Rural medical communities: The call of the small

A nightmare episode has forced Dr. Martin Ellingham to give up a successful vascular surgery practice in London. He has developed a pathological fear of blood. As the recently arrived PBS series begins, “Doc Martin” has relocated to a tiny coastal town in Cornwall. He’s obviously less than thrilled with his assignment. Yet no matter how hard he tries to keep patients and neighbors at arm’s length, the people of little Portwenn insist on being friendly. That’s the way it is in small towns.

Meanwhile, in an equally tiny, far-northern Maine community, real-life nephrologist Jenie Smith, M.D., can’t help making the comparison: “(Portwenn) is Eastport,” she says. “I feel like I know every one of those people.”

But there’s a big difference. Smith is delighted to be near the ocean and to associate with people in a tiny island community on Cobscook Bay. There, she spends two days a week with patients at a dialysis center in Eastport, Maine, where she’s the director. Her delight at being near the ocean more than makes up for the 200 miles she drives from Auburn, where she lives, and Lewiston, where she’s in a group of five practitioners.

Her husband, a choral and orchestral conductor, often rides with her to Eastport, and they spend relaxing time at a beachfront cottage. But, she adds, “Wherever you go in town, you can still see water.”

After only one visit to the coast while in medical school at the University of Minnesota, Smith says, “I knew I wanted to be in Maine.” Thirteen years later, “I convinced my now partners that they needed me more than they knew.”

The story of the dialysis center itself is inspiring. Before it was built, patients had to travel for three hours or more, three times a week, for treatment in Bangor, Maine. Eight years ago, leaders at Eastport Health Care, the outpatient primary care facility, called a meeting to discuss what to do. As CEO Holly Gartmayer-DeYoung recalls, in a town of about 1,200, more than 500 residents came out. The consensus was that this was the most compelling need in the community. Fresenius SE & Co., a for-profit organization, agreed to build it and, says Gartmayer-DeYoung, “it became the focus of town fundraising for a year.”

Practicing medicine in a small, rural location

While Smith herself finds fulfillment in a practice that keeps her near the ocean, other physicians have found satisfying practices in various friendly, small locales across the U.S.  These niches are appealing for a variety of reasons, but mainly they boil down to (1) a penchant for small-town life—as opposed to overcrowded, congested metropolises; (2) a sense of obligation to care for often-underserved populations; (3) recreational opportunities tied to the great outdoors; (4) a penchant for history and tradition; (5) the self-reliant image of the people, and (6) the charming traditions, and even the one-of-a-kind shops and restaurants.

Considering their size, many communities provide sophisticated medical care and facilities, and they’re not necessarily as remote as might be expected.

Only about 12,000 people live in West Plains, Mo., but its commercial and medical services reach out to a 160,000-person population area. It boasts a “very, very vibrant downtown,” according to Chamber of Commerce director Joanne Wix. Its hospital, Ozarks Medical Center, has 114 beds, with staff physicians in most specialties. In addition, the small Southern Missouri Community Health Center operates in West Plains. Only a hundred miles away is Springfield, southern Missouri’s major population center. “That’s four lanes all the way,” says Wix.

Baker City, Ore., population 10,000-plus, is nestled between mountain ranges in far-eastern Oregon. In times past it was a well-known stop—or final destination—for travelers on the Oregon Trail. The ride is a little smoother these days along I-84, which skirts the eastern edge of town. According to its website, the local hospital “has been providing health care to humanity” on the trail for more than 100 years. The number of beds has definitely increased during that time, and so has the number of physicians. Last year, its name changed from St. Elizabeth Health Service when it joined one of America’s largest Catholic health organizations, Trinity Health and the Saint Alphonsus Health System, and became Saint Alphonsus Medical Center-Baker City.

In more than 60 years of operation, Allendale County Hospital in tiny Fairfax, S.C., on the Savannah River, has developed a tradition for long-time service by devoted physicians. Their portraits line the entry foyer. Today, its staff includes 20 physicians, but, according to ER practitioner Brent Alan Armstrong, M.D., more primary care physicians are badly needed. It’s a statement that echoes among hospital executives and doctors in all four communities.

