An ethos of service ingrained in IU medical professionals in training
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Mention "health care" anywhere in the U.S. and word association inevitably leads to "crisis." Toss "rural" into the mix and witness the blurring exodus of medical scrubs and orthopedic footwear away from one-third of Indiana's population. Already 42nd in the nation in doctor-to-patient ratio, Indiana's precarious state of public health worsens when illness arises in the countryside.
Never before has the need been greater, say experts with the Indiana University School of Medicine, to expand initiatives for young doctors to not only stay in state, but to take their skills into rural settings. One way to address the problem, they say, is through new rural health initiatives like a fledgling effort in Terre Haute that has brought together an array of government, business and education partners.
IU School of Dentistry students travel all over the state with SEAL INDIANA program.
For Indiana and the nation, the statistics are relentless in their exigency: More than 115 million people in the country with no health or dental insurance, half of Indiana's counties federally designated as medically underserved, a family of four has seen insurance premiums double since 2001.
Never before have IU School of Dentistry students been more challenged to drill away at the appalling federal statistic that found nearly half of all rural children under age 5 failed to see a dentist last year. Yet drill away they do, in record numbers, traveling throughout the state participating in service-learning programs like the SEAL INDIANA mobile dental health program, which in just five years has exceeded a 15,000 child-patient benchmark.
Only about a quarter of the nation's population is rural, yet that population is left to share but 10 percent of the nation's doctors, a group of professionals who can then testify that Medicare spends less on, and that Medicaid is less likely to assist, rural patients over those in similar health who live in cities. The numbers don't lie: For every 100,000 rural residents (there are nearly two million in Indiana), there are 40 medical specialists and 40 dentists, yet their urban counterparts can find 134 specialists and 60 dentists to choose from.
Never before have IU School of Optometry students been more in demand to deliver free eye screenings, work rural clinic hours or see that a child or senior citizen is fit with a pair of free or low-cost eyeglasses. Evidenced through service-learning programs like Eye Care Community Outreach (ECCO), the Rural Health Clinic Program, Volunteers in Medicine, Especially Kidz Health and Rehabilitation Center, and InfantSEE, students come face to face with the reality of challenging demographic settings that include growing needs in the Latino community, the rampant effects of diabetes on eye health and that nearly half (47 percent) of rural children live in poverty.
"Our students are surprised and sometimes amazed at the conditions they see, because, well, they just haven't seen or been in these rural settings before," said Dr. Karen Yoder, director of the IU School of Dentistry's Division of Community Dentistry. "It becomes an extremely important educational experience for them."
One example of how Indiana University is taking on the health-care worker shortage is through an effort by the IU School of Medicine to participate as a founding member in the Rural Health Innovation Collaborative (RHIC) announced recently in Terre Haute. Dr. Stephen Leapman, executive associate dean for educational affairs at the school, said the campaign is specifically designed to turn medical students into rural doctors.
"The IU School of Medicine-Terre Haute center has been proactive for several years in the national effort to increase the number of primary-care practicing physicians and has been proactive in creating a rural medical program at the Terre Haute center to encourage graduates to return to the area after completing their training," Leapman said. "This collaborative will amplify the efforts of the medical school and produce a dynamic health professions educational environment with positive outcomes for the community."
In anticipating the need for programs like RHIC, the medical school two years ago increased its Terre Haute program's first-year class size by 50 percent, to 24 students, and since it was expanded again, to a 32-student cap. Supplementing that commitment was the announcement just a few months ago that all medical students accepted into the school's newly designed rural-focused curriculum would remain in Terre Haute for all four years of their training.
Leapman added that the total number of students enrolled at the Terre Haute program would grow again, from the current 32 to at least 64 "and possibly higher."
The partnership, which also includes Union Hospital, Indiana State University, Ivy Tech College Wabash Valley, Terre Haute Economic Development Corporation and the City of Terre Haute, has also recognized there is an important economic component accompanying any health-care initiative.
Family physicians in Indiana have an economic impact of $949,269 per doctor, per year, Leapman noted, adding that for every five jobs generated by the health-care sector, another four result elsewhere in the community.
Economics does affect health care, and there is a contingent of health administrators who argue states and the federal government should do more to incentivize new medical, dental and optometry graduates moving into rural areas by forgiving student loans, offering grants and loans for equipment purchasing and providing tax credits and assistance to establish clinics. But Yoder recognized that IU is also trying a new tactic as it searches for potential health professionals who in the future could be prone to go rural.
"Giving a dental student from the city a three-day rotation in the SEAL program in a rural area is not going to convince them that is where they want to work," she said. "Now maybe if you put them to work in a rural health clinic for six months; that would really work. But what you are seeing more of now are schools like IU School of Medicine recruiting more students from rural areas. I think that is a mechanism that is going to work because we need to be recruiting from where we need to send people."
Ryan Petty graduated from the IU School of Optometry and began practice in the rural community of Paoli in 2003. He agreed with Yoder that growing up in the 800-resident setting of Elnora set the stage for the high comfort level he now feels in his rural practice.
"Not that I was uncomfortable during the three months I spent (doing service learning) in downtown Indianapolis," he said. "But I don't think you may relate to people as well. And it's also as much or more about the patient's comfort level."
Petty said he sends patients to specialists in Louisville, only to have them return saying, "I didn't understand what he was saying."
The IU School of Optometry provides a myriad of service-learning programs that benefit low-income, rural families that range from ECCO (Eye Care Community Outreach) -- collaborative project with IUSM's Department of Ophthalmology designed to assist low-income families -- to the school's largest commitment, operating three eye clinics through its Rural Health Clinic Program.
Operating through clinics in Clay City, English and Jeffersonville, the program provides eye-care services and low-cost eye glasses to low-income, uninsured individuals of all ages. IU provides faculty optometrists at the clinics, most of whom volunteer their services, along with other volunteer optometrists and an annual cadre of up to 30 fourth-year optometry students.
The experience allows students to sense both the challenges and the benefits of working in rural settings and provides a foundation from which they can base decisions on about where they may practice in the future, according to School of Optometry community outreach director Dr. Jeff Perotti.
"The positives include a great number of wonderful staff and health-care providers who seem genuinely dedicated to the people they serve and remain committed to serving in rural America," he said. "The negatives are some difficulties finding providers and funding for providers to work in rural clinics."
Pointing out that support programs like Medicaid and the Health Indiana Program (HIP) "exist to help patients pay for their medical care," Perotti admits they "won't necessarily change access issues in rural America or Indiana."
But fourth-year IU dentistry student Natalie Muir believes she knows one way to address access issues in rural areas of Indiana. Expected to graduate this spring, the Noblesville native has practiced service-learning dentistry from the Amish country farm lands of Indiana to the rain forests of Ecuador (IU dentistry students also travel there annually), and though she may not seek out a public health-care position and is more likely to opt for private practice, Muir still sees herself as part of the answer.
"Taking care of patients in private practice is very rewarding, and even more gratification can be found in service," she said. "I am so thankful for all the experiences that I have had throughout my education, and because of them, I feel that I should give back to the community which has provided me so much. I do not necessarily want to pursue a position in public health, however, I guarantee you that in my private practice I will incorporate service to the underprivileged."
Especially hitting home for Muir were those days she spent at an elementary school in Frankfurt, knowing full well at the time that children with poor oral health don't perform as well and miss more school than children who receive regular dental care.
"I would love to spend one day every couple weeks in this clinic taking care of children who will not see a dentist except for those who volunteer their time," she pledged. "Community service is an integral part of dentistry, and it provides an alternative avenue for gratification within the practice."
