Janet Sheridan: Winds of change for rural medicine

Each morning I wake up happy and mostly healthy in Craig, a town with 9,189 residents. When I moved here in 1996, my new hometown had eight family doctors serving the far-flung, hardy inhabitants of Moffat County.

Shortly after settling in, I had a routine physical to establish myself as a patient with a recommended, longtime doctor.

A few evenings later, I received a call about my lab results. Everything looked fine. I didn't receive this news from a nurse, office worker, or recording. Dr. Thomas Told himself chatted with me at length about my results, an unheard-of act in the urban area I came from.

Rural health care took on a rosy glow.

Eleven years later, the glow faded as word spread: Dr. Caroline Reilly, worn down by endless on-call hours, was relocating to Grand Junction. Dr. Told, unable to recruit a replacement, would close his clinic when he left to teach at a medical school.

Dr. Andre Huffmire, after 27 years of family practice, planned to retire. Around town, people abandoned weather as a conversation opener to ask, "What are you doing for a doctor?"

If doctors aren't accessible to provide care, universal coverage doesn't help. It unnerved me to be without a family doctor to accept my insurance card. It must frighten those rural residents who are responsible for children or who suffer chronic health problems.

Sixty-five million people in the United States live in areas where health care providers are unevenly distributed or too few. In Colorado, the underserved areas are primarily in 47 rural counties.

A majority of the rural counties, including Moffat, are subcategorized as frontier, with fewer than six people per square mile.

My mother once commented when traveling from Dinosaur to Craig through country beautiful in its barrenness, "I can see the bones of the earth. I like that. But living here would require pluck or pioneer ancestry."

Pluckiness would be helpful to folks in the 15 Colorado counties having two or fewer doctors caring for broken bones, flu, strange rashes, all the ailments encountered during a lifetime. I thought access to care meant having a doctor in town willing to repeatedly hear about my sinuses. When I consider the long, lonely miles many must travel for care, I realize how naÃive I was.

The causes of our primary-care dilemma are as numerous as our mountain peaks and can seem as insurmountable. Long-time rural doctors are aging; some are working fewer hours; many are nearing retirement.

The patient populace also has changed. They are aging along with the doctors, increasing in number and holding higher expectations for care as a result of technological and pharmaceutical advances.

As my uncle complains, "What can be so hard about finding a cure for foot cramps?"

Meanwhile, most graduating physicians choose to practice in urban areas. Rural communities are widespread, tucked near mountain passes or surrounded by acres of undisturbed plains.

They are places where a new doctor can smell sage and count constellations, but where he or she might be the only health provider in town.

Medical students train in cities; they consult with fellow professionals, access the latest equipment, practice in updated facilities - benefits not commonly found in Burlington, Westcliffe, Meeker or Wray.

Spouses may object to living in small towns and geographic isolation.

"Husbands and wives seem to be the biggest deal breakers for rural placement," explains Dr. Thomas Told, of the Rocky Vista University College of Osteopathic Medicine in Parker. "Rocky Vista targets students with rural backgrounds whose spouses are likely to have similar roots and appreciate rural living."

It's tough to lure new doctors and their families to a town with limited employment opportunities for the spouse, one restaurant, no airport and two letters missing on the gas station sign.

Money is also a stumbling block for young people considering a career in family medicine. Medical students pay for years of rigorous, expensive training; many take out loans exceeding $160,000. They leave their residencies ready to serve, sleep deprived and burdened with debt.

Specialists can repay loans more easily.

"Specializing," Told said, "is a matter of economics. Doctors leave medical school with enormous debt. The medical community's reimbursement system favors procedural specialties, not general care. Many new doctors have the heart to serve in rural areas, but not the means."

Patient load, lack of support from a larger medical community, and frequent on-call hours can overwhelm a rookie. According to Told, "We recruit primary-care physicians to our small towns, then work them to death. There is little privacy in rural areas; people know how to find you. Family doctors are available 24/7."

Dr. Reilly typifies Told's statement: "I was captivated when young by 'Sally Quinn Medicine Woman' and 'The Little House on the Prairie.' I wanted that life. All my decisions led to rural placement. "

"At first, my practice flourished, but after eight years I became one of two doctors in my clinic who delivered babies. I was on call every-other night, sometimes pulling overnighters, unable to attend my children's hockey games or take vacations. You can't be more than an hour away when on call. It was exhausting : too much."

After 10 years, Dr. Reilly left the rural practice she had looked forward to most of her life.

Programs now exist to attract a new generation of Marcus Welbys to remote areas: placement services match doctors with areas of need. Repayment programs help pay student loans in return for rural practice.

Medical schools have taken steps to graduate family physicians ready to practice in remote regions. Rocky Vista University College of Osteopathic Medicine in Parker was founded in 2005 to train students from rural backgrounds and place them in similar areas.

Back home, the situation has improved. Family physicians were recruited. Three months after Dr. Told left, I found another doctor, a young lady enlisted by Craig's Federally Qualified Health Center. She cares for me with skill - and comments on the novel I carry into the room.

My conversations with others who feared being without a doctor reveal that most, with varying degrees of difficulty and satisfaction, secured care. "It took four tries, but I'm finally settled," an older patient told me. "Here's hoping I die before this one leaves."

A crisis has been averted in this community and for now. But the reprieve could be temporary. Family practitioners recruited to Craig, Conejos and Crowley may or may not settle in and stay. And when they go, it hurts:

"I didn't want to leave Craig," Dr. Reilly confided, "but I had to."

"I trusted Dr. Reilly," a former patient lamented, "And she trusted my instincts as a mother. Losing her was devastating."

This column originally appeared in the Denver Post on Sept. 20, 2009.

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