PROGRESS 2014: Local programs hope to deter nationally declining number of health providers

Family practice residents, nurse practitioners vital to future of health care in area

By Katie Demeria

Family practices play a vital role in the daily health of many across the country. But for the past several decades, the nation has seen a steady decrease in the number of primary care providers, and that trend is evident in the Shenandoah Valley as well.

According to Dr. Frank Dennehy, director of the Front Royal Family Practice Residency Program, any solution to this lack of primary care providers is complicated and would involve a major shift in the country’s approach to health care.

But educational programs in the valley are still doing their best to hinder this trend on the local level — and their efforts have been largely successful.


Front Royal Family Practice’s Residency Program was founded in 1997 after a national study based in Richmond noted the severity of the shortage of primary care providers.

“It’s very hard to recruit trained people to an area, but it’s easier to train people and encourage them to stay,” Dennehy said.

The program takes three years to complete. Residents, who are already licensed physicians when accepted, are trained to become a family care provider, which means, according to Dennehy, they learn a little bit of everything.

Family care providers are trained to understand a wide variety of specialties so they can assist their patients’ daily needs, Dennehy said.

“If a doctor wants to do general care, they have to know how to take care of adults, both sick adults and in prevention; they have to know how to take care of children and how to do baby checkups, all of it,” Dennehy said.

Primary caregivers also have to cover obstetrics, because, for a long time, the reason people would go to the doctor is because they were pregnant, he added.

Family practice physicians’ knowledge reflects what health issues patients deal with throughout their lives. This is why it is such a vital part of health all over the world, Denney said.

“People in urban areas don’t have family practices, usually,” Dennehy said. “They go to a lot of different specialists for every symptom they have, and there’s no communication.”

While a general practitioner could look at all of a patient’s symptoms and pinpoint the issue as anxiety, for example, other multiple specialized doctors could not do the same.

Primary care physicians are an important part of the health of many people, Dennehy said — that is why their shortage is so serious.

“This is an issue we’re seeing all over the world,” he said. “Not just here.”

The curriculum for Front Royal Family Practice residents grew out of the knowledge that they would need to know how to care for an individual from conception to death.

“From that you get a general practitioner who knows how to do the bulk of what people need,” Dennehy said.

The point of the residency is to hopefully keep those physicians here in the valley.

“We’ve been successful, most are staying in Virginia, and most are in small towns,” Dennehy said. “We’re the largest source of the family practice doctors at Winchester Medical Center.”

Seventeen of the 62 family practice physicians who have graduated from the program teach in the Valley Health area, or the area immediately surrounding it, he continued.

Rural areas, Dennehy said, will sometimes see a shortage of care providers because those areas are also usually the poorest, and it is harder to keep physicians there.

He referred to the Shenandoah Valley, though, as the “land of opportunity.” All of Virginia is continuing to keep its younger residents within the commonwealth, so educational programs have been able to prevent the problem from becoming too severe.

The issue is not limited to family practice physicians, either. The nation is also seeing a shortage of nurse practitioners, who, though not trained to the same degree as physicians, are still able to provide primary care services.

Shenandoah University’s nurse practitioner program is designed to teach registered nurses the skills required to become a useful primary care provider in the current health climate, according to Professor Kathryn Ganske, Dean of the Eleanor Wade Custer School of Nursing.

“A lot of our students are from the local area,” Ganske said. “And the ones that are from here usually stay here and serve in the valley.”

Nurse practitioners work beside general care physicians, and in some areas of the country even run their own practices, Ganske said. A shortage of nurse practitioners is likely to have a serious impact on the national health care system.

“We know that there is an anticipated need,” she said. “Schools with programs are trying to accommodate that need with the number of faculty and clinical sites available to train their students.”

Shenandoah University has been trying to keep up with the changing demands their students are seeing in the medical world.

“This shortage applies almost everywhere,” Ganske said. “It’s all kinds of medical professionals, like pharmacists as well. And it’s changing the way our students are approaching the working world when they leave here.”

