Ashland, Kan., has a new model for rural medicine
04/29/2012 7:16 AM
08/08/2014 10:10 AM
Jerry Baker was getting ready for bed April 18 when the pain struck.
“My chest really ripped me,” he said.
Baker, 69, drove himself the few blocks to Ashland Health Center’s hospital. Later, he was taken 50 miles to the Dodge City hospital for surgery to correct complete blockage in an artery.
But he figures the emergency treatment he received from doctor Daniel Shuman and the nurses that night at his local hospital saved his life.
What if the hospital had been closed? Or if there hadn’t been enough staffing to have an emergency room? Or if no doctor had been available?
All are problems for rural hospitals in Kansas and across America. Openings for primary care doctors, physician assistants and nurse practitioners have almost tripled in Kansas since 2005.
It wasn’t too long ago that Ashland’s hospital went 18 months without a doctor.
But the hospital was running smoothly the night Baker arrived. In part, it was because Benjamin Anderson, the hospital’s young, innovative administrator, created a recruiting model based not on financial reward but on paid time off for volunteer and mission work.
“We don’t have the exorbitant salaries to get people out here,” Anderson said. “What we can give them is time off. We can give them quality of life.”
The bottom line: Those who have a heart for service in the mission field are drawn to filling the needs in small towns and are likely to stick around.
Shuman, 43, took Anderson up on that offer last July. He left a thriving practice just north of Austin to come to the southwestern Kansas town of 855 people, 2½ hours from Wichita.
“I’m doing better now because Dr. Shuman saved my life,” Baker said.
He shudders to think what would happen if the doors of the hospital ever closed. The hospital and Ashland’s schools go back and forth as the town’s largest employer.
“A hospital to a town like this is life or death almost,” Baker said. “If we lost the hospital, we will lose the school. If that happens, we’ll look like a ghost town.”
Rural hospitals everywhere have staffing concerns.
“Workforce shortage is acute at hospitals in rural America,” said Brock Slabach, regional vice president for the National Rural Health Association.
That includes Kansas.
As of last week, there was a shortage of 73 primary care physicians in the state’s rural areas, said Joyce Grayson, director of the University of Kansas Medical Center’s rural health, education and services office in Wichita. She oversees recruiting of doctors to rural Kansas.
“We fill a position and two more open up,” Grayson said.
In 2005, there were 81 openings for primary care doctors, physician assistants and nurse practitioners. Now there are 220.
There are plenty of reasons for the doctor shortage in rural areas, including less money and a lack of amenities in small communities.
Young doctors can come out of medical school with a six-figure debt. Rather than opt for primary care pay, they move into a specialty field. A cardiologist can command an annual salary of $1 million or more, Slabach said.
A brand-new orthopedic surgeon can make up to $450,000.
Family physicians average $175,000, Slabach said.
‘What do I do?’
Anderson, 32, was well aware of those issues long before he left his job recruiting doctors for a private firm in Dallas. Most of his clients were hospitals in rural areas of the country.
After visiting with CEOs of rural hospitals in Oregon in 2008, he began to question the purpose of his work.
“What I am doing is taking a doctor from one hospital and putting him in another one and charging 30,000 bucks,” he said. “That in itself is not gratifying.”
Anderson and his wife, Kaila, a teacher who will receive a master’s degree in social work from KU next month, knew they wanted more. He knew Kaila, who is from Sabetha, wanted to live in rural Kansas.
So he started making early-morning cold calls to small Kansas hospital CEOs with the following pitch: “I’m a 29-year-old MBA from Dallas. I want to be like you when I grow up. What do I do?”
Eventually, he was directed to what was described to him as the “challenged” hospital in Ashland.
When he took the job in January 2009, the 24-bed hospital built in the 1950s had been without a doctor for eight months and had had seven administrators and 11 doctors and physician assistants over the previous 18 years.
What’s worse, he knew the situation wasn’t atypical. Administrator turnover in rural Kansas hospitals averages every two years, Anderson said.
He had to find a way to do things differently.
For one, Anderson began collaborating with other hospitals in the area to share services and personnel to make the load easier for everyone.
But getting a doctor was a prime target. Physician assistant Jon Bigler had been handling all the duties, but he needed a break.
Anderson wanted a missionary-minded doctor because he knew that would be the best fit for a rural hospital.
“I’m not saying Ashland is Third World,” he said, “but we share some of the same challenges — access to health care. And the same solutions apply.
“The same people who are willing to live in the most remote parts of the world, they don’t need a Starbucks or Nordstrom, an airport down the street, country clubs or gated communities. These people are here to serve.”
Depending on skills
That would be Dan Shuman.
