Ten years ago, West Virginia's officials realized that the number of the state's health care providers was dwindling. Forty-nine of the mid-Atlantic state's 55 counties were severely under served. Older doctors were retiring or dying, younger doctors were leaving rather than pay the region's highest malpractice insurance, while others simply didn't want the country lifestyle that goes with living and working in a mostly rural state. To help compensate for that decline, especially in rural areas, nurse practitioners began to grow in popularity. In Meadow Bridge, West Virginia this new breed of health care provider is making a difference.
Margaret Bruns felt that becoming a nurse practitioner would be a great way to help West Virginia's rural communities while advancing her own career. Like her fellow nurses, she can diagnose routine and chronic illnesses, but like doctors, she can also prescribe medication. However, since she did not attend years of medical school, she works for considerably less.
Today she's talking with patients Shawna and Ray Toth, who've come to the Meadow Bridge clinic. Mr. Toth has a severe case of poison ivy.
It's a good place to come," says Ray. "People like it here. It's a lot closer."
We're on a first name basis," says Shawna. "How many places do you know where you can do that?"
Mrs. Bruns has been visiting Meadow Bridge and other clinics in the area for about two years. She currently sees 10 to 20 patients a day, but expects those numbers to go up as she becomes better known. The nurse practitioner says that developing a rapport with patients is one of the first rules of good rural health care.
"The more they see you, the more likely they are to come back," says Mrs. Bruns. "If patients can be seen on a more regular basis, if they don't have to drive real far to get to the doctor, they are more likely to be followed for chronic illnesses, that need's pretty routine following like every six months, every three months, or even more often. We can hopefully catch things before we get to a stage where they need to the emergency room."
That's just one of many reasons nurse practitioners are so important to the state, according to Dr. Robert Walker, Medical Director of Marshall University's Center for Rural Health.
"Rural areas are often inhabited by a higher number of older people, people with no insurance, the poor, people with less education and chronic diseases, so really they often need even more care than people in urban areas," he says. "We should have more health care workers there, than urban areas, but of course we don't."
But he notes, those who do practice in rural areas are usually very committed to their jobs. Every day, Mrs. Bruns makes the hour-long trip from her home down winding, twisting mountain roads to one of a handful of clinics scattered in the isolated communities.
"We teach women how to do breast self-exams, then we follow that up with clinical breast exams yearly, we do the annual pap smears, teach family planning, and teach parents about children's development through yearly physicals, immunizations," she says.
Sometimes good health care also includes easing the burden of payment or doing away with it altogether.
"If you don't have insurance, medical care is extremely expensive," says Mrs. Bruns. "Paying out of pocket is a lot of pennies. The clinics I work for get federal funding for those who don't have coverage."
Besides working at the clinics, the nurse practitioner also visits shut-in's and local schools, where she does everything from treating minor illnesses to giving immunizations. Today, she's set up a tent at Meadow Bridge Junior High school's football practice to examine the players.
"We don't just deal with skinned knees and sprained ankles," says Mrs. Bruns. "We can talk to kids about nutrition and hopefully prevent some of the teenage risk behaviors that can cause trouble down the road."
Nurse practitioners are improving rural care not only with school visits and clinic appointments, but also through their influence on other health care providers. Mrs. Burns is often accompanied on her rounds by a health care student. The state's major universities recently made it a requirement that all their student doctors, nurses, dentists, physical therapists and even pharmacists do several rural rotations.
Dr. Robert d'Lesandrai, dean of West Virginia University's Health Sciences Center says it's an effective way to encourage students to stay in the state after graduation.
"It isn't so much that learning in a rural setting is different it's that the setting is different," he says. "What you learn in terms of caring for patients is the same. You see the same number of patients, you see the same kinds of problems, pneumonia, infections, high blood pressure, the living conditions are different, the social conditions are different, the impact that living in a rural area has on health is different and the life style is different. I think it's introducing students to the fact that they can practice medicine or their profession in a way that is both rewarding financially, socially and personally."
Dr. d'Lesandrai says the new emphasis on rural rotations has increased the number of health care students who stay in the state. Ten years ago, he says you could count the graduates opting to practice rural medicine on one hand. Mrs. Bruns says she thinks she knows why - many graduates don't consider rural work exciting.
"We're out in the middle of nowhere," she says. "We don't have the resources you do in a big city. I don't have three or four people who I can call for counseling. I have to do it. If that person doesn't want to go there, I'm in big trouble, cause I have no place to send them."
There are other challenges too, like trying to figure out how to get a patient who needs advanced medical care to a city with a bigger facility when that person has no gas for their car, or perhaps no car at all. But Mrs. Bruns says the benefits outweigh all that. Living and working in small towns gives young doctors the chance to get to know clients personally - as friends rather than just patients. A clinic appointment often ends with a hug good-bye and Mrs. Bruns says it makes it all worth while.
"I can't say I change peoples' lives but sometimes you say the right thing at the right time and you know, you've made a difference for the day," she says.
Dean Robert d'Lesandrai says nurse practitioners make a difference, not just for the day, and not just for patients, but for the entire health care industry.
"Physicians recognize that health care is best done by a team and all of us - all health care professionals need to work together to form that team, that helps to improve health care and the health status of people in different communities." he says. "I think NP and PA's have a very important place especially in rural communities in helping to provide health care."