Painfully aware that recruitment programs alone were not enough to fill the need for physicians, people in central Appalachia developed a radical plan.

They created their own medical school and began training their own doctors.

The first group of 40 homegrown physicians from the Pikeville College School of Osteopathic Medicine finished their residency programs in July and have begun opening offices in communities throughout the mountain region. Hundreds more are in the pipeline.

"It's been a long road," said Thad Manning, who began his practice this month at Regina, a tiny coalfield community about 10 miles south of Pikeville. "You're talking quite a long period that you put your life on hold, without work, without income, but there's just such a need for medical care in this area."

When Paintsville attorney G. Chad Perry III first proposed a medical school in eastern Kentucky a decade ago, he said people scoffed. When he put up $1 million to help fund such a school, even the naysayers stopped and took notice.

Now, Perry, 75, has made a Pikeville graduate one of his personal physicians.

"When I recommended we start a medical school in eastern Kentucky, a few people said that Perry fellow must have something wrong with him, that can't be done," Perry said. "It's a blessing that's been a long time in coming."

For decades, the central Appalachian region has worked hard to increase the number of doctors in the area, primarily by recruiting physicians from other states and countries. Even so, the region has only about one primary-care physician for every 1,200 people, said John A. Strosnider, dean of the Pikeville medical school.

The ratio is even lower in the region's most economically distressed counties.

For example, Owsley County, with 4,800 residents, has only two doctors. Strosnider said that falls far short of the standard in urban areas of one primary-care physician for every 900 people.

"I could go to a larger city, to Lexington, to Louisville, but what you do there really doesn't make the difference like it does here," Manning said.

The Pikeville medical school, established in 1996 with $10 million from private corporate and government donors, has 270 students, with 180 more going through three-year residency programs.

Osteopaths undergo training similar to that of medical doctors, and like M.D.s can prescribe drugs and perform surgeries. Osteopathic medicine places a special emphasis on the interrelationship of organs and body systems.

Graduates are not only encouraged to work in communities with few doctors, but are expected to.

Manning said starting a medical school in the region was a great idea.

"Actually being trained here, I think, prepares us better to practice here," he said. "Out of the doctors coming out of the Pikeville residency program, we're all staying somewhere out here in Appalachia."

Strosnider said the medical school would not fulfill its directive if most graduates did not open offices in the mountains.

"Our mission was to try to get physicians who would be willing to practice in rural Appalachia," Strosnider said. "That's what they're doing. Most of them were picked from this area, trained in this area and did residencies in this area. They speak the language. They know the needs. That's the ideal family practice physician."

Strosnider said this year's crop of homegrown physicians will not be nearly enough to eliminate the deficit.

"We're not going to be flooding the market," he said. "There's a big gap here. We hope over the years to fill that gap."