I enjoyed talking with you earlier today. This response should help you with your plans to target young rural Nebraskans. I have also included some other important areas of concern. Some of these come from my past experiences as a 29yr old recent graduate of a Family Practice Residency Program who started up a solo rural practice in Nowata, OK, in 1983.
When I started practice, I knew nothing about the structure and function of rural communities and a key person for me (a non-rural) was the young newspaper publisher who taught me some of the ropes. Even rural background folk need to learn these ropes when they move to new rural communities. In some sense this was easier for me because physicians are expected to relate to the community. Other young people may not have similar connections other than through church. Rural churches and ministers may be helpful in examining and resolving these issues.
Another issue brought up by you and the Chamber is the lack of involvement of young people. I saw this as a key concern in Nowata as well. From my younger perspective, I saw several young people try to do something for the community, and for various reasons they failed and never tried again and some left, often with a resolve to never locate rural again. I had my own run in with the powers that be (noted below). In my own situation, I loved my rural practice and my position in the community. Nothing comes close to the feeling of belonging and being of service that I had while in Nowata as a rural doc. My CPA told me to practice good medicine for two years before getting "involved" but at the start I was not very busy, I really liked getting involved, and the town was in great need of economic development so that my business and others could survive (By the way the CPA that gave me that advice went bankrupt.). Within 6 months I was on the board of the Chamber of Commerce. I was an officer in Kiwanis the next year.
After 4 years there, I did not want to leave, but Nowata was a bedroom community of Bartlesville and the Phillips 66 difficulties there plus the loss of other oil-related jobs plus the agricultural setbacks of the late 1980s forced me to leave. They lost their Walmart and about 2000 of 12000 people from the county during the decade. When I left, 20% of the housing was vacant. I went from taking in $20,000 a month my third year to less than $6000 with difficulty covering expenses. As the new doctor in town, it was last in, first out. This was sad because only in the last year was I seeing the type of patients that I felt I would see for the next decades. Many had not seen any physician for the past 4 years since Dr. Reed died, and only now felt they knew enough about me to come in for a visit. Rapid turnover of physicians is a bad situation for rural communities and this may also be a factor in poor utilization of local docs.
My own run in with the community fathers (or mothers) came regarding two annual health fairs. I had participated in health fairs prior to practice. I wanted to initiate this project and I got some grudging support from the other doctors. The AARP and Kiwanis (I was an officer) gave good support. We had about 20 booths and drew blood for cholesterol, etc. I was able to work a deal with the newly completed city-county library that the Glass Foundation had constructed for the benefit of the community. I got over the phone permission for the use of this facility and really did not know who was on the city county library board, a key mistake. The hospital finally pitched in late in the second year’s fair. The second year I delegated out most of the booth activities and we drew 200 people with 60 volunteers. Two weeks after the second health fair, the city county library board called me in. I was very pleased with the fair and expected their help planning one for next year. The board grilled me for 30 minutes about the long lines (we opened one hour before the scheduled opening time), the black marks on some of the floor from moving furniture, and the fact that the furniture was left out of place. I stared holes in my shoes and realizing that further comment was useless given my current state, I excused myself. Needless to say I did not organize another fair. It was at that point that I also first entertained the thought that I might not be in the community for the rest of my life. Only about ten years later did I put the pieces together and realize that I needed the community’s informal designated health leader (the bank president’s wife) to accept the health fair or propose it. I had other run ins with the local hospital board about my proposal to broaden the hospital by adding a retirement village, do trauma preparation, deal with an incompetent physician, lease office space to a dentist (still never used since 1981), work more closely with community agencies, and maintain my office. The hospital board, all older, many with vested interests selling the hospital propane or other items, all with positions handed down from father to son, seemed unresponsive (the hospital is also run by someone else now).
Looking back on my own and other situations, part of the problem is that young people are impatient and expect immediate results. They often do not make key connections and build consensus. They are easily frustrated. Rural communities are often tough to penetrate if you want to have impact and make a difference. The one area that did help in this was the economic development training I received as a member of the local chamber of commerce. I also felt most supported by the local Ministerial Alliance, the AARP, the chamber, and the newspaper publisher. At times we kept a score sheet of control areas. The progressives like me had control of these groups and the school board, but the local governments, the hospital, and the banks (2nd safest bank in America there) were controlled by those who seemed happy with the status quo.
The older generation has the experience. If this can be matched with the enthusiasm of the young people, it would be great.
Another difference in the generations is the work situation. In Nowata, most of the younger families had two or more wage earners, or single parent mothers with jobs. Often one of these earners commuted to another town for work and often used them for other services such as health. In tough economic times, all that could worked at whatever they could find, and many of the volunteer groups suffered. We traced a lot of teen pregnancy to the fact that no one was home with the teens who then had plenty of opportunity to enjoy themselves without supervision.
