Name: Bob Moser, MD, FAAFP; CAQ- Sports Medicine
Clinic: Greeley County Health Services
Years a Rural FP: Twenty
HPSA-designated Community? Low Income
Critical Access Hospital? Yes, since 2003
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Profile of a Rural FP: Bob Moser, MD, FAAFP
Dr. Bob Moser, Lauren, Madison and Dalene
I knew I wanted to be a Family Physician from the time I entered medical school. I grew up in the community I practice in, which is rural western Kansas. My parents ran a local business that I worked at and it allowed me to interact with all ages in the community. I was one of the few boys who took the health occupations class in high school and though it was geared toward encouraging nursing training, I found I enjoyed the direct interactions with patients and the support of our medical community. I have tried to carry on the tradition since starting my practice. Many high school students have shadowed the providers and other health care department heads to gain insight to career opportunities. Many have gone on to health careers and some have returned home to provide their services in our communities.
Dr. Moser with his parents, Bob and Maggie
I attended the University Of Kansas School Of Medicine on the Kansas Medical Student Loan program that required me to serve 4 years in a medically underserved rural area of our state after residency. I chose a residency based on my goal to return to rural Kansas, Smoky Hill Family Medicine in Salina, Kansas. While there, all my elective rotations and extra work assignments I could find revolved around getting as complete a training in comprehensive family medicine as I could get. I wanted to experience delivering babies and attending to our patients in nursing homes, and feeling comfortable with all the various injuries and illnesses that rural family physicians see and manage in the emergency room. Many of the visiting family physicians that spent time assisting residents in clinic at Smoky Hill were rural family doctors, and listening to their life experiences and joys of practice only confirmed my choice.
Tribune, Kansas
Community
Tribune is a friendly, progressive, close-knit community. We are an agriculturally-based economy in a frontier area of western Kansas with a county population of 1400 people, with about 10% of the population Hispanic. We grow mostly wheat, but also some corn and milo. We also have cattle feedlots and a couple of large-scale dairies. The community has many activities for youth and adults alike with a Community Recreation Board, Senior Center, Community Band, and Community Theater group that has improved and operates the local movie theater. There are youth groups such as Boy Scouts and Girl Scouts, 4-H and others as well as adult social groups. It is not uncommon in a rural community to find yourself involved with more local activities then you can sometimes keep up with. Many of the citizens are active supporters of the school athletic and scholastic activities, even long after their own children and grandchildren have graduated. Religion remains a strong backbone of the community fabric in our community and there are many activities related to our church groups.
Tribune is a friendly, progressive, close-knit community. We are an agriculturally-based economy in a frontier area of western Kansas with a county population of 1400 people, with about 10% of the population Hispanic. We grow mostly wheat, but also some corn and milo. We also have cattle feedlots and a couple of large-scale dairies. The community has many activities for youth and adults alike with a Community Recreation Board, Senior Center, Community Band, and Community Theater group that has improved and operates the local movie theater. There are youth groups such as Boy Scouts and Girl Scouts, 4-H and others as well as adult social groups. It is not uncommon in a rural community to find yourself involved with more local activities then you can sometimes keep up with. Many of the citizens are active supporters of the school athletic and scholastic activities, even long after their own children and grandchildren have graduated. Religion remains a strong backbone of the community fabric in our community and there are many activities related to our church groups.
Greeley County High School
We have been challenged economically to remain a viable community. But within the last three years, community action teams and an economic development board have been very active and, as a result, many positive changes are occurring. Unlike most of the counties around us, we have actually seen an increase in our population in the last three years as a result of these efforts. We were one of the first counties in Kansas to consolidate all the rural school systems into one united school district and just this year, our community voted to consolidate our city and county governments into one board of Unified Supervisors. We will become only the second county in Kansas to do this.
Our health care system is one of the largest employers in our community, next to the school and local grain cooperative. The health care system has probably been the largest contributor to the economic development of our community in the last 15 years. When I started my practice, the hospital, clinic and nursing home employed about 45 people and the gross revenues for the hospital were around $800,000 with 24% of that coming from our tax base. Now we have over 145 employees, the health care system grossed over 12 million dollars last year and only 4% of that came from the tax base.
