Angus Leader - Saving Rural Health Care

News Article

By Steve Young

Leo Astleford was delirious.

It's been years ago now, but the 75-year-old White River rancher can still tell you how the rattlesnake bite felt like a weed brushing against his pants.

How he climbed into his pickup in the middle of nowhere and drove himself the three miles home. How his throat tightened on the way, his hands started to go numb, his chest felt like someone was sitting on it.

And this -- during an agonizingly long ambulance ride from White River to the Valentine, Neb., hospital an hour away, how he was absolutely convinced that his feet were pushed up hard against the back doors the entire way.

Not so, his mother would correct him later. She was there beside him. His feet, she said, were two feet from the door.

"I guess I must have been sicker than I thought," he surmised. "But I don't remember that I panicked at all."

In the most rural areas of South Dakota, where the closest health care provider can be 30, 40 miles away, people understand that panic doesn't very often save lives. Staying calm just might, as Astleford can attest. But state officials aren't about to leave their rural citizens to the mercy of their nerves.

Instead, Gov. Dennis Daugaard and a task force he convened two years ago to look into the state's most critical primary health care needs continue to look for ways to lure doctors, physician assistants, nurse practitioners, pharmacists and more to the places where people like Leo Astleford live.

How? By paying off school loans of health care graduates who agree to practice in rural communities at least three years. With money for providers who take time from their work to mentor those students. Through programs that encourage middle school and high school students to consider health care careers.

And this grand experiment -- the Frontier and Rural Medicine (FARM) program -- which the Sanford School of Medicine rolled out in July and, for the first time, places third-year medical students in rural hospitals and clinics for nine months in the hope they fall in love with the experience and want to come back.

That's how David Kapperman, a country kid from Hartford, ended up recently in a Mission clinic learning the art of doctor-patient interaction. A Lakota woman, Whitney Brave Hawk, sat on an exam table beside him. Eighteen weeks pregnant, she was explaining to him how her morning sickness was worse with this, her fourth pregnancy. And her back hurt, too.

In a few minutes, he would share all this with his mentor, Dr. Anora Henderson, when she came into the room. But first he wanted to check for baby's heartbeat. "Do you want to help me?" he said, turning to Brave Hawk's 3-year-old daughter, Jalisa, as he held up the portable doppler that would find and amplify the heartbeat within mom's belly.

"Uh-huh," the little girl responded, and her smile sparkled as the room filled with a thump-thump-thump-thump.

Later, outside the exam room, Kapperman, 24, explained why he would prefer the life of a rural primary care doctor to a big city practice.

"I grew up on a farm," he said. "I've always been in Hartford and Humboldt, you know, just small communities. I like the feel of how everybody kind of knows each other a lot in small towns. I guess you could say I'm just more of a small-town guy; I don't like being in the bigger cities much."

That fits the profile of students the Sanford School of Medicine selects through an application process for its FARM sites in Winner, Platte, Parkston, Mobridge and Milbank. Many of those students are from South Dakota's smaller communities. This fall, 34 percent of the medical school's first-year class will come from towns with less than 10,000 people, its dean, Dr. Mary Nettleman, said.

It makes sense then that at the other end of the process, when the bookwork, clinicals and residencies are complete, that South Dakota's medical school would be placing a higher proportion of family medicine physicians in rural areas -- by federal definition, that includes every town in the state but Rapid City and Sioux Falls -- than virtually every other medical school in the country, Nettleman said.

That's the good news. But at the same time, the Department of Labor just released projections that showed the state will need an additional 7,305 health care workers by 2022. As of today, 53 of South Dakota's 66 counties are either partially or entirely short of health care professionals, according to the federal government.

And where there are physicians, the statewide median age is 52 years old; almost 70 percent of those doctors are 45 or older.

"I think the concern in those numbers, especially for rural South Dakotans, is the limitations in access to care," Nettleman said. "Those limitations require them to drive a long ways to get even simple care. I think there is some evidence then that people in those situations put off getting seen, for example, for preventive care. That means they have less ability to stay healthy."

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Small Town Risks

THEY EXIST FOR BOTH PATIENTS, STUDENTS

It also means that if you choose to live in rural outposts, you need to understand the risks. Krischelle Bear Heels, 22 years old and 31 weeks pregnant, sat in an exam room at the Mellette County Community Health Center in White River and described a terrible car accident that involved her mother's former boyfriend four, five years ago.

There had been a fight. He roared off in a drunken rage, was going too fast and rolled his vehicle, Bear Heels said. Hours passed on the isolated road before he was found, his back snapped.

"Out here it's so far from anywhere," she said. "He's no longer able to walk now. Had it not been so isolated, and had they been able to get to him quicker, who knows?"

East of the White River clinic, standing out in front of her house, Marge Homan offered a lighter-hearted look at the dangers of small-town living when she described how her niece's cat was darting and swiping one day at a rattlesnake that had slithered into the yard.

Of course it was a much more serious matter a year ago this past Fourth of July when that same niece came over and found Homan, 63, slurring her speech and struggling with a blood infection.

"The ambulance came and loaded me up," Homan said. "It was the longest ride. Every rut in the road, you felt it. I was strapped down on a flat board 77 miles to Pierre."

But that's life in rural South Dakota, said Dr. Anora Henderson, the family practice physician who coordinates the FARM program at the Winner site.

Every time her mother had a baby, she traveled 100 miles from their home in Kadoka to the hospital in Rapid City, Henderson said. High school classmates who remain in Kadoka today continue to make that journey.

