WHITESBURG, Ky. — As a graduate of Harvard Medical School, Dr. Katherine Gish could have set up practice anywhere in the country. She chose to return to her hometown in rural Appalachia.

        The workload has been heavier and the paychecks lighter than she would have had in larger cities, but Dr. Gish said helping the sick in the impoverished mountain region is its own reward.

        “I've gained more by just being here than I could have ever gotten from a paycheck,” Dr. Gish said during a break from her rounds at the 90-bed Whitesburg Appalachian Regional Hospital. “If I wanted to go to an urban center and make more money, I could. That's not what I'm about.”

        Dr. Gish and other homegrown physicians who share a loyalty to Appalachia are helping to ease the shortage of primary care doctors in a region that has been declared “medically underserved” by the government.

        Some of the region's brightest men and women have recognized the need and are stepping up to fill the gap. Scores of physicians with local ties have opened practices in the region over the last decade.

        Dr. Michael Trivette, a graduate of the Marshall University School of Medicine, set up his practice in the tiny Pike County community of Meta, near the underground coal mines where he worked for 10 years. His sister, Dr. Brenda Baker, opened her family practice in the small coal town of Fleming-Neon after she completed her training at the same school.

        Dr. Trivette, who said he became a doctor to help the people of the region, never considered practicing medicine anywhere else. “I was born and reared in eastern Kentucky, and I'm perfectly content here,” he said. “The Appalachian people are special. They deserve the best possible medical care.”

        Dr. John Strosnider, dean of the Pikeville College School of Osteopathic Medicine, said the Appalachian region needs to make significant gains in doctor-to-patient ratios. The region overall has only one primary care physician for every 1,200 people. 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. Dr. Strosnider said that exceeds the standard in urban areas of one primary-care physician for every 900 people.

        “The need is so great here,” Dr. Strosnider said. “If you look at eastern Kentucky and the Appalachian states in the South, if every one of our students stayed right here, I don't know that we would ever have enough.”

        The Pikeville medical school, established in 1996 to help overcome the doctor shortage, has graduated 116 doctors. Nearly all of them plan to begin practices in underserved areas when they finish the three-year residency program, Dr. Strosnider said.

        Working in areas with few doctors is not only encouraged at the medical school, it is expected.

        Dr. Gish, 38, said she experienced the opposite at Harvard when she announced her intentions to return to Whitesburg as a primary care physician.

        “People told me, literally using the words, that I was wasting my education,” she said. “I was told I shouldn't have gone to Harvard if that's all I wanted to do. But people in Appalachia deserve the same health care as people in Boston or anywhere else.”

        Dr. Gish said small-town living has given her more time with her family, including her 6-year-old daughter and 7-year-old son.

        “It's absolutely wonderful for someone who is homegrown to come back and make a real contribution to improving the health and well-being of people,” said Dan Dickson, a spokesman for Appalachian Regional Healthcare, which operates seven hospitals in the mountains of Kentucky and West Virginia.

        Mr. Dickson said increasing the number of physicians is critical.

        “It takes a real commitment on the part of a physician to come to a medically underserved area,” Mr. Dickson said.

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