Greeley County Family Medicine Clinic
Clinic/Practice
Until 1954 when a county hospital was built and opened, our health care system was mostly based upon the physician and his clinic. In 1975, a newer 18-bed hospital was built next to the original one and the old hospital became the doctor’s clinic with a dental office attached.
When I started my practice in 1988, our county hospital was operated by an outside agency. Our physician’s clinic building was county-owned but operated by the physicians. Also, there was a county-owned nursing home operated by a different outside agency then the hospital. I joined a physician who had practiced in the community for over 30 years. We shared weekend call with a physician in another community 25 miles away and rotated local nightly call between the two of us.
When the older physician moved in 1991, I practiced alone. I was the County health officer, medical director of EMS, medical director of the nursing home, coroner and the clinic administrator as well as the only physician. I observed that the different health care entities in my county were taking care of the same patients, so having three different administrations didn’t make sense. With assistance from my hospital board, which is appointed by our county commissioners, we consolidated the clinic, hospital and nursing home all under one board.
I found out how little the government understands about the rigors of rural medicine when while seeking a partner, I was told we needed only one physician for every 3500 population. Never mind that I drew patients from areas beyond my county line, or that I offered a complete line of primary care services – deliveries (including c-sections), tonsillectomies, stress tests and endoscopies -- but had no time for those services as I was busy covering hospitalized patients, seeing clinic patients as well as covering our hospital emergency room. Because they didn’t consider our county underserved, we were unable to utilize some resources for recruitment of another physician, such as the National Health Service Corps.
In late 1991, the physician in the county north of us retired after over 30 years of service to his community of Wallace County. Their economic development director conducted a survey of the community asking with whom they would like to affiliate their health care. Our health care system was selected by over 60% of the respondents. I already knew that I was seeing more than 50% of that population so when they asked if I could help run their clinic to keep health care available locally, I asked my hospital board for assistance, asked my community to help by forming a recruitment committee, and we hired a mid-level to assist with the new clinic in Sharon Springs. I felt if we didn’t take the opportunity to provide service to this community, someone else would and our hospital admissions and my chances to recruit another physician would be adversely affected.
Until 1954 when a county hospital was built and opened, our health care system was mostly based upon the physician and his clinic. In 1975, a newer 18-bed hospital was built next to the original one and the old hospital became the doctor’s clinic with a dental office attached.
When I started my practice in 1988, our county hospital was operated by an outside agency. Our physician’s clinic building was county-owned but operated by the physicians. Also, there was a county-owned nursing home operated by a different outside agency then the hospital. I joined a physician who had practiced in the community for over 30 years. We shared weekend call with a physician in another community 25 miles away and rotated local nightly call between the two of us.
When the older physician moved in 1991, I practiced alone. I was the County health officer, medical director of EMS, medical director of the nursing home, coroner and the clinic administrator as well as the only physician. I observed that the different health care entities in my county were taking care of the same patients, so having three different administrations didn’t make sense. With assistance from my hospital board, which is appointed by our county commissioners, we consolidated the clinic, hospital and nursing home all under one board.
I found out how little the government understands about the rigors of rural medicine when while seeking a partner, I was told we needed only one physician for every 3500 population. Never mind that I drew patients from areas beyond my county line, or that I offered a complete line of primary care services – deliveries (including c-sections), tonsillectomies, stress tests and endoscopies -- but had no time for those services as I was busy covering hospitalized patients, seeing clinic patients as well as covering our hospital emergency room. Because they didn’t consider our county underserved, we were unable to utilize some resources for recruitment of another physician, such as the National Health Service Corps.
In late 1991, the physician in the county north of us retired after over 30 years of service to his community of Wallace County. Their economic development director conducted a survey of the community asking with whom they would like to affiliate their health care. Our health care system was selected by over 60% of the respondents. I already knew that I was seeing more than 50% of that population so when they asked if I could help run their clinic to keep health care available locally, I asked my hospital board for assistance, asked my community to help by forming a recruitment committee, and we hired a mid-level to assist with the new clinic in Sharon Springs. I felt if we didn’t take the opportunity to provide service to this community, someone else would and our hospital admissions and my chances to recruit another physician would be adversely affected.
