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May 1, 2008

Community profile: Upper Peninsula, Michigan

Gateway to the UP, Mackinac City overlooks the harbor.

Gateway to the UP, Mackinac City overlooks the harbor.

Anyone with less than a B.A. in geography might think of Michigan’s Upper Peninsula as a kind of Bali Ha’i, that mysterious "special island" hidden in the mist.

The more knowledgeable might recall this 16,452-square-mile piece of real estate as a territorial leftover the state got stuck with after losing the so-called Toledo War in 1836. Giving up a thin strip of northern Ohio was the price Michiganders paid for statehood. Most thought no good would come from owning this region cut off from "civilization" by cold Lake Superior, Lake Huron, Lake Michigan, and - more logically - part of Wisconsin. Some said its weather could be defined as "ten months of snow and two months’ poor sledding."

Skeptics would soon discover the advantages, and, much more recently, so would some enthusiastic physicians from other parts of the U.S., some with nostalgic childhood memories. Richard Armstrong, MD, grew up, coincidentally, in Toledo. "My uncle," he fondly recalls, "used to spend time at a cabin near Black Lake. I liked Northern Michigan probably better than anywhere I ever went as a kid. One morning, (a recruiter) called me. She kept going on and on about this great opportunity in the Midwest in a beautiful recreational area on the Great Lakes. I said, ’Where is this?’ She said, ’In the Upper Peninsula of Michigan. Now don’t hang up.’"

The opportunity was in Ironwood with another doctor practicing solo after his father’s retirement. "I flew up from Chicago. He took me out to a fish fry in a local bar." The next morning, they talked business, inspected the hospital, and Armstrong agreed to make the move. But, the clincher, as he describes it, was "the solitude, pine trees, sand, smell of the trees, the lake like glass, the sun coming up in a mist. They reminded me of my feelings when I was a teenager, and I guess it was that, more than anything, that persuaded me to come.

"(In Ironwood, with Grand View Health System) I did all the vascular, trauma, and