The pioneers’ legacy: Baker City, Ore.

Considering its location in the far west, it might seem that Baker City, Ore., should be a sparkling modern city. In some ways it is. But its people are also proud that their town came into being because of courageous pioneers wending their way through difficult territory to an uncertain future in a faraway place. And they want to protect that heritage.

For a time, thanks to the pioneers, it was the largest city in the state. Today, a good number of Oregon Trail descendants still live there.

In the 21st century, the adventuring class is more likely to include whitewater rafters on the nearby Rogue River, one of nature’s several contributions to the area, which include Hells Canyon National Recreation area, the Hells Canyon Byway and other national parks. The Powder River runs through the center of downtown on its way to the Snake River. The Anthony Lakes ski area is a mere 3 miles away.

That location is a boon for Eric Sandefur, M.D., an orthopedic surgeon who arrived almost 14 years ago and is affiliated with Saint Alphonsus Medical Center-Baker City.
“My whole family skis,” he reports. He and his two sons prefer snowboarding, although “I don’t do crazy stuff like the boys.” His wife and two daughters are happier on skis. Hiking, mountain biking and rafting are also part of the Sandefur free-time menu.

Having grown up in a small Colorado town, he wanted to return to the west to practice and to a smaller community to raise a family. But when a recruiter called, the prospects in his home state were “places where I didn’t want to live.” Baker City fulfilled his requirements. For a big-city fix, Boise, Idaho, is just two hours away.

Today, he says, “People are more than happy to have an orthopedic surgeon here.” In the past, the nearest town for services like his was 45 miles away. He himself had to adjust to the lack of colleagues with whom to consult, and he missed the interaction with other doctors, residents and grand rounds. But the “homesickness” gradually faded as his practice increased. “For a town of about 10,000,” he notes, “I stay busy all the time and have a full-time assistant as well.” Not only that, “I have everything here that I need to do the practice effectively. If something is not here, I can get it sent in.”

As for the city itself, Sandefur says, “They’ve done a really good job of restoring Baker City.” Among the standout examples is the historic downtown Geiser Grand Hotel.
“It’s funny to see how oceanside people’s perception changes when they come here,” reports Davey Peterson, Saint Alphonsus’ marketing director. “A lot of folks have moved up here from California because they want to find some leg room.”

As far as he’s concerned, the city’s Chamber of Commerce slogan is just right: “The premier rural living experience in the Pacific Northwest.” But he hopes this kind of promotion won’t spark a great growth surge. “Otherwise, we’d lose what’s unique about the area.”

And Sandefur has been able to recapture a cherished part of his boyhood life. “I live outside of town on a very small ranch,” he says. “If I get stuck in the snow, I plow. If I’m gone, the neighbors do it.”

Practicing medicine in Ozarkland

After time as an employee in western Kansas’ natural gas industry, Selma Taylor, D.O., made a life-altering decision. “I was going to night school and got interested in medicine,” she says. Eventually, her interest led her to a degree from Kansas City University of Medicine and Biosciences, and a residency, with an Ob/Gyn specialty, on Long Island. But she wanted to get back to her native state.

“I had several interviews lined up through a physician employment agency,” she says. But then she looked on PracticeLink.com—and found the perfect job not in Kansas, but at the Ozarks Medical Center in West Plains, Mo., about 160 miles due south of Jefferson City, the state capital, and within a wink of the Arkansas border.

“For a town this size, it’s a remarkable hospital. (Most little towns) don’t come near the quality of medical care and the progressiveness of services.” There’s a very plausible explanation. It serves an 11-county area, it staffs 18 outlying clinics, and its medical staff numbers more than a hundred, with a total of 1,100 employees.

According to Colleen Schmidt, the physician recruitment director, “We’ve hired 28 new physicians in the last two years (including Taylor), we have most specialties on staff and also a brand new state-of-the-art ER with 16 private rooms.” Not to mention “close to 600 deliveries a year.”

