THE WIRED PRAIRIE

By Christine Gorman

The people of Garden City, Kans., have always lived at the end of the world. In the 1870s and '80s, wagon trains plodded along the Santa Fe Trail for a month or more from Kansas City, on the state's eastern edge, to the scrappy little community near its western border. Even today the trip takes eight mind-numbing hours by car. No wonder Garden City (pop. 24,072) and hundreds of other rural communities in western Kansas have had a tough time persuading physicians to come and set up a practice. In fact, more than half the state's 105 counties are considered critically underserved for health-care needs.

For decades the state legislature tried to plug the gap with economic incentives. It offered scholarships to the state's only medical school, in Kansas City. It forgave hundreds of thousands of dollars in educational loans. But it was always the same story: no matter how generous the financial package, no matter how idealistic the students, after six or more years of advanced medical training, most newly minted doctors dropped any thought of hanging out a shingle on the prairie.

Now there's a group of Kansas nurses who think they have a better idea. Most of the time, they note, people seek a doctor for what is known as primary care: the aches and pains, the colds and allergies that are readily treatable. Those also happen to be the sorts of illnesses that nurse practitioners--registered nurses who have undergone an extra two years of medical training--are particularly adept at taking care of. So if doctors are scarce, then why not increase the number of nurse practitioners? And if moving to the city for training creates too many temptations to forget about home, then why not use interactive technology to bring the classroom to the prairie? Ideally, to complete their training, students who have strong ties to their rural communities would never even have to set foot on an urban campus.

The nurses are clearly on to something. Four years after they started the Kansas Primary Care Nurse Practitioner Program, almost 250 nurse practitioners have graduated. Two-thirds of them practice today in underserved rural areas. Most of the rest work in low-income clinics in the inner city. Indeed, the Kansas program has proved so successful that it is fast becoming a model for delivering basic health care in rural areas across the U.S.

Like an old-fashioned barn raising, it took the skills and hard work of hundreds of people to turn this vision into reality. Four different nursing schools pooled their resources to make classes available to students all over Kansas via compressed video, a medium that digitizes both visual images and sound, then "compresses" the information for transmission over high-speed telephone lines to specially configured television sets. But if any two people can be said to represent the heart and soul of the program, they are Helen Conners, 54, and Gemma Doll, 48.

An associate dean at the University of Kansas School of Nursing in Kansas City, Conners is that rarest of all professionals, a bureaucrat who is also a successful innovator. She conceived the idea for the long-distance educational program, drummed up the seed money and shepherded the concept through countless meetings and strategy sessions. "I've always enjoyed thinking about new ways of doing things," Conners says. "Once we got started, the whole thing just kind of snowballed."

When it comes to teaching medical techniques, of course, some of the instruction has to be hands-on, and that is where people like Doll come in. A longtime nurse practitioner from Garden City, Doll also happens to be a Dominican sister who lives in a modest home with two other members of her order. By day, Doll works for two community-health clinics that care for about 1,300 children, most of them Mexican American, whose parents may work but may not necessarily have insurance. In the evening she teaches local nurse-practitioner students how to suture wounds, treat joint injuries and interpret X rays, among other things. "The call to nursing came first, followed by the spiritual call," she says. "Ever since I was in the first or second grade, I've wanted to reach out and help others."

What links these two women--and dramatically shrinks the distance from Kansas City to Garden City--is one of the shrewdest applications of telecommunications technology that can be found anywhere in medicine today. In 1995 Kansas extended its network of high-speed telephone lines to reach Garden City specifically so that St. Catherine Hospital, a local 132-bed facility owned by the Dominican Sisters, could set up a compressed-video classroom and become part of the statewide nurse-practitioner program. "It breaks the isolation," says Doll, who sits in on her students' classes at the hospital. "It keeps us abreast of all the latest things."

