In 2006, when she found out she had breast cancer, Ginger Lovins of Shelbiana in Pike County made a vow to her mother: "Should something happen to me, I want you to know I gave it everything that I have, that I did what I felt was best."
For her, that meant going to Lexington — about 3½ hours away — for her treatment. There were doctors closer to home, but Lovins thought Lexington's cancer care specialists would be best for her.
So she made what some call "the bobsled run" down the Mountain Parkway to Lexington for medical treatment.
Lovins, 37, a mother of five, is now cancer-free, but her decision illustrates a dilemma in Kentucky medical care. There simply aren't enough doctors. And most physicians are clustered in the cities, so rural Kentuckians must travel long distances to get care.
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Kentucky's shortage of doctors isn't new. The state has never had enough doctors. It is behind in primary care, specialty care and care for patients who live in rural areas.
About 2,200 more physicians are needed in the state to meet the national standard of 267.9 doctors for every 100,000 people. Kentucky has about 213.5 active physicians for every 100,000 people.
"But we probably need significantly more just to keep up with the needs of the future," says Emery Wilson, director of the University of Kentucky's Office of Health Research and Development.
And, Wilson says, if federal health care reform is passed and access to health care eased for those without insurance, 600,000 additional Kentuckians will come into the health care pool, overwhelming the state's physician resources.
Now, a battle is brewing over how to give Kentuckians more medical attention in the future — as the state's residents, already beset by a host of health maladies, grow older and sicker, and more people seek care.
In one corner: medical schools, which are both adding new slots for more students and stepping up their efforts to train physicians to work in traditionally underserved rural areas.
In the other: nurse practitioners, who are pushing for an increased role in serving patients.
Increasing the number of physicians is a slow route, entailing getting students through four years of medical school and three or more years of residency. And medical schools can't easily expand.
Even if the number of medical students are increased at the state's three medical schools — UK, the University of Louisville and Pikeville's College of Osteopathic Medicine — "that's just a drop in the bucket," says Wilson.
The nurse practitioner way can be controversial. The Kentucky Medical Association opposes giving nurses more authority to do things such as prescribe medication without the supervision of doctors. And the fate of a bill in the General Assembly that would allow them to do so is uncertain.
Still, the need is there.
An unhealthy state
The health of Kentuckians isn't good. State health statistics show that more than a quarter of the state's citizens are obese, more than a quarter still smoke, and the number of diabetes cases and vehicle crashes is up. Of the state's 4.2 million residents, 13.3 percent are over 65, well above the national average.
One possible approach to caring for that population is to expand the role of nurses. Senate Bill 75 would do that, allowing them to prescribe a broader range of drugs, including controlled substances.
A second proposal, Senate Bill 127, would allow regional universities to offer a doctorate to nurse practitioners, delivering a group of extremely well-trained nurse practitioners into the state's health care ranks. The Council on Postsecondary Education has sought an attorney general's opinion on whether such an advanced nurse practitioner degree could be offered.
A nurse practitioner is a registered nurse with advanced training in diagnosing and managing common medical conditions. In some cases, nurse practitioners can be part of a patient's primary care.
But SB75 makes some doctors nervous. They fear Kentuckians may find themselves unable to distinguish who can best help them, particularly when they have complicated medical conditions.
"I'm not so much worried about who is what," says Dr. Baretta Casey, director of the University of Kentucky Center for Excellence in Rural Health in Hazard, who says she opposes the bills. "I'm worried about the patient."
Wendy Fletcher, a Morehead nurse practitioner who runs her own practice and is president of The Kentucky Coalition of Nurse Practitioners & Nurse Midwives, says such fears are groundless, that nurse practitioners are already leading the way in primary care in some areas of Kentucky and that the doctorate level of training is already the standard for nurse practitioners in some other states.
Nurse practitioners have been writing prescriptions since 1996, she says, and prescriptions for controlled substances for three years. What SB75 would allow, Fletcher says, is for nurse practitioners with clean prescription-writing records to write them for longer periods and in some cases without the sponsorship of a physician.
She says nurse practitioners write only 3 percent of the state's controlled substances prescriptions: "We are not contributors to the drugs problem, in any way."
Marty White, spokesman for the Kentucky Medical Association, says the KMA opposes the bill. "Nurse practitioners, he says, "have their place and are a valuable resource in the medical community."
"We just believe that if you want to be a doctor you ought to go to medical school," White said.
