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FOREST HILL, W.Va. (AP) - In the green hills along a narrow road to nowhere in particular, a stream of patients come and go from the small, nondescript doctor's office in the middle of town. Some pay for their treatment, some receive a dose of medicine unique to their rural setting.

This is where Dr. James Blume grew up. And, at a time when West Virginians worry about physicians fleeing the state to escape escalating insurance costs, this is exactly why he is staying put.

In this community of 75 where more horses can be seen sauntering around than humans, Blume counts 7,000 of the region's residents as his patients. The people he wants to help.

Between the family practice he has had in Forest Hill for 11 years and his work as an emergency physician at three area hospitals (Plateau Medical Center in Oak Hill, St. Luke's Hospital in Bluefield and Pocahontas Memorial Hospital in Marlinton) he works 365 days year.

Though his schedule allows little time to spend with his wife and seven children, Blume is happy he returned to southern West Virginia after 14 years away.

His job, he says, is his calling.

"God has a plan for everybody. Just takes a while to find it sometimes," said Blume, who recently finished a 5-year stint as preacher at the nearby Countryside Baptist Church. "I know this is God's plan for my life."

He's at the office during snow storms and power outages. When he was diagnosed with colon cancer last year, he saw patients the day after starting 10 months of chemotherapy.

"Me and him are buddies now. We're survivors," said 70-year-old Raymond Coleman, of Hinton.

Coleman sports a long curly, gray mane he grew after completing his own chemotherapy for thyroid cancer. He jokes with Blume about how the hair on Blume's legs is finally growing back.

Blume grins and blushes a bit.

Coleman, who worked in the coal mines for 37 years, is at the doctor's office on this Monday because of swelling in his ankle and pain in his lungs. He complains that he has trouble fishing because he can get down the bank, but not back up.

"Well, you just need a longer line then!" exclaims Blume.

The jocular relationship repeats itself throughout the day as the 46-year-old doctor makes his way through cramped halls decorated with pictures of the children he treats and the "Get Well" cards sent to him during his chemotherapy. He prides himself on the familial office atmosphere he and his staff have created.

"If I'm more accessible, then medical care is more accessible," he said.

In acknowledgment of his work and dedication, Blume was named Country Doctor of the Year by Staff Care, a Texas-based medical staffing firm that has been honoring rural doctors for eight years. As part of the award, a physician will cover Blume's practice for a week so he can take some time off.

West Virginia is the second most rural state in the nation; 41 of its 55 counties are considered a primary health care shortage area.

"It takes some special people to practice in the really, really rural areas of West Virginia," said Jill Hutchinson, executive director of the West Virginia Primary Care Association.

Doctors in remote areas feel isolated from the rest of the medical community and regularly labor under long hours. "They often times have a heavy case load if they're the only game in town," Hutchinson said.

In an effort to attract doctors to West Virginia, the state has implemented a number of programs using state and federal funds to provide sign-on bonuses and help repay up to $90,000 in educational loans.

Still Blume has found it difficult to attract a partner to his practice in the hills.

"I could put three or four family doctors to work here," he said.

On a Friday that started without a single scheduled appointment, Blume had seen 26 patients by closing time.

Another threat to a rural doctor's survival is the shrinking financial viability of the country practice, said George Wright, an economist and professor with the Department of Family Medicine at the University of Washington, home to one of six federally funded rural health research centers.

Rural areas are often too isolated and too poor to have a large enough economic base, said Wright, who conducted an economic study of rural medicine in Washington state.

"There is a need for their services, but not a paying demand," said Wright.

As medical costs and the price of malpractice insurance rise while the payouts from Medicaid and Medicare don't, the value of a practice in a poor area diminishes.

Summers County, where Blume's practice is located, has the state's oldest median age, 43.4. The area's median household income was $21,672 in 1999.

About 60 percent of Blume's patients are covered by Medicare or Medicaid, but these patients represent only a third of his revenue. He also sees patients who have no insurance at all.

"I see them and let them pay whenever," Blume said. "I typically don't want to know these statistics."

Many of the nation's rural doctors are exactly the type of doctor patients want.

"Patients who go see that doctor know he's there for them and not for a buck," said Wright. "These guys are heroes."

On a recent morning, as the stream of patients came and went, 60-year-old Bob Martin escorted his 81-year-old mother into Blume's office to check on her back ache. Martin's entire family comes to Blume for treatment, including his wife, who once nearly severed a toe with a chain saw.

"She hasn't had a minute's trouble with it," he said.

Martin was one of several patients who admitted they trusted Blume more than the local hospitals.

"If we didn't have Doctor Blume, I don't know what we'd do 'round here," Martin said. "He's a super good guy with it, good friend and all."