Nurse practitioners

With the shortage of primary care providers continuing, and an aging population threatening to make the need even greater, the area may see a higher demand for providers such as nurse practitioners, who can perform a wide variety of services.

According to Professor Patti Krauskopf, financial incentives will have to change as the demand adjusts and nurse practitioners play a more prominent role in primary healthcare.

“Nurses have to fight an uphill battle because there is money out there available, somewhat, to help fund clinical education for physicians,” Krauskopf said. “Practices get reimbursed for having residents and students in the office, but we don’t have that kind of educational reimbursement for nurses and nurse practitioners.”

Funding nursing programs so schools such as Shenandoah are able to take in more students and produce more nurse practitioners will play a vital role in fighting the shortage in years to come, according to Ganske.

In September 2013 the school was awarded a $1.1 million grant aimed at increasing nurse practitioners in rural areas by the U.S. Department of Health and Human Services Health Resources and Services Administration.

“And if we’re going to fight this shortage, we’ll need more funds like that,” Ganske said. “Because we need to keep up a teaching staff and continue providing clinical sites to our students.”

Shenandoah’s nursing program has been preparing its students to meet the changing health care climate. Nurse practitioners are expected to operate within a team now, providing a wider variety of services.

According to Sara Lombardi, nurse practitioner with Front Royal Family Practice, nurse practitioners are working collaboratively with general care physicians more and more.

For Lombardi, that type of health service usually works to the patient’s benefit.

“Nurse practitioners offer a different slant on health than is offered by physicians, because we have a nursing background,” she said. “We’re another piece of the puzzle, and can offer a different perspective.”

Nurse practitioners are trained to take a more holistic approach to health issues, taking into account a global picture of the patient’s background.

“We’re usually taught to have a more empathetic manner, where we know that sometimes it is just important to sit and listen,” Lombardi said.

For many rural areas, nurse practitioners are a vital part of the health systems, she added. They are sometimes the only medical professionals available for miles around.

“And that access to care is so important,” she said. “It takes a special sort of person to work in a family practice, and that includes physicians. You develop relationships with your patients that aren’t present in a lot of other areas — and a lot of times, those relationships can make a huge difference to the patient’s health.”

So while the shortage of primary care providers is a serious issue, Ganske and Krauskopf said, even over the next year patients may be able to see an improved health experience, with their providers all working together to create quality care.

Explanations for the shortage

The declining numbers of primary care providers has been evident since the 1960s, according to Dennehy. For many medical students, he pointed out, choosing to do family practice is not as exciting as pursuing a specialized medical field.

“Many students view the primary care specialties as a bit more hassle, harder work, and lower prestige,” Dennehy said. “And some people view that prestige in terms of average income.”

Areas like neurosurgery get a lot more attention, for example, than general care, Dennehy pointed out. Many medical students get drawn to more narrow areas, and those decisions are oftentimes based on a misconception of how much general care physicians must know.

“Because it’s not that I know everything, I do know a little bit about most things,” Dennehy said. “Everyone here is an expert in the common, and what happens a lot, and we recognize the other things.”

Another major factor into students moving away from general practice has to do with school loans. When many medical school students graduate with $200,000 in debt, Dennehy said, they are more likely to choose what is thought to be a prestigious, high-paying position.

“And they will overlook general practice as something that is not going to allow them to pay off those loans,” he said.

For Ganske, another issue present in the issue of declining primary care providers is an aging population.

As the Baby Boomer generation grows older and the level of care they require increases, they will need more health care services from professionals like family care physicians and nurse practitioners.

The implementation of federal programs like the Affordable Care Act is also increasing the amount of patients general providers must treat.

“There’s a huge amount of unknown with this,” Ganske said. “But with more insured patients you’re going to need more providers, and we will need more nurse practitioners to step in and provide those services. We’re gearing up to try and fill that need.”

Contact staff writer Katie Demeria at 540-465-5137 ext. 155, or kdemeria@nvdaily.com