Other health-care experts have championed various kinds of satellite broadcasts, which can cost $2,000 an hour, for long-distance learning. But the Kansans' choice--compressed video-- costs just $30 an hour. Its quality is almost as good as satellite TV, enabling students and teachers to interact with only a slight, almost imperceptible lag. And since transmission occurs over telephone lines, the cost of adding on to the network is relatively low.

Just as important, compressed video can serve many functions. When not being used for classes, for example, the network can be tapped for long-distance consultations with medical specialists. "You can see and hear all kinds of things with compressed video," Conners says. "You can hear subtle heart sounds. You can see into the ear better than you can with the naked eye."

Conners and her colleagues haven't stopped there. Instructors are adapting their course work for the World Wide Web. Students undertake collaborative projects, complete exercises and even take exams over the Internet. "It makes for a richer educational experience," Conners says. "There's no sitting in the back of the class, hoping you don't get called on."

All the technology in the world makes no difference, however, if people's lives are not changed for the better. And that is where nurse practitioners like Doll truly shine. When she started working in Garden City seven years ago, she was one of only two nurse practitioners, and childhood immunization rates hovered around 50%. Today there are six nurse practitioners, and immunization rates have jumped to 75%. That may not seem like much of a coup, but it means that somewhere there is a little girl who did not suffer brain damage because she never developed measles, somewhere a little boy who did not have to spend long weeks in the hospital battling whooping cough.

Doll has even revived the time-honored tradition of house calls. "Many of my patients don't have phones," she explains. "So if I want to know what's really going on, sometimes I just have to drive out to their house and find out." Patients pay $5, or whatever they can afford, for an office visit. Occasionally, Doll has taken her fee in enchiladas.

One of Doll's more successful forays involved a young mother and her baby girl, who did not show up at the clinic until the infant was six weeks old. "I realized the baby couldn't see," recalls Doll. "Her eyes didn't follow the movement of my hand in front of her face." In talking to the mother, Doll soon discovered that she could not see very well either, nor could the baby's older brother; they all suffered from congenital cataracts. An ophthalmic surgeon who flies in from Denver periodically agreed to operate on all three, but they kept missing their appointments. Finally, Doll drove out to their house and discovered the trouble: the mother did not want her children to wear glasses. After talking with Doll, the woman finally agreed to the surgery. "Now," Doll says, "everybody in that family can see."

Sometimes the work is harder than it needs to be. Kansas law does not give Doll or other nurse practitioners the same degree of autonomy they would enjoy in other states, such as Washington, for example. With some notable exceptions, Kansas doctors have been reluctant to give up their exclusive privilege of writing prescriptions. So as a compromise, nurse practitioners must develop a protocol with a local physician that sets out in advance which drugs they will use and under what conditions.

In rural areas, putting that compromise into practice can turn out to be a very convoluted exercise. The physician is not required to examine the patients or work in the same town as the nurse practitioner but is still legally responsible for the results. Adding to the confusion, each bottle of medicine must bear the doctor's name, not that of the nurse practitioner who ordered it. So if the pharmacist has any questions, it is the doctor, who usually has never seen the patient, who gets called. "It's a paper game, and it can inhibit the quality of care," Doll says. Nurse practitioners have tried to get the state to streamline the process but, so far, to no avail.

In spite of such obstacles, the Kansas nurse-practitioner program is starting to pay off. Eight students from the Garden City area graduated this summer without ever having set foot on campus. Five of them found jobs in southwestern Kansas, including two who serve towns with fewer than 5,000 people. Like Doll, they are committed to staying in their rural communities. But by maintaining their technological ties, they remain in contact with each other and keep up with medical developments.

As word of the program begins to spread, health officials from Nebraska to Australia are taking a closer look. Even some forward-thinking doctors have started to follow the nurses' lead. The University of Kansas medical school hopes to use the compressed-video network launched by the nurses to allow future medical students from rural areas the opportunity to complete as much as possible of their education right where they live. "Technology can't replace the content of what we teach," Conners says. "But it allows us to minimize the dislocations, and that's the key to keeping our rural areas healthy." That, and the ability to keep dreaming up new solutions to old problems.