The provision that would allow nurse practitioners to prescribe powerful drugs is also a concern for some.
Dr. Boyd Buser, dean of the school of osteopathic medicine at Pikeville College says that, given "the serious problem that we have with prescription drug abuse and diversion in the state," it makes little sense "to increase the number of providers writing prescriptions for those substances."
State Sen. David Boswell, D-Owensboro, one of SB75's sponsors, says it's a move to assure that more patients have access to health care: "I think everyone realized that there are many parts of Kentucky that are medically underserved.
Still, the prescription drug concerns may be a tipping point for the bill.
Plugging the hole
Deborah Whitehouse, associate dean of the College of Health Sciences at Eastern Kentucky University, says the Kentucky initiatives for nurse practitioners are in line with the higher degree of training and responsibility that they are taking on nationally.
Whitehouse says she volunteers one day a week at a Richmond clinic heavily staffed by nurse practitioners where many people have no insurance. "That's the only way they get care. ... I see huge needs, particularly in southeastern Kentucky."
The advanced nurse practitioner programs, she says, would allow more patients to get a toehold in the health-care market.
"If you have enough patches, it puts it all together," Whitehouse said.
But Dr. Tony Weaver, a Morehead physician who mentors UK students studying rural medicine, is more skeptical about setting up nurse practitioners as potential physician-equivalents. "You need, at some point, the top of the medical team," he said.
And that top is the doctor, with other medical professionals elsewhere down the chain, he said.
Buser, Pikeville's dean of osteopathic medicine, agrees that the empowerment of nurse practitioners raises concerns about the degree of expertise being brought to patient care.
"Certainly we recognize the need for mid-level practitioners, nurse-practitioners and physician assistants to help serve the health care needs of underserved areas," says Buser. "But we believe the physicians .... should be the leader of the health care team."
He said a nurse practitioner's training is, from a clinical perspective, "roughly equivalent to a third-year medical student. Physicians certainly don't believe that a third-year medical student is qualified to provide comprehensive health care to citizens."
Whitehouse at EKU acknowledges doctors oppose the idea but thinks that nonetheless the state's medical care gap must be addressed. She notes schools such as the University of Kentucky and Bellarmine University, a private college in Louisville, already offer the advanced nurse practitioner's degree.
Dr. Douglas Scutchfield, a professor at UK's College of Public Health, foresees a possible future in which Kentuckians don't just go see a doctor, but check in at a "medical home" — an office that would include doctors, physician assistants, nurse practitioners and pharmacists, all working together.
At a "medical home" setup, a patient might come in complaining of a sore throat. The patient may initially be checked by a nurse practitioner, who may then catch a condition that spurs a referral up the line to a physician.
Training more doctors
Jay Perman, dean of the college of medicine at UK, says the school is working hard to boost the number of doctors it trains.
"We're trying to increase the output of physicians," he said. But "it's going to take a long time even if we expand like that" — he snaps his fingers — "to get doctors out into the community."
Five years ago, UK took in a class of 100 students per year; now that's 115, including students who will complete their final two years of medical school at Morehead to gain more exposure to rural medicine. If UK gets a similar program at Murray, that will add an additional 10 annual slots. The University of Louisville has a class of 165 students starting this year.
Part of the trouble with training more physicians is that it is both time-consuming and expensive — for both the school and the students. Estimates of the debt for graduating medical school students range anywhere from $100,000 to $300,000 and more. And it's widely agreed that graduating with a debt that is the equivalent of a home mortgage is a disincentive to practicing in one of the lower-paying specialties, such as family practice or pediatrics.
"You can't graduate with $350,000 in medical school debt and go to work for $125,000," says Scutchfield.
Perman says high debt loads force new doctors into higher paying specialties.
Scutchfield agrees: "The pocketbook nerve leads straight to the heart."
Buser's medical school in Pikeville figures that having a few more medical school graduates in the pipeline can't hurt. It has an entering class of 75, a number it hopes to increase to 125, and its primary focus is putting doctors into areas where they will practice — starting with training them in Pikeville.
But U of L tries to grab students even earlier, by trying to catch the interest of potential rural doctors in middle school.
Even that may be too late, says UK's Perman. He says the commonwealth's future doctors may need to have their interest tapped in elementary school.
"You've got to catch these kids early and keep the fires burning," says Perman. "The payoff is obviously a long way down the road."