U.S. Congressman Jerry Moran, 1st District, Kansas, discussing rural health care with Dr. Moser and Dr. Wendel Ellis.
Our health care system began operating the Wallace County Family Clinic in January 1992. I continued as the only physician between the two counties and the sole provider for after hours and emergency care. The mid-level in Sharon Springs lasted 9 months. But by then, my community recruitment committee, with help from my old residency, landed a National Health Service Corps loan repayment family physician, Dr. Wendel Ellis and his family for our community. He joined the practice in July of 1993 and we were soon doing the procedures and preventive medicine I hadn’t been able to do because of the lack of time and support. Our practice quickly grew between the two communities.
As our practice captured more of the population between our Greeley and Wallace County practice sites, we saw the need for additional support services. In 1997, Brian Miller, RPT joined the system as our physical therapist and soon he was busy in three counties, as well. We also added a Home Health Agency in 1997.
We did not become a Critical Access Hospital (CAH) until 2003 as the program did not fit our model of care when it first started in 1993 as the EACH/PEACH program. When the EACH/PEACH program started, we would have had to stop doing surgeries and we didn’t want to be providing OB care 85 miles from someone capable of doing cesarean sections. Then when the CAH program began, we would have been restricted on the length of stay before referring the patient to the regional hospital or transferring to a lesser level of care if stable. When we were finally able to continue to provide the types of services we wanted and the CAH program allowed surgery services and a running average of 4 days for length of stay, we became a Critical Access Hospital. In the meantime, we were successful with several grant programs that allowed us to computerize our health care system, hire a behavioralist for our clinic and have a full time patient educator. We were one of the first rural healthcare systems to be named a National Center of Excellence in Women’s Health by HRSA. Also, we were able to recruit administrative and financial personnel that allowed our health care system to take over our own management as we formed Southwind Health Resources.
With the great contributions of Dr. Ellis’s skills and vision to our health care model and other family physicians and mid-level provider’s efforts, we now boast 4 family physicians, 2 mid-levels, a patient educator, Physical Therapy, Home Health Care and have a CT scanner, Nuclear Medicine, Ultrasound, Mammography, Cardiac and Pulmonary Rehabilitation and other services provided by outreach consultants. These services allow us to provide needed medical services in a culturally competent manner in the patient’s community. We do comprehensive family medicine care and now serve three clinics in three counties along the western edge of Kansas as well as two critical access hospitals between these three counties. In 2004, our name was changed to Greeley County Health Services.
Of the 4 current family physicians on staff in our health care system, one has family medicine and preventive medicine certifications as well as a MPH degree, one has family medicine certification, a MPH degree and experience with substance abuse medicine, and then my partner and I are certified in family medicine. I also held certificates of Added Qualifications through the American Board of Family Medicine in Sports Medicine and Geriatrics, though I recertified in Sports Medicine, I have allowed the Geriatrics certification to expire for now.
We continue to encourage local high school students to spend time with us in clinic and hospital settings to gain an understanding of the lifestyle and joys of providing health care in a rural setting. The students often remark how genuinely grateful patients in our practice are to have such health care services available locally. Perhaps we can change the perception that to returning to your home town doesn’t mean you haven’t achieved as much as you could have living somewhere else.
As our practice captured more of the population between our Greeley and Wallace County practice sites, we saw the need for additional support services. In 1997, Brian Miller, RPT joined the system as our physical therapist and soon he was busy in three counties, as well. We also added a Home Health Agency in 1997.
