john-jonik-so-tell-me-how-were-you-ere-you-saw-elba-cartoonI was in a meeting today of the Alabama Family Practice Rural Health Board. Their primary charge is to improve health delivery in Alabama by targeting resources to improve health manpower, specifically by increasing the number of Family Physicians in rural Alabama.  The conversation soon turned to Elba, Alabama. Elba was founded as a ferry crossing site on the Pea River. Health care delivery in Elba has been problematic at least since the turn of the last century. From the Elba website:

The story of “Little Noah Tucker” is one of the most often remembered  and retold. Eleanor Talbot Tucker and her husband Ed Tucker became the  parents of Noah at the Elba Hotel during the flood. The mother had to be moved from room to room during the birthing because room after room  crumbled and fell into the swift water currents. The baby was named Noah since he lived through the flood like the biblical Noah.

While things may never get that bad again, there are problems on the horizon

The Board of Directors of the Health Care Authority of Elba, Alabama has announced that Elba General Hospital will close its Emergency Room and  discontinue accepting new inpatients as of January 31, 2013. Officials  say they’re working with area hospitals to transfer any patients who will need continued hospitalization.

The hospital completed a renovation exactly one year ago. The nearest hospital is appoximately 17 miles away.

The conversation at the meeting was about the closure and the story not told.

Rural hospitals are in trouble under the best of circumstances. The hospital in Elba provided limited services so many prospective patients did not even stop there, electing to go to Andalusia or Enterprise which provided a more comprehensive range of services. This had been going on for a while so was likely not the proximate cause. The reimbursement in Alabama is done in such a way that Critical Access designation, a lifeline for many rural hospitals in other state, is not a viable option for many hospital in Alabama. The fact that this hospital was less than 35 miles from its competitors may have precluded this option but, again, not a new problem

The death knell for this particular hospital was an older medical staff, unexpected illnesses, and no one in the pipeline set to return to Elba and practice Family Medicine, or any specialty for that matter.

The Office for Family Health, Education, and Research at the University of Alabama Birmingham, Huntsville Campus has just published an amazing study. They plotted out every rural Alabamian and every primary care doctor (87% are Family Docs). This report finds flaws in the current “pipeline” way of thinking, flaws that are exemplified by the situation in Elba. The report offers the following solution:

Its goal must be, at a minimum, to admit rural pipeline and BMSA awarded students to in-state family medicine residencies (Henderson 2003) and, during residency, promote resident/rural community relationships. Within the infrastructure of Alabama’s medical schools and current primary care pipeline initiatives, there is the potential to increase medical student selection of in-state family medicine residencies. However, there is no established method for directing graduated residents to rural communities other than the BMSA’s requirement of serving in an underserved community of less than 50,000 people and independent private based enterprises.

Nick Saban would never allow Alabama high schools to drop football in all but the largest cities. He knows that talent needs to be developed in many settings. The majority of medical students in state schools are from Jefferson, Mobile, and Madison Counties. The majority of Alabamians do not live in these counties. The pipeline has to start and end in the community.