Those who would get involved do, but with their families. They do Girl Scouts, soccer, T-Ball, Little League, 4-H, etc. In Family Medicine, our national leaders lament the lack of involvement of younger family practice faculty, yet they teach us that involvement with families is important. Many of us do get involved, but others are spending time with their families now and hope to get involved more later. About half of family physicians are females now, and nearly all of them have working spouses. This makes it tough for them to participate. It also is tougher to recruit female family physicians to small towns for this reason.
This will likely be the same with the technical or professional people that the Chamber hopes to attract to the area. One job is tough enough, but recruiting two professional or technical people is even tougher. The newly recruited high school football coach can often get his teaching spouse a job with the local school district, but the local physician may have a tougher time getting his or her spouse a teaching job or work as a CPA, computer programmer, or lawyer.
A person who may be helpful in understand the dynamics of rural communities and the attitudes of young people is John Allen, a rural sociologist at UNL. I am sure you have run across him before. You might want to organize a series of town hall meetings using local groups with younger members to get young people to voice their concerns.
The state is surveying new arrivals to Nebraska when they get a driver’s license. The information from these surveys may be a help.
The following is some information that I prepared about UNMC activities in the southlands. Some are specific to South Platte and some outside. The first part is more specific to addressing your concerns. The last part involves some areas of frustration that I and others experience regarding health care organization and recruitment. We, too, are losing young well-trained Nebraskans from the state. We only recently have realized that we need to work more closely with local communities and we invite your help in this area.
The area of community organization continually comes up as important to all these. Many times different groups in the state or even within communities are trying to do the same thing. Shared resources could help to provide a critical mass which could be more successful. Another sociologist, John McKnight, gave a super presentation at the Nebraska Rural Health Association. He talks about community organization and using local assets that often exist in every community. One key point he makes is working with associations of associations. The South Platte Chamber is such a group and is therefore in an effective position to make a difference.
Response to South Platte Request For Information
Options for Obtaining Information on Health Services State Health Department and UNMC Both have demographic information about many of the areas in the South Platte. David Palm at the Health Department and Keith Mueller at UNMC are key contacts. Keith mentioned some study of young people leaving the state as well.UNMC Community Connections Program Physician Assistant, Nurse Practitioner, and Medical students receive two weeks of training in this program sponsored by the National Health Service Corps amd the State Health Department. Students then work with rural communities by doing needs assessments for rural hospitals, health departments, and managed care activities. Sites in the south include Pawnee City (hospital), Lexington (migrant population), Columbus (hospital and potential health department), Louisville (environmental concerns). Other underserved sites are north of the Platte. This is directed by Dr. Bowman wearing his Department of Family Medicine hat. Students do projects during the summer with some working part time on follow up of these projects in the fall and winter. Communities and hospitals willing to do projects involving health services should contact Dr. Bowman.
The cost of a Community Connections project is less than that of a phone survey, but the information and methods are different. The mailed survey approach costs about $3000 for the student and $500 for training, but local costs are much more. The local costs include survey preparation, a local coordinator, mailing costs, data input, software, and materials. Mailing costs can be extensive depending on % of the population surveyed and the response of the community. Local sponsorship by a hospital or community group is necessary. Projects sponsored by known groups with good media cooperation have a better response rate. The students spend about 6 weeks on site in the summer and the communities must have projects organized and waiting. Students can work with mailed surveys, do focus group interviews, and do some data entry (local help also needed). Modification of standard questionaires or questions to ask (plus probes) for focus groups does take some time and effort and preparation. The final product is a report of activities and impressions, and a database for further analysis. The process can be more open-ended if focus groups are used.
The cost of a consulting firm to do phone surveys done recently was $15000 for three communities for 750 valid final responses. Certain population groups can be targeted by consulting firms. They will pilot test the questionaire, allow and suggest some final changes, and prepare a database for further analysis by the contractee.
No matter which method is used, experience with asking questions is absolutely necessary as communities often ask too many questions (low response rate), questions that have no potential for action, or poorly defined questions with no hope of analysis.
Managed Care Demonstration Project The Department of Preventive and Societal Medicine works with the David City and by their request, the Southeast Rural Physicians Alliance, a group of rural physicians organizing to prepare for managed care activities in the future. Contacts are Dr. Gerald Luckey and Dr. Darrell Loschen. Part of the project is preparing a managed care notebook suitable for physicians and community leaders. Another part is collecting and compiling demographic and health service information for the physicians. One of the barriers in this group is lack of physician participation even though the group already has over 60 members in a short time. Success with groups like this will mean some rural voice in health services. Failure will mean rural communities are at the mercy of urban-based networks. The notebook and important information about those leaving local services will be available as a resource to other Nebraska communities. Contact is Dr. Bowman with Preventive and Societal Medicine.
Hospital Board Training and Leadership The START program was a strategic planning process in several rural Nebraska counties. START identified hospital board chairs that did not even know the approximate yearly revenues of the hospital. National studies show lack of hospital board training and activity to be a problem. START ended two years ago, but START leaders and materials are still available. Contact John Navis at UNMC.