A former Army doctor who served a tour in Iraq, he has also been on missions in Haiti, Mexico and South America.
“One of the biggest questions people will ask is, ‘Why do you need to travel halfway across the world to serve when there are people right there in your community?’ ” he said. “Well, we drive right past those people every day. What am I doing to help those people?
“You go and serve and come back and you realize, ‘Oh, and some of those people are in my backyard, they’re my neighbors.’ There’s an awareness.
“Poverty in the Third World is at a different level. But need is need. Ultimately, money is not everyone’s need. There’s a spiritual need, an emotional need or just a need to know that someone cares about you. It doesn’t matter if you are in Mexico or in Wichita. Basic human needs are human needs.”
And so he and his wife, Meredith, and five children — including three girls adopted from Colombia — left suburbia to serve in rural Kansas.
“Yeah, there are challenges,” he said. “But you realize you don’t need things — like Target at 10 p.m.”
Having worked in Third-World settings also makes him a better doctor, he said.
“You are forced to be innovative in a Third-World country,” Shuman said. “You have to be creative. Often times here in the U.S., we say, ‘I don’t have this machine or what I need.’ You get over there and depend on your basic physical exam skills and listen to the patients.
“You don’t have fancy equipment to figure it out. It really helps my skills here. It’s easy to get in the trap of, ‘I don’t know what it is, so I’ll order a bunch of stuff or send them to a specialist.’ That’s not always the best thing for a patient.
“If I can figure it out, I can save people time, trouble, money and anxiety. It can make a difference in Ashland or Wichita.”
8 weeks paid leave
Before Anderson could think of recruiting someone like Shuman, he had a long talk in the fall of 2009 with physician Todd Stephens, who used to work in his hometown of nearby Minneola and had provided part-time primary care coverage at Ashland Hospital in the early 2000s. Anderson wanted to find out how to recruit a mission-minded doctor.
In 2008, Stephens helped start Via Christi Health’s International Family Medicine Fellowship, a yearlong program that trains young family physicians to deal with rare illnesses and primitive clinical conditions they’re likely to face as medical missionaries. He is the program’s medical director, based in Wichita.
From all that experience, Stephens gave clear guidelines that would encourage a doctor and keep the work load reasonable. Out of those discussions came the plan to offer a doctor eight weeks of paid time off to use however the doc wanted to use it.
“These small communities can’t dangle enormous salaries in front of doctors,” Stephens said, “but they can pay them with time off. Time is a valued commodity.”
The eight weeks comes from combining vacation, allotted sick days and time off for continuing medical studies.
“It’s not that much different from other places,” Anderson said. “We’re just wrapping it all into one big thing. If you’re not sick, ‘Merry Christmas, go use it.’ ”
It also keeps mission-minded doctors working in rural America at least 10 months of the year instead of overseas for 12 months.
“It’s better to have them for 10 months than not at all,” Anderson said.
While other rural hospitals, including those in Lakin and Minneola, use some variation of the model, Anderson also offers extra paid time off to all of his hospital staff. While a doctor starts with eight weeks, others start at four weeks and build up to eight.
“Ben has taken it to the next level,” Stephens said. “Offering it to all hospital staff is huge.”
But it’s even more unusual because Anderson took Stephens’ challenge to serve on the mission field himself.
“I’d never been outside of the country,” said Anderson, who grew up in the urban setting of Oakland, Calif.
In the fall of 2010, he and Kaila made the first of two trips to Zimbabwe. He helped put screens on missionary housing so cobras and malaria-infected mosquitoes would not get inside.
“I put my money where my mouth was,” Anderson said.
The boss wasn’t just talking about others serving; he was participating.
“It creates a bond and trust,” Anderson said.
And in the process, it creates a service-minded hospital setting that stabilizes health care in Ashland. The best retention plan is creating an atmosphere where people will want to stay because it fits who they are.
“That’s what really makes this model unique,” said Slabach, of the rural health foundation. “It focuses on overlapping of folks who have heart for missions and the needs.”
Not that the hospital’s board and community didn’t push back some when Anderson first presented the model.
“There were legitimate questions the board was asking,” he said. “Where is the boundary between faith and publicly funded health care? That’s the elephant in the room.”
The hospital is supported by city tax dollars.
“The board was wondering, ‘Are we bringing someone in who is stapling gospel tracts to prescriptions? Are we hiring a preacher MD? What are we signing up for?’ ” Anderson said. “There is a legitimate boundary.
“My faith motivates everything I do. But I’m not here to violate the trust I have with the people in the community by forcing my views on them.”
Kendal Kay, Ashland’s mayor and president of one of the town’s two banks, had his doubts, too.
“I’m a banker,” he said. “I’m always going to say, ‘How can we afford all this?’
