get to do a lot of things for these people. They're very appreciative and they trust you a lot.” 

Working in a larger city and practicing something other than family medicine makes it more difficult to develop a relationship with patients, which Hays said is something she held in high regard when she decided to become a doctor.

“I really enjoy the aspect of getting to know people and getting to know their family,” she said. “If a patient really likes you they’re going to bring their mom, dad, sister, brother, daughter, son, cousins — everybody's going to come to you. I've had several patients that really enjoy my method of caring for them, so they recommend me to friends and family. I really like that aspect of rural medicine.”

Practicing family medicine in a rural area also allows doctors to “exercise their brain” and gain ample experience in multiple disciplines, Hays said.

“You're an endocrinologist, a cardiologist and other things sometimes the same day sometimes with the same patient,” she said. “It makes work worthwhile.” 

When she was growing up, Hays said the only doctor she ever saw was her family doctor, and in her mind, that is what it was like practicing medicine.

“If you're not doing all of these things family doctors do in rural areas, it doesn't feel like real medicine to me, so it was important to me to do all of those things and wear all those hats,” she said. “When I got to do that with family medicine and coming back home, I got to be that doctor for people that I wanted to be.”

Hays was also never tempted by the allure of making more money as a doctor in a big city. She said some things are much more valuable to her than money. 

“One of those things is my free time,” she said. “I didn't want to be on-call nights and weekends and work holidays no matter how much money I was going to get. It wasn't worth it to me. There's a little less stress in general in a rural lifestyle. I don't think you can really put a price on that.”

Perhaps the most critical facet of the Trover Campus is its location. Crump said if medical schools get students from small towns and they are trained in big cities, “you lose them, too,” he said. “Getting doctors to practice in rural areas is our claim to fame. You have to get them where they live and keep them where they live.” 

Crump said the doctors that typically stay and practice in small towns are the people who look and talk like their patients and getting those medical students back to those areas as doctors is the more likely remedy to the shortage. Hays also said understanding and speaking the Appalachian dialect, which is peculiar, expansive and unique, is essential for medical professionals that chose to practice in rural Kentucky or anywhere in Appalachia. 

The McKee Medical Clinic in Jackson County. (Courtesy White House Clinics)

“Patients have told me they like that we can understand each other,” Hays said. “Understanding the slang and the accent of people in rural areas, especially in Kentucky and in Eastern Kentucky in particular, is important. It can be difficult for people who are from larger areas or big cities to come in and make any headway. A doctor and patient understanding each other sometimes means they have the same accent, but sometimes that just means not talking over the patient's head. It really doesn't matter what accent you have. If you’re using words and phrases the patient can't understand, they're still not going to get the message you're trying to give them.” 

Hays said she is “very appreciative” of Crump and the Trover program because it created the path to get her back to Jackson County and doing what she wants to do. 

“I hope other people can do it, too, because it is really rewarding,” she said. “At the end of the day, I enjoy my job. I enjoy taking care of people I know and coming back to serve the community where I grew up.”

Crump’s process with students starts early with UofL’s High School Rural Scholar Program, which is designed, among other things, to maintain or increase students’ interest in a rural health career. The program began in 2000, and 75% of the 290 students that have participated since its inception have gone on to careers in the health care field, Crump said. 

“The MCAT (Medical College Admission Test) that gets you into medical school is a bear,” he said. “Students who go to small high schools don't do well on it at all, so we give them MCAT prep. We help them with a lot of things. We do everything we can to get them into medical school.” 

Once those students are enrolled in medical school, they spend the summers before and after their first year and their final two years at the Trover Campus. 

“They do their first two years in Louisville, and they pick up and move here for their entire third and fourth year,” Crump said. “That's how we get 43% of our graduates going into small-town practice, and they go into every specialty you can imagine.”

UofL’s College Rural Scholar Program began in 2002 to facilitate an understanding of small-town physician practice. Crump said 97 pre-med students have participated, and of the 83 that finished college, 60% chose to attend medical school. He also mentioned the importance the University of Kentucky College of Medicine Rural Physician Leadership Program in Morehead has in addressing the doctor shortage. The program is designed to train future physicians and health care leaders to provide care in rural settings.

“It only takes putting one or two primary care doctors and each of our rural counties to turn the tide. It's not a big number. We are almost there,” Crump said. “We've been here for 23 years, and UK’s program in Morehead has been there for 10 years. Rather than see them as competition, I trained their people. They came here and watched how we did things, and they have built there what we have here. If you're from that end of the state, you need to go to Morehead for your third and fourth year. If you're from this end of this state, then you need to come here. We'll fight over the ones in the middle.”