Nebraska Rural Health Association has excellent sessions on topics important to hospital boards and community health leaders. UNMC and the Health Department support these sessions in a major way. NeRHA annual meeting is each fall in Kearney. State Health Department Office of Rural Health, other Health Department folks, some UNMC personnel available to help in a limited fashion with training. Contact Dick Spady, President of NeRHA.
UNMC participates in the training of agricultural leaders (LEAD Program) and has an internship for business leaders. This could be of interest to some.
Service Delivery Geneva, Cambridge, and McCook are currently 3 of the 5 Combined Outstate Residency Experience (CORE) sites. Sites in the south have included Superior and Imperial in the past. Sites must be short of physicians. Resident physicians go for two month rotations and see patients and share call. Each site has 5-6 residents a year. This 3 FTE rural physician equivalent of CORE is supplemented by resident weekend services on a locums or temporary basis, serving in rural emergency rooms. All CORE sites except one have recruited additional help during their 2-3 year time as a site. Other programs at Clarkson and Creighton have rural sites for training. Contact Jim Stageman, M.D., Program Director of the UNMC Family Practice Residencies.
Locums services to relieve local physicians are being explored by the Health Department and emergency physicians from Grand Island, Kearney, and Hastings. Contact Tom Rauner at the Office of Rural Health.
Poor Organization of Recruitment Activities This is a major problem with only the tip of the iceberg seen. Recruitment is difficult in Nebraska where over 50 small rural hospitals with less than 10,000 in their respective counties (3rd in the nation behind Texas and Kansas) compete with larger states, thousands of state and professional recruiters, and hundreds of major health care corporations. Over 350,000 Nebraskans live in these small rural counties that still have a hospital. The state only has one recruiter, Tom Rauner, to assist all of Nebraska. Economic impact is a key concern for the rural areas and the state, as each rural physician is worth $380,000 and 18 jobs as well as the survival of local health services in the area. Access to physician services also impacts on job and business recruitment and retention. Examples of some frustrations include the following:
Win and Place By Just Showing Up Over a year of repeated mailings failed to get five (of fifty) communities to turn in a simple listing to the health department. Mailings and calls for UNMC’s Annual Rural Recruitment Fair only turned up 16 rural communities interested in sending representatives. Each community gets a chance to examine nearly the entire primary care output of the state for the next three years at one convenient two hour session, meeting with all physicians assistants, most family practice residents, and nearly all family nurse practitioners. In order to meet costs, 23 booths needed to be sold. Due to the lack of rural community sign-ups, 3 urban networks and 2 Iowa communities were able to have booths. Of the 16 communities, only one bothered to send a physician as one of their representatives. Local practitioners are key components of successful recruitment. Communities have been encouraged for three years to come and meet residents at noon or invite them to evening dinners. This is the first year of any response at all and three rural communities have done so. One urban network found out about this and has held two events so far with more to come.
Advantage: a Nebraska Location Near AAFP Headquarters For years rural communities have been offered a chance to take a brief trip to Kansas City to meet with and recruit Family Practice residents at their annual meeting in August. Until last year no one bothered to take advantage of this. This year a few did. Only four communities jumped at the chance to visit the annual American Academy of Family Physicians even with the support of the Nebraska Academy of Family Physicians. This meeting has located two physicians for Broken Bow and over 100 contacts of experienced physicians who are thinking about moving.
Not Recognizing the Potential of Mid-Level Practitioners Of 9 graduating nurse practitioners, 2 left the state for other rural communities. When looking in Nebraska people did not make them feel comfortable. Family practice residents have also been unable to find suitable communities in Nebraska due to unrealistic contracting, poor local organization of the hospital or clinic, poor participation or resistance of local physicians, and other factors.
Failure to Address Critical Mass One community in the south woke up when they were down to only two physicians, but now they have none. Four to share call and support a hospital are a minimum. Communities with less than four physicians will need special efforts to survive. Physicians must have time off, especially female physicians. It takes months or years to get a practice going. Managed care groups estimate it takes an investment of well over $300,000 before a physician is productive in their employ.
Loss of Patients to Health Services Outside Local Physicians/Hospital Recent surveys of rural communities in Nebraska are in agreement with other rural studies showing outmigration to be a particular problem with young people in the community. A study showing some of the factors would be a significant and new contribution to the literature on health economics. Possible interventions are studies of young people, more inclusion of young people in health care leadership positions such as hospital or advisory boards, leadership training for young people.
General Health Organization The Health Department has assisted with the development of several physician and hospital networks in the area. Sheila Rowe has been helpful in several projects as the director of Rural Health Partners. This network includes most of the counties in South Platte. Ron Ross, former NeRHA president, has been active in helping to organize many rural practices into Rural Health Clinics, which take advantage of federal regulations to assist rural practices.
Prepared by Robert C. Bowman, M.D., UNMC Departments of Family Medicine and Preventive and Societal Medicine, 600 S. 42nd St. Omaha, NE 68198-3075, (402) 559-8873 or 8118 fax.