“But then we got to the next level, and they collaborate with other hospitals. That’s where the financing and how they can afford it starts to make sense.”
Anderson said he doesn’t pressure hospital employees to use their paid time off to do faith-based mission work.
“If they want to use all that time for vacation, use it,” he said. “If they want to do volunteer work at the Denver rescue mission, go do it. We’re just giving them the mechanism to do what they want.”
Hospital employees must raise their own funds for mission trips, but some of the town’s seven churches have been quick to help with the finances. A community garage sale is being held next month to help pay for a trip by Anderson, a nurse’s aide and a hospital maintenance employee to Zimbabwe this summer.
A walk through the Ashland’s medical center gives a glimpse of a broad cultural setting. The staff includes a Hispanic office manager, a medical tech from the Philippines and director of the long-term care facility from Sierra Leone.
A Maasai warrior in Kansas
No one gets the culture of missions better than Lacey and Enkaiye Mollel.
Lacey and Enkaiye, both 26, were childhood playmates in Tanzania, where her parents were missionaries. She moved back home to Indiana to go to college, but stayed in contact with Enkaiye, who is a Maasai warrior.
They married in December 2009 and came to Ashland in November to work at the hospital. Lacey’s a nurse’s aide; Enkaiye is in maintenance and working hard to learn English.
“We want to serve the underserved,” Lacey said. “Small towns in this country function very similar in some ways to those in Tanzania. Very warm and welcoming.
“Sometimes we’ll go out to eat and find out someone has paid for our meal.”
Lacey admits that as a mixed-race couple she and Enkaiye get some double looks when they’re out and about. It’s not often that you see a Maasai warrior in western Kansas.
“We’ve had some challenges,” Lacey said. “But being in a community that is like-minded with a mission mindset makes your ability to handle the ups and downs easier because people will walk through the process with you.”
The hospital hopes to add more. Physician Brianne Clark, who is from Dodge City and has been on numerous on mission trips in the Amazon, is finishing her training in Oklahoma City.
The board is considering hiring Clark so she can start working in Ashland in August. She would work three days in Ashland and two days in nearby Laverne, Okla.
That would fulfill one of the other directions that Stephens gave Anderson: Don’t make a doctor work alone; hire a second doctor to avoid burning out one.
“Good doctors don’t practice alone,” he told Anderson. “The days of solo country doctors are over.”
So Anderson made sure Shuman has that help.
“Young doctors are trained to work among colleagues,” Anderson said. “They need to be able to bounce a complicated case off someone. And there’s a fear of isolation. It’s scary to be out here with all the liability associated now with health care.”
Kay, the mayor, said he understands it’s difficult to recruit doctors or other medical staff to rural towns. But he figures once Ashland or other small towns can get them away from the bright lights, they’ll stay.
“I like to go to the city,” he said, “but I like to come home better. I like knowing where the kids are going to school, who there friends are. Nine times out of 10, our driveway is covered with kids. It’s great.”
While the rural shortages are real, Grayson, the rural health director, said, “Kansas is also doing a lot of things right.”
To increase the number of medical school graduates, KU last year expanded its medical school in Wichita to four years and established a small, four-year campus in Salina. It also opened a pharmacy school in Wichita last year.
There are also several programs that allow doctors to have their student loans repaid by the state if they locate to a rural site that needs their services.
Seven or eight of Ashland’s medical staff have taken advantage of a new state program — rural opportunity zones — that waives state income taxes from 2012-16 for those who move from out of state into a county that has had dwindling population over the last decade. Clark County, where Ashland is located, qualifies.
“There is proactive working being done,” Grayson said. “But we need fresh ideas to change with the environment. An innovative model like what Benjamin created is the cherry on top.”
Caring with love
Apparently something is working right. In March, the Ashland hospital had 50 percent more patients than it did for the same month in 2011, Anderson said.
Certainly he’s made a believer out of Jan Shaw, a former hospital board member who was leery about Anderson’s plan.
And then for six months she sat in the Ashland hospital with her 100-year-old father before he died in February. She saw the loving care given to her father.
“The night my father passed away, a number of people who weren’t on duty or even on call — Dr. Shuman, nurses, Jon Bigler — came back in to just to be there,” Shaw said. “They were there because they really cared.”
Anderson is looking to add another nurse and more nurse’s aides for the center’s long-term care facility. But he wants the plan to grow beyond Ashland.
“I’m hoping to hand this blueprint off to seven or eight other towns in western Kansas,” he said, “so we can have medical hubs. We can stabilize care and will be able to recruit instead of having one-doc shops.
“The more medical missionaries we have in the western part of the state, the better off we’ll all be.”