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More than 60% of Kentucky's counties are considered to be health profession shortage areas, having far too few primary care physicians. Despite a recent increase in the number of primary care physicians trained by U.S. medical schools, the number in non-urban areas has not changed over the last 20 years (1). The published literature shows clearly that doctors tend to set up practice in towns like those in which they train (1). As shown in the Figure, the pipeline to the production of rural physicians begins with high school and continues through the retention of rural physicians in practice. This pipeline is described as "leaky," with many opportunities along the way for rural students to become attracted to big-city life during their education. Because of the "leaky pipeline" phenomenon, some medical schools now have regional rural campuses that provide an opportunity for students to spend the last two years of clinical medical school training in smaller towns.

Recent studies from the two traditional medical schools in Kentucky showed that there are some predictors of who will ultimately practice in rural areas in Kentucky. The study from the University of Kentucky (UK) supported the "affinity model" that suggests that a student who has a positive experience growing up in a small town is more likely to practice in a similar-size town (2). The study from the University of Louisville also supported the affinity model, but the mathematical model was better at predicting who would not ultimately practice in a rural area (3). The authors suggested that to make a significant impact, our medical schools would have to admit more of those from rural backgrounds, including some who are not currently applying. Although there are no published reports as yet, the Pikeville College School of Medicine (PCSOM) is an osteopathic initiative based on the affinity model, intended to produce physicians primarily for rural eastern Kentucky.

Education is a central element of the Trover Foundation begun almost 50 years ago in Madisonville by brothers Loman and Faull Trover. As it has developed into a modern rural integrated health system with a large multi-specialty clinic and a regional tertiary care hospital, education remains in the core mission. The Trover Foundation began the first Family Practice residency in the state in 1972, and 80% of the 176 graduates practice in rural areas. Almost 30 years ago, the U of L Department of Surgery began the Surgery Project that places 4-6 third-year medical students (M-3) at Trover each 8 week block for their required general surgery rotation (4).

The next phase of rural medical education at Trover began with the collaboration with U of L that created the Off Campus Teaching Center in Madisonville. Begun in 1994 with a proclamation by Governor Brereton Jones, only summer programs were supported until 1998. During 1998-2000, the effort was supported by one-time equal contributions from U of L and Trover Foundation. These contributions began the period of clinical campus activities, allowing rising third-year medical students to move from Louisville to Madisonville for their entire third and fourth years of training. During this period an on-site Associate Dean was recruited and the campus graduated 3 students, all entering FM residencies.

In 2000, the Madisonville program was continued through a special initiative from Governor Paul Patton's office using coal severance funds. During this time the Trover Campus further developed the pipeline activities, including college premedical programs and a High School Rural Scholar Program. The high school program was developed in close collaboration and co-sponsored with the West Kentucky Area Health Education Center (WAHEC). This program placed students in health care settings in their hometowns and provided a virtual classroom to assist them with development of skills needed to increase their chances to enter and complete a premedical curriculum(5). Although there are other programs that give these rural students the opportunity to go to a big city for a similar experience, the negative message in these programs is that to do something really special in health care one must leave the rural area. The Trover Campus program reverses that process, bringing the classroom to the students, allowing them to discover the positive aspects of small town practice as they shadow health professionals in their hometowns. Also in 2000, an elective course in Rural Medicine for M-2 students was developed in collaboration with the KAFP.

In 2002, the campus graduated 5 students who entered primary care residencies (2 FM, 2 OB/Gyn, and 1 Peds). The High School Rural Scholar program was expanded to 20 students and the virtual classroom activities increased significantly in sophistication through collaboration with Murray State University. Students from 65 Kentucky counties have participated in the Madisonville programs so far. The Trover Campus is unique and represents the best in collaboration between an urban medical center (U of L) with a commitment to train physicians who meet the state's needs and a rural integrated health system (Trover Health System) with a 50-year experience in training students. In addition, the administrative infrastructure now includes an on-site Associate Dean, a Director of Rural Health/Student Affairs, and other support staff. This allows the further development of the necessary pipeline activities for students beyond those at U of L. Premedical students from Murray State, UK, Brescia, Bellarmine, Transylvania, Western Kentucky, Centre College, and Kentucky Wesleyan College have participated in summer programs. The campus does bring new costs. In addition to the personnel, the rural campus requires new funding for video-conferencing equipment, as the Trover-based students receive all the same lectures as the Louisville-based students in real-time by interactive video connections (6). Fortunately, no additional facilities are required because of the contribution of existing facilities by the Trover Health System. With strong support from U of L, a proposal for Trover Campus funding was approved by the Council for Postsecondary Education for the 2002-2004 biennium, again funded by coal severance funds. Strong support continues from the office of Governor Ernie Fletcher, himself a family physician.

The Trover Campus has continued the development of all aspects of the rural education pipeline. This includes active involvement with the U of L admissions process to facilitate entry of more rural students. Almost 25 years of studies show that while students from rural backgrounds (and therefore much smaller high schools) have lower overall math and science scores on standardized tests, once they are admitted to medical school, they perform on par with their urban classmates (7). Using the affinity model, students from small towns (whether or not they are designated Health Profession Shortage Areas) are more likely to choose small towns to practice. The Trover Campus exists to give those students another two years away from the "urban disruption" that may result in their being attracted to a big city. At the same time, the campus provides the one-to-one instruction that community-based programs offer. Activities will continue at the premedical and high school levels to facilitate the success of promising rural students to prepare them for admission to medical school. Based on almost 30 years of experience with regional campuses in other states, the Trover Campus is expected to place practicing physicians in Kentucky's smaller towns. Early results show that more than 80% of Trover Campus graduates are practicing in rural Kentucky. This will begin to address the many health problems created by inadequate access to medical care. In addition, physician recruitment is a powerful economic engine for Kentucky's small towns. The Trover Campus Rural Pathways programs promote health careers at the high school and college levels, ultimately leading to more medical school applicants from small towns. This initiative is a unique collaboration, carefully crafted and proven, to assist development of Kentucky's rural areas into the CPE's vision of: "vibrant communities offering a standard of living unsurpassed by those in other states and nations."

References

1. Blackman JR. Predoctoral Education for Rural Practice. In Geyman JP, Norris TE, Hart LG (eds). Textbook of Rural Medicine. 2001. McGraw-Hill, New York. Pp 359-367.
2. Elam CL, Rosenbaum ME, Johnson MMS. Geographic Origin and Its Impact on Practice Location in Kentucky. Journal of the Kentucky Medical Association 1996; 94:446-450.
3. Looney SW, Blondell RD, Gagel JR, Pentecost MW. Which medical School Applicants Will Become Generalists or Rural-Based Physicians? Journal of the Kentucky Medical Association 1998; 96:189-193.
4. Polk HC. Can AHES Really Influence the Distribution of Physicians? Journal of Medical Education 1977; 52:633-638.
5. Crump W, McCall L, Phebus C, England L. The Rural Health Career Pipeline Program. Report of a Pilot Project, Summer, 2000. Kentucky Academy of Family Physicians Journal 2001; 47(2):16-18.
6. Crump WJ. Stepping into the 21st Century: Interactive Videoconferencing for Community-based Medical School Experience. Louisville Medicine 1998; 341-344.
7. Rabinowitz HK, Diamond JJ, Markham FW, et al. A program to increase the number of family physicians in rural and underserved areas: impact after 22 years. JAMA 1999; 281:255-260.