She felt compelled to address that reality by working in a rural setting. "I kind of wanted to get back to an area so people don't have to" make those long trips, she said. And to Winner's benefit, it didn't hurt that the man she fell in love with and married was from there, either.

Whether Kapperman and a second student who has been placed at the Winner site, Heather Walker, find enough in the rural experience to lure them back remains to be seen. There are two years of medical school left for each, then at least a three-year residency. And Walker, 26, also has an Army obligation to meet -- four years for Uncle Sam in a military health care setting after her residency.

With all that in front of the lieutenant colonel, why sign up for a stint in rural South Dakota?

Like many drawn to rural life, it's the opportunity to get to know people beyond the medical interplay in an exam room, Walker said. It's the small-town tradition of sitting beside each other at a football game, running into each other at the grocery store, spooking pheasants together in an area cornfield or knowing that someone's grandmother just fell and broke her arm.

"Knowing them as a whole person and not just seeing them in the clinic, that would be important to me," she said.

But there are no shopping emporiums in rural South Dakota, no grand pavilions filled with the kinds of cultural enlightenment that can attract people of means.

Henderson smiled. It's true that some of her classmates had to look up Winner on a map when they heard her plans after residency. " 'My gosh. Are you crazy?' they asked me," she said. " 'What if you want to go to the symphony? What if you want to go to the mall?' "

Well, she has a membership to the Great Plains Zoo in Sioux Falls, Henderson said. If she wants to take her children there, or go to a performance at the Washington Pavilion, or do some shopping, she schedules a day off and they go.

"If you live in Sioux Falls, you probably don't go to the pavilion or the mall every day, or even every week. It's just that you're closer if you want to," Henderson said.

"I can schedule a day off and do that. But the rest of the time, I'm not fighting with traffic. When I get in my car in the morning and drive in from the farm, it's 25 minutes. It could take me that long just to get down 41st Street in Sioux Falls in the morning. Now I live in a town where I know most of the people, and I dodge more deer than I do pedestrians. It's not bad."

Shopping? Walker said she can do that online. If they want to see a movie, Kapperman said, they fire up Netflix. He loves to fish, loves to hunt, loves to be around the farm animals he knew growing up. So for him, rural South Dakota makes sense.

As for the quality of the medical education experience in Winner versus a Sioux Falls or a Rapid City, again, Henderson understands the doubters.

"They're saying, 'Wow, you're in a big town like Sioux Falls. There's just lots and lots of patients coming through. How are you going to emulate that?' " she said.

But here's the deal, Kapperman and Walker say. Their interests at this point all tie into primary care -- family medicine, internal medicine, obstetrics and pediatrics. They want to deliver healthy babies. They want to treat ear infections and high blood pressure. They want to help prevent diabetes.

In their nine-month stint in Winner, they will experience all of that in morning rounds at the hospital, in daily clinic appointments and in weekly outreach to communities like Mission and White River, where they will help young women like Bear Heels and Brave Hawk deliver their babies.

When the phone rings at night and an accident victim is rushed into the emergency room in Winner, they are called, too. When the schedule requires them to be in clinic but an interesting case unfolds in surgery, they are free to go observe.

"People get sick everywhere," Kapperman said. "There's no one area of the state that gets more heart attacks or more diabetes than any other. It's the same everywhere.

"So here I'm seeing the same things as my classmates in Sioux Falls. But in the bigger cities, where there's third-year students and fourth-year students and residents at these hospitals, I might be low man, learning behind everyone else. Here we're the only ones. Here we're on the front line."

Walker added: "And if there's anything we want to follow, we are are free to go to Sioux Falls and follow our patient there. Or follow them to Pierre. That way we're exposed to all the specialized care that happens."

The beauty of the program, she added, is the six weeks at the end of their third year, when if she and Kapperman haven't experienced everything required of them in Winner, they will go back to Sioux Falls and fill in the gaps.

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Bottom Line

INCREASING THE NUMBER OF DOCTORS IS THE BOTTOM LINE

It turns out that unlike the other four FARM sites, there is an interesting twist to this first year of the program in Winner.

As the community waits to see if Kapperman and Walker fall in love with the life and the opportunity it represents, they already have fallen in love with each other and will be married in a month.

"When we applied to FARM, we were just friends," he said. "We got selected for here, and we started spending a lot of time together and started dating, and, well ..."

What that means for their long-range plans remains to be seen. Kapperman still believes he'll end up in South Dakota eventually working in a rural setting. And maybe they will, his bride-to-be said.

But it's also possible that she will want to make the Army a career, Walker said. "I would be interested in going back to a rural community," she said, quickly adding, "I haven't decided anything yet."

The question then is: How many of these FARM students have to end up in rural South Dakota to make the program a success?

That's not easy to answer, Henderson said. She would love to be training her future partners. But if not that, if all the FARM candidates end up working in big cities or going into specialty medicine, at least they will have the knowledge of what it means to practice medicine in rural South Dakota, she said.

And if they choose to live in the big cities but come out to rural communities weekly or monthly with specialty skills, "that is going to be a win" for the program, she said.

Maybe.

It's clear when you talk to the governor or the dean of the medical school or others that from their perspectives, more rural docs is clearly the end game for FARM.

"I think the ultimate goal is, we want to make sure the program is good, the students are satisfied and the communities are satisfied," Nettleman said. "The bottom line will be, are we putting more doctors into rural areas of South Dakota?"

Daugaard agrees. If all South Dakota gets from the program is a greater appreciation for rural medicine and only a commitment to outreach, "I don't think those would be successes," he said.

"We want rural practitioners in rural areas," the governor concluded. "If this program doesn't accomplish that, we'll try something different."

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