We did not become a Critical Access Hospital (CAH) until 2003 as the program did not fit our model of care when it first started in 1993 as the EACH/PEACH program. When the EACH/PEACH program started, we would have had to stop doing surgeries and we didn’t want to be providing OB care 85 miles from someone capable of doing cesarean sections. Then when the CAH program began, we would have been restricted on the length of stay before referring the patient to the regional hospital or transferring to a lesser level of care if stable. When we were finally able to continue to provide the types of services we wanted and the CAH program allowed surgery services and a running average of 4 days for length of stay, we became a Critical Access Hospital. In the meantime, we were successful with several grant programs that allowed us to computerize our health care system, hire a behavioralist for our clinic and have a full time patient educator. We were one of the first rural healthcare systems to be named a National Center of Excellence in Women’s Health by HRSA. Also, we were able to recruit administrative and financial personnel that allowed our health care system to take over our own management as we formed Southwind Health Resources.
With the great contributions of Dr. Ellis’s skills and vision to our health care model and other family physicians and mid-level provider’s efforts, we now boast 4 family physicians, 2 mid-levels, a patient educator, Physical Therapy, Home Health Care and have a CT scanner, Nuclear Medicine, Ultrasound, Mammography, Cardiac and Pulmonary Rehabilitation and other services provided by outreach consultants. These services allow us to provide needed medical services in a culturally competent manner in the patient’s community. We do comprehensive family medicine care and now serve three clinics in three counties along the western edge of Kansas as well as two critical access hospitals between these three counties. In 2004, our name was changed to Greeley County Health Services.
Of the 4 current family physicians on staff in our health care system, one has family medicine and preventive medicine certifications as well as a MPH degree, one has family medicine certification, a MPH degree and experience with substance abuse medicine, and then my partner and I are certified in family medicine. I also held certificates of Added Qualifications through the American Board of Family Medicine in Sports Medicine and Geriatrics, though I recertified in Sports Medicine, I have allowed the Geriatrics certification to expire for now.
We continue to encourage local high school students to spend time with us in clinic and hospital settings to gain an understanding of the lifestyle and joys of providing health care in a rural setting. The students often remark how genuinely grateful patients in our practice are to have such health care services available locally. Perhaps we can change the perception that to returning to your home town doesn’t mean you haven’t achieved as much as you could have living somewhere else.
Greeley County Health Services Long Term Care
Typical day
Since we provide comprehensive family medicine, our day often starts out making hospital rounds on our patients and setting up the day and week’s schedule with our office staff. We take care of calls and letters and lab results before clinic and then see patients in clinic from 9 to 5. Since we deliver babies, our clinic schedule often ranges from newborn and OB visits, well adult and preventive health visits, managing multiple chronic diseases, followed by assessing the capacity and needs for an elderly patient to continue to live at home independently and making nursing home rounds. No two days are ever the same. Since we usually know our patients outside of their health care as community members, we are often catching up just as old friends do before we get down to the task at hand. If an emergency call comes in during clinic hours, the providers in the clinic at that time are responsible to respond.
All of us have continued to do house calls as well when necessary for the patient or the family’s convenience. We rotate call at night as there is no emergency room physician to be found for more than 90 miles and besides, these are our patients who come in to the emergency room. Having more than one family physician in such a rural frontier area allows us to have one-in-four call so there is plenty of personal and family time available.
Since we provide comprehensive family medicine, our day often starts out making hospital rounds on our patients and setting up the day and week’s schedule with our office staff. We take care of calls and letters and lab results before clinic and then see patients in clinic from 9 to 5. Since we deliver babies, our clinic schedule often ranges from newborn and OB visits, well adult and preventive health visits, managing multiple chronic diseases, followed by assessing the capacity and needs for an elderly patient to continue to live at home independently and making nursing home rounds. No two days are ever the same. Since we usually know our patients outside of their health care as community members, we are often catching up just as old friends do before we get down to the task at hand. If an emergency call comes in during clinic hours, the providers in the clinic at that time are responsible to respond.
All of us have continued to do house calls as well when necessary for the patient or the family’s convenience. We rotate call at night as there is no emergency room physician to be found for more than 90 miles and besides, these are our patients who come in to the emergency room. Having more than one family physician in such a rural frontier area allows us to have one-in-four call so there is plenty of personal and family time available.