In fact, says Taylor, “We have more patients than we can fit in each day.” That includes “a large population of women past childbearing age.”

West Plains offers not only high-quality medical service but a vibrant and interesting city in its own right. The city promotes itself as “a great place to live, learn, work and play.” All the terms are relevant, especially the “learning” designation. More than 2,000 students attend Missouri State University-West Plains.

In 2006, the town was selected as one of 10 Missouri “inductees” into a special governor’s revitalization initiative. Today the uniquely designed Courthouse Square, dating from the 1880s, is a thriving center of activity with unique shops complementing the opera house and the courthouse itself. Some 50 dealers and the Window on the Square coffee bar occupy an Antique Mall, a bookshop features area histories and authors, and a specialty women’s apparel shop, the Kloz Klozet, attracts shoppers from miles around. Altogether, according to director Joanne Wix, the Chamber of Commerce counts more than 500 members. A few miles out of town, skilled craftsman Tom Rowley owns the busy Riverwood Stair Company, creating unique and intricate handcrafted staircases for customers within a 100-mile radius. After a nine-year hiatus in St. Louis, Rowley says, “This is where I want to live.”

But it’s the all-encompassing scenic wilderness, with a multitude of fishing and boating opportunities, that attracts most visitors. The 1.5-million-acre Mark Twain National Forest practically surrounds the city. The spectacular “Little Grand Canyon” and a 200-foot natural bridge beckon in Grand Gulf State Park. Trout, bass and catfish abound in scenic rivers, hundreds of wildlife species and flowers abound and fall foliage is spectacular. Taylor and her colleagues are anything but immune to these relaxing surroundings. In fact, she has no qualms about saying, “I’m a great fisherwoman!” But not necessarily for the legendary trout and bass. “I go for the catfish.” In Missouri, that’s no small quarry, either.

While the medical center provides almost any kind of care imaginable, the Southern Missouri Community Health Center serves its own clientele but with a minimal staff. Last year, primary care became much more quickly available when Leann Benson, M.D., signed on as the center’s second internist. Her husband, Garry Finke, M.D., became the first pediatrician on the staff, another very welcome arrival. Before that, they had spent two years as medical missionaries in Kenya. In a way, the West Plains center is an extension of that service. “Our goal is to improve the health of the community, especially for patients who don’t have any resource to health care,” says Benson. “My husband and I both felt we had something to offer.”

Several factors enticed them to locate in southern Missouri, state funding for their positions being one. “But there are a lot of things (here) that we enjoy doing. We enjoy the outdoors, and my husband definitely enjoys fishing. We also like being close to a big city, Springfield.” With a 1-year-old daughter, Benson also likes the fact that she’s on call only one in six weekends. But job satisfaction is high on her list. “One of the things that has been really encouraging to me,” she adds, “is when I see patients for the first time and then they bring in their families. I enjoy getting to know multiple members of a family.”

For Schmidt, the medical center recruiter, West Plains became a refuge. “After working in corporate healthcare, I wanted to get as far away as possible,” she says. “This is a community where, as soon as you get out of your car and walk into a restaurant, you’re greeted with a smile. If your car breaks down, people rush to help. And when I bought a microwave, three different gentlemen stopped and asked to help carry it to my car.”

North by Down East

You can’t go any farther east in Maine without tripping into Canada. In fact, citizens of Eastport are proud to say that their town is where the rising sun first hits American shores. And you can’t go very far in any direction without crossing a causeway. The city is made up of islands, with Moose Island as its hub. It’s bordered by two bays—Passamaquoddy and Cobscook—that meet as they merge with the ocean.

While Eastport claims the title of the U.S.’ easternmost city, Lubec, its neighbor to the south and across Cobscook Bay, asserts that it’s the easternmost municipality, a distinction that makes most outsiders scratch their heads. To the north, across Passamaquoddy Bay, Perry is a Native American community. All three locations have health care facilities: Eastport Health Care, HealthWays Regional Medical Center at Lubec and the Pleasant Point Health Center, a facility operated by the Passamaquoddy tribe. The towns are among several in Washington County, and it’s not unusual for all of them to need new physicians from time to time.

