This story is part of our series "Shortage in Rich Land" on Missouri's Bootheel region. Click here to see all of the stories.
It’s early morning. The sun is shining brightly on the corrugated metal siding of the Otto Bean Medical Center in Kennett, Mo., and inside the building, Judith Haggard is pricking the soles of her patient’s feet with a pin.
Otto Bean is part of the SEMO Health Network, a Federally Qualified Health Center which operates several clinics across southeast Missouri.
Haggard is a nurse practitioner and one of the ranking medical providers here at the clinic, which has no full-time doctor. She has just 15 minutes to spend with her patient, a 71-year-old diabetic on Medicaid.
Fifteen minutes is the standard length of a visit here. In that time she must examine and educate him, prescribe medicine and discharge him. Fifteen minutes, she says, is hardly enough time.
“Diabetics take longer,” Haggard says. “And you don’t get through with a diabetic in 15 minutes unless they are totally controlled. And that patient generally is not.”
In a perfect world the patient would see an endocrinologist – a doctor who specializes in diabetes. Time spent with a nurse practitioner, diabetes educator or even a nutritionist would make up for the time the doctor couldn’t give.
But this is the Bootheel, a region emblematic of the social and medical problems facing rural Missouri, and really, all of rural America. Life expectancy here is among the lowest in the state. A fifth of the population lives in poverty. About a quarter are smokers.
“If you look at a sociology map,” Haggard says, “we are the red flags of the state. We have the worst.”
And adding to those red flags is a critical shortage of doctors, especially for the region's poor, like the patients Haggard sees.
“It has been at least two years at this point [since we’ve had a physician],” Haggard says, adding, “And every time somebody leaves it's another full year at least before we get somebody back in.”
Every Bootheel county is a designated Health Professional Shortage Area (HPSA) – a measure of a population’s access to healthcare based on their ratio to providers.
There are three categories for which this distinction exists – primary medical care, mental health and dental – and the Bootheel is short on all of them.
For perspective, the Health Resources and Services Administration, for an area to be designated a HPSA its population to provider ratio must be at least 3,500 to 1 for primary care (3,000 to 1 in areas of high need). For dental the ratio must be 5,000 to 1 (4,000 to 1). 30,000 to 1 (20,000 to 1) for mental health.
Standing against the wall of a busy classroom in Sikeston, Mo., Sandy Ortiz reflects on the need those numbers represent.
“It’s such a simple statement,” she says. “We’re just short of healthcare providers.”
SEMO AHEC’s aim is to grow the area’s healthcare workforce and fill the provider gap. To do this, they give medical students in Missouri a taste of rural medicine by placing them in clinical rotations in the area; hoping the students like it enough to return here after their residencies.
But the Bootheel’s small communities lack the allure of big cities, as well as their critical mass of people toBootheel’s small communities lack the allure of big cities, as well as their critical mass of people to
sustain a medical practice. Even a loan repayment program through the National Health Service Corps– where doctors working at certain clinics in the area can have their student debt repaid by the federal government – often isn’t a big enough draw.
Usually it’s the people from the area who are most likely to return. And that’s why Ortiz and SEMO AHEC also work with students before they finish high school, which is what brings her to a classroom at the Sikeston Career and Technology Center.
“We do have some kids go into healthcare professions but they don’t come back to the area,” she says. “We just need to show more kids, get more kids interested in healthcare professions and then come back to this area to practice.”
One of those kids is 17-year-old Erin Schlitt, a student in the health occupations course. Before joining this class, Erin didn’t always see herself in a health profession. This was a chance to try it on for size.
“I knew nothing about [health professions]” Erin says. “I was like, ‘Oh I should try this [class] just to see if I like it and if not I can drop it at semester, no big deal.’ And ever since then I’ve liked it. Definitely changes the outlook on life.”
SEMO AHEC doesn’t run this class but they do visit once a month with a hands-on activity, sometimes taking the students out into the field. And they look for other ways to engage students like Erin with the kind of science learning that schools in small, rural districts generally cannot afford.
Pointing to a photo on the wall of the classroom Sandy Ortiz says, “This is showing a young student how to give injections on an orange.”
“The schools with budget cuts and such as," she adds, "we bring kids together and dissect cow eyeballs, we dissect minks.”
Today’s lesson is not quite as exciting. The students are learning about careers in oral health by playing “Inter-professional Pictionary.” Erin draws a picture with fellow 17-year-olds Kaylan Butler and Dajanay Wallace.
The girls were given only clues about which professional to draw, they think it’s probably a dentist though they’re not sure.
“Want to see our drawing?” Kaylan asks.
“No!,” Erin retorts. “It’s so ugly, it’s so bad.”
Dajanay is decidedly less embarrassed. She points out the details of the drawing.
“There’s the teeth,” she says, bumping the other girls out of the way. “There’s the toothbrush. There’s the mirror. There’s the little chair that they use.”
Kaylan joins in, adding, “and that’s the health professional person.”
While oral healthcare might not be their calling, all three girls do want to join the medical field. Erin is looking at anesthesiology, Kaylan at pediatrics and Dajanay wants to be a registered nurse.
From AHEC’s perspective that’s the first step toward success. The next challenge is getting them to return after they’ve been trained. And right now the girls are on the fence.
“I always wanted to get away from Sikeston,” Kaylan says. “But there is something about that hometown that you always want to come home to. I might come back. Start up a little business for all the kids who can’t afford it and try to give back to them later in life.”
“If I decide to come back,” she adds.
Erin is planning to go to college away from the Bootheel, and she think’s she’ll miss home.
“I’ll come home and be here for a few years,” she says. After reflecting further she adds, “then I’ll get tired of it and move away finally.”
Judith Haggard felt the draw of home 15 years ago when she finished her own training and started practicing down here in the Bootheel.
“It was everything they told me not to do,” she says about working as a nurse practitioner in Kennett. “'Don’t go without a doctor!’ But I was here. I lived here. I didn’t want to travel. And so it started.”
The hope now is that, when the time comes, these students will feel the same way.