Challenges
The greatest challenge is recruiting physicians to this type of practice. There are a lot of misconceptions about rural family medicine and what is involved to provide it. On one hand, students are told family medicine isn’t challenging enough for their talents. On the other hand, they’re informed they can’t possibly know enough for the broad base of services family doctors provide.
Since students are mostly trained in a specialty-oriented medical school, often at a tertiary hospital, the environment often discourages primary care. We need the best and brightest capable of the skills and knowledge to provide and adapt to the needs of a community as well as the skills to manage many other aspects of health care. Federal and state programs underpay for primary care services and overpay for procedures, and believe that we can make up for the difference in volume. No matter how good you are, you will only be able to see a certain number of patients per day and still provide good comprehensive care.
Insurance programs underpay primary care, which further discourages students from choosing primary care when they have large student debts to address after training. Even though numerous studies have expounded the importance of a large primary care base in providing economical and quality medical care compared to one emphasizing specialty care, federal, state and local programs continue to underpay primary care.
I have felt the best way I can address the decreasing interest of students in primary care is to continue to provide opportunities for high school, college and medical students to rotate at our health care center, to see first hand that family physicians who provide comprehensive medical care can make a good living and have a rich and rewarding personal experience doing it. It has also led me to be actively involved in our state and national chapter of the American Academy of Family Physicians, as well as serving on a state primary care physician workforce committee to address these issues at the state and local levels.
The greatest challenge is recruiting physicians to this type of practice. There are a lot of misconceptions about rural family medicine and what is involved to provide it. On one hand, students are told family medicine isn’t challenging enough for their talents. On the other hand, they’re informed they can’t possibly know enough for the broad base of services family doctors provide.
Since students are mostly trained in a specialty-oriented medical school, often at a tertiary hospital, the environment often discourages primary care. We need the best and brightest capable of the skills and knowledge to provide and adapt to the needs of a community as well as the skills to manage many other aspects of health care. Federal and state programs underpay for primary care services and overpay for procedures, and believe that we can make up for the difference in volume. No matter how good you are, you will only be able to see a certain number of patients per day and still provide good comprehensive care.
Insurance programs underpay primary care, which further discourages students from choosing primary care when they have large student debts to address after training. Even though numerous studies have expounded the importance of a large primary care base in providing economical and quality medical care compared to one emphasizing specialty care, federal, state and local programs continue to underpay primary care.
I have felt the best way I can address the decreasing interest of students in primary care is to continue to provide opportunities for high school, college and medical students to rotate at our health care center, to see first hand that family physicians who provide comprehensive medical care can make a good living and have a rich and rewarding personal experience doing it. It has also led me to be actively involved in our state and national chapter of the American Academy of Family Physicians, as well as serving on a state primary care physician workforce committee to address these issues at the state and local levels.
Rewards
I get to live in a community and provide health care services to its citizens and see the benefits to the community as well as the individual patients. I have had the opportunity to see children I delivered grow up and become young men and women and start their own families. No other type of practice allows you to do that while also taking care of their extended family members. I also get to see the benefits of a strong health care system for our communities in regards to economic development.
I get to live in a community and provide health care services to its citizens and see the benefits to the community as well as the individual patients. I have had the opportunity to see children I delivered grow up and become young men and women and start their own families. No other type of practice allows you to do that while also taking care of their extended family members. I also get to see the benefits of a strong health care system for our communities in regards to economic development.
Advice
Find a rural family physician and spend some time with them in their community and with their practice. You will see the challenges, rewards and opportunities in rural family medicine in just one day of shadowing a family physician. Look at the community as you might when you would be ready to join them. As a student you might be more interested in activities for youth and college ages. But as a physician, you might be more interested in how active the ministerial alliance is with assisting those in need, how good the school system is, and what opportunities there are for your spouse or extended family.
Find a rural family physician and spend some time with them in their community and with their practice. You will see the challenges, rewards and opportunities in rural family medicine in just one day of shadowing a family physician. Look at the community as you might when you would be ready to join them. As a student you might be more interested in activities for youth and college ages. But as a physician, you might be more interested in how active the ministerial alliance is with assisting those in need, how good the school system is, and what opportunities there are for your spouse or extended family.
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