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NURTURING COUNTRY DOCTORS WHERE THE NEED IS GREATEST

When Christine Perry is asked about Dr. Reddy Rebala, she's quick to reply.

"He's a godsend in this area," she says.

Rebala and his partner, Dr. Ravi Kumar, are heaven-sent to their patients, who praise them as the kind of doctors anyone would want: patient, thorough and dedicated. They even make regular house calls.

Rural Western New York needs to find a few more like them.

Though medical professionals are readily available in Buffalo, its suburbs and the area's other population centers, people in the country often aren't as fortunate.

Many rural residents have trouble finding primary-care physicians who not only tend to minor medical emergencies, but also provide ongoing preventive care.

That's one of the reasons behind Gov. George E. Pataki's announcement last month of $28 million in state grants to finance primary-care programs in places like Cowlesville.

Rebala applied for one of those grants 2 1/2 years ago to set up the medical center in Bennington, the town that surrounds the hamlet of Cowlesville, just over the Erie County border from Marilla. But he didn't wait for it to come.

He purchased a former plumbing supply building on Route 354, equipped it and convinced Kumar to run it and staff it five days a week.

Rebala's faith has been justified, and his patience with the sometimes slow pace of government action was rewarded with the news that his application for $223,000 had been approved.

"When I came to this country, I felt I was very well taken care of," said Rebala, 63, who was born in India. "It's time for me to pay back."

His repayment helps address the long-standing problem of making quality health care available in places where it sometimes can be difficult to find.

The challenge of attracting -- then keeping -- doctors has been one rural areas have struggled with, according to Jerilyn Thornburg, who keeps track of medically underserved areas for the federal government.

"In New York, we know there were 100 health professional shortage areas as of Dec. 31," said Thornburg, director of the division of shortage designations for the National Health Service Corps.

"Residing in those designations are about 3.5 million people, and we estimate that out of those 3.5 million people, about 1.7 million are unserved because of primary-care physician shortages," she said. About 70 percent of those people live in rural areas.

Those are areas where there is fewer than one primary-care physician for every 3,500 people, or groups of Indian tribes, can be designated as health professional shortage areas. In Western New York's eight counties, there are 16 of these areas, one of which includes Bennington.

In addition, the government also designates medically underserved areas, using a formula that calculates infant mortality rates, poverty rates, percentage of the population that is elderly and the number of primary-care physicians.

Though Bennington isn't considered medically underserved, the nearby towns of Arcade, Orangeville, Sheldon, Java and Wethersfield are.

Nationwide, the National Health Service Corps estimates that about 45 million people live in communities, both urban and rural, without access to primary health care.

Reasons for the shortage

Why is it difficult to place primary-care physicians in rural areas?

There are several reasons, according to Dr. Thomas C. Rosenthal, who heads up the University at Buffalo's Department of Family Medicine and who began his career as a rural doctor.

More and more medical students opt for better-paying specialties, rather than what used to be called "family doctor." Rosenthal did a study showing that, in 1989, only 4.9 percent of the state's medical school graduates entered family medicine residencies.

"You can be a caring, wonderful ophthalmologist and make $300,000 a year," he said, "or you can be a caring, wonderful family physician and make $100,000."

Even if they want to go into family medicine, young doctors often owe several hundred thousand dollars in medical school expenses. Working in a suburban practice generally pays more, meaning those loans can be paid off faster.

With the exception of resort or retirement communities, rural areas also tend to be poor, which means doctors tend to charge less for their work and may have problems collecting what is owed them.

Dr. Tim Seiple, a family physician in Springville for 28 years, noted that HMOs have helped in that area.

"Back in the old days, our fees were consistently lower than Buffalo's," he said. "Today, they have an HMO, and we charge the same fee and are reimbursed at the same rate as somebody in Williamsville."

But Rosenthal said rural physicians are nearly three times more likely to list Medicaid, which generally reimburses at a lower rate than other insurers, as a major component of their practice than urban doctors.

Rosenthal's study also showed that doctors in smaller communities saw more patients each week, worked more hours each week, were on call more frequently and saw a patient after hours more often.

Other studies have shown that medical students from rural areas are much more likely to return to the country to practice, whereas one study showed that only 5 percent of medical students from urban areas are likely to settle in rural areas.

"But while 24 percent of Americans live in rural areas, only about 15 percent of the applicants to medical schools come from rural areas," Rosenthal said.

Medical professionals and surveys say spouses play a big role in attracting doctors to rural areas and in keeping them.

Wives of male doctors can find they have very little in common with the other women in the neighborhood, Seiple said.

"There's no special activities for the kids, like gymnastics," he said. "They can become very unhappy, and that situation can last two or three years before the spouse gives an ultimatum."

Seiple said his wife, Ginny, made the adjustment, "but it is a big adjustment."

Today, the spouse of a doctor is also likely to have a career, and it can be difficult finding a job in that field for the spouse, experts say.

"Half the medical students these days are women," said Elaine Brautigam, officer manager for Westfield Family Physicians, the Chautauqua County practice founded by her husband, Dr. Don Brautigam.

"Traditionally, when the male is a physician, a certain number of (their wives) are likely to be homemakers," she said. "Traditionally, if the woman is a physician, her husband is not likely to be a homemaker, and he's looking for a job in business or industry."

Brautigam also said doctors in more populous areas can more easily blend into the general population once office hours are over.

"Sometimes people would prefer that distance," she said. "They can practice in a suburb . . . and limit their relations with their patients to a professional relationship, whereas if we didn't take care of our friends, we wouldn't have any patients."

A number of agencies and programs are working to help lure medical professionals to the country and underserved urban areas, including the state program that resulted in Rebala's grant.

Since 1970, the National Health Service Corps has offered scholarships and loan-repayment programs to those who agree to practice in underserved areas.

Housing is an issue

Locally, the state's first rural Area Health Education Center opened in Western New York in 1999. Among its goals, according to Associate Director Jane Munro, is attracting medical students to do their rotations in rural areas.

But it's easier for medical students to do rotations closer to their schools, where they already have housing.

"If you're trying to get a student from UB to do a seven-week rotation in Allegany County, you've got to find housing or some other incentive," Munro said. "They're not going to commute."

One solution is renting houses for students, as the Western New York Rural Area Health Education Center has done in Chautauqua County.

Munro said the center is also working toward using videoconferencing and computers to help rural doctors keep up on the latest techniques and medicines, as well as deal with unfamiliar conditions and diseases.

"You want to be able to turn to somebody when you have a problem and say, 'I don't know how to deal with this, can you help me?' " said Sharon Mathe of the Southern Tier Health Care System, which also works to provide health care in rural Cattaraugus County.

Patients at the Bennington clinic don't have to go very far for both general and specialized care.

If specialists are needed, Rebala has arranged for them -- a cardiologist, a surgeon, a neurosurgeon, a urologist, an eye, nose and throat specialist -- to make regular stops at his clinic in nearby Alden.

Kumar, who runs the Bennington clinic, can provide ongoing treatment and take care of minor emergencies. His patients say they don't feel like they're being herded in and out of his office, and that he always follows up with phone calls.

"Everybody goes to him around here, my children and my grandchildren," said one of his patients, Florence Kluga, 64. "He sits there and talks with you. He takes his time every time."

Kumar, 32, said he enjoys the professional and personal relationships he has developed in Cowlesville. He said patients were reluctant to come at first because they weren't sure he would stay.

"I tell them I'm here to stay," he said. "I don't want to leave."

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