The region’s two critical-access hospitals are located in Calais and Machias.

This is “a high-risk county for diabetes, cardiovascular disease, hypertension and chronic (behavioral problems),” according to Holly
Gartmayer-DeYoung, the CEO at Eastport Health Care.

The need for specialists in those areas is great, as well as family practitioners and/or internists. Gartmayer-DeYoung herself left the madding crowds of Long Island 13 years ago “to come to a place of sanity,” not unlike harried physicians who are willing to trade high pay and big-city amenities for the great outdoors with its beauty, solitude and sporting opportunities.
Telemedicine and a tradition of team-oriented family practice play a big part in patient care at the Lubec facility, which opened in 1971 and, as CEO Marilyn Hughes reports, developed from a one-doctor practice into “one of Maine’s largest rural community health centers,” although its current staff includes only two full-time M.D.s and one half-time.

Hughes emphasizes that the facility is “strictly outpatient,” providing a conglomerate of services from primary and dental care to child care and fitness center. Complex cases are transferred to a community hospital in East Machias, about 26 miles west of Lubec. HealthWays also provides care for newborns but Ob/Gyn care is no longer part of the mix.

The Passamaquoddy tribe is one of a group of Wabanaki tribes in Maine and in Canada’s Maritime Provinces. Its health center, Pleasant Point, on the U.S. side opened in the 1980s and offers primary medical and dental care, with specialty clinics based on such needs as podiatry, optometry, chiropractic and massage therapy. Like the other medical centers, it provides psychological and psychiatric treatment for patients with behavioral, alcohol and substance abuse problems. It has become a valuable backstop in the community, albeit with only one physician. Emergency and more serious cases are stabilized and transferred to hospitals in larger cities.

Eastport has suffered through business downturns. At its height of prosperity, in the 1880s, the town boasted 13 sardine canning factories, but they closed long ago. Today, some residents make their living by fishing and farming.

But new life seems to be arriving. On a small scale, its Victorian-style downtown has been attracting artisans and quaint shops. Most encouraging, though, is the burgeoning shipping business, thanks to the fact that Cobscook Bay is the deepest port on the East Coast as well as the closest point of arrival for European cargo ships.

The area’s maritime heritage translates into a plethora of activities for local residents, physicians and tourists whose passions include canoeing, kayaking, fishing and whale watching. There’s also no dearth of “landlubber” activities such as cross-country skiing, snowmobiling, hunting, biking and golfing. All in all, the Bold Coast, as it’s sometimes called, exudes a “call of the wild” ambience that can be very appealing. Jenie Smith, M.D., is pleased that she’s found the best of both worlds.

Laurie Churchill, M.D., has a different, but equally happy perspective. “This is my home, so that makes a difference,” she says. After eight years at Tufts University, a four-year public health commitment in North Carolina and a residency in Portland, Maine, she finally returned to her hometown, Calais, about 17 miles north of Eastport.

She spent 15 years in private practice, but the practice became more and more difficult to handle.

“You can’t do it very easily without some government funding, and you can’t do it with (longer patient visits),” she says. In January, her professional “pilgrimage” finally led to a clinic associated with Eastport Health Care. She’s proud of her meticulous on-time record in seeing patients. “If a case is complicated, I try to make the appointment before lunch—or plan for extra time with the patient,” she says.

While cultural events may be more modest than in bigger cities, Eastporters are proud of their Passamaquoddy Bay Symphony Orchestra, now in its fourth season, and a series appropriately titled Cabin Fever Concerts. Although some special events, such as the Lobster Festival, relate to the local culture, others, such as the Eastport Pirate Festival, verge on the exotic, although the pirate event does include a lobster boat race. A big tourist draw is the Down East Spring Birding Festival in May, which attracts dedicated birders from all over the U.S.

During this spring migration, binocular-laden visitors can search for almost 300 species, take boat tours and guided hikes.

In keeping with the Down East spirit of individualism, Eastport people join with their Canadian neighbors for their own unique way of marking New Year’s Eve. In New York, the big ball drops at midnight. Far north on the coast of Maine, it’s a double-header—two times in two different time zones. At midnight Atlantic time (11 p.m. Eastern), a maple leaf drops, and a band plays “O Canada.” An hour later, in Eastport, the “drop” is a paper sardine. The band plays “Auld Lang Syne.”

Working in Thoroughbred County

For job seekers, the good word at Allendale County Hospital in Fairfax, S.C., is that the search is always on for “an adequate number” of physicians to care for a growing patient population. Those who respond to the call will find themselves transferred to a location where the word “frenetic” hardly exists and where legendary hospitality is still alive and well.

It’s a Tennessee Williams kind of setting, complete with cypress swamps, historic plantation homes and live oak lanes. And, although the tourism slogan has it that “We’re WAY more than horses,” the term Thoroughbred Country isn’t amiss. There are miles of equestrian trails, and visitors can reserve vacation time in horse camps. There’s also a new kind of “leisure” opportunity, the Allendale Paleoamerican Expedition, an adventure in archaeology at one of North America’s most ancient, but only recently explored, sites. For $466 a week (the current price), enthusiasts can join the dig.

South Carolina has also become a golfer’s paradise, with some 300 courses throughout the state. But in Allendale County, halfway up the Savannah River, the slogan is, “Watch in Augusta, play in South Carolina.” In other words, game addicts can be spectators at the Masters tournament in the Georgia city, then head east to play only 20 miles away on the South Carolina side.

This town on the Savannah River is not so isolated as it would seem. Only about 80 miles south are the cities of Savannah, Ga., and Charleston, S.C., as well as Hilton Head Island. In fact, ER physician Brent Alan Armstrong, M.D., makes the commute to a Charleston suburb every week. For him, it’s an ideal situation. He covers the ER for 24 or 48 hours, two days, then enjoys his family for two to four days between shifts. “In a small community hospital I’m able to do 24-hour shifts because there’s a lower patient level, usually 20 to 40 in Fairfax,” he says.

“This is a better lifestyle, in my mind. I’ve got four kids, and I can see their basketball and lacrosse practices, and go fishing. I’m also available three or four days a week to help with homework.” And, he calculates, “For similar pay in the city, I’d have to do five days a week” Another serendipity: “I live four miles from the beach.” The cost of living, he adds, is “about average.”

Armstrong’s lifestyle, he says, is in line with a growing number of his medical confrères.

“Physicians don’t look at it like the priesthood anymore,” he says, “so why should we sacrifice ourselves and our families?” He adds that he chose his current situation over “a couple of lucrative offers in town.” Another major reason for his commute is that his wife prefers to live in a bigger city and has sisters in Charleston.

Hospital authorities take the critical care designation seriously. Following one of the guiding principles, they offer “swing beds” where patients can recuperate near home and in a more relaxed environment after serious surgery at a larger facility in another city. The hospital also provides hospice care in large, pleasantly furnished rooms set aside for that purpose.

Hospital personnel are especially proud of their role in the state legislature’s adoption of “Daniel’s Law,” which specifies that anyone who abandons an unharmed baby will not be prosecuted as a criminal. “Daniel,” only a few hours old when discovered in a local landfill, was named by nurses whose care saved his life.

It’s the kind of TLC that doesn’t surprise Armstrong. Having grown up on a ranch in Utah before arriving at the Medical University of South Carolina in Charleston, he recalls, “The first couple of years, the politeness almost blew me away. Now, when I go out west, I feel like people are rude because they’re not asking me what I’m doing.”

He—and the hospital administrators—would like to share the lifestyle with more primary care physicians, who are badly needed. It’s sometimes a four-week wait for a new patient to schedule an appointment, he reports. In the meantime, “20 to 40 percent of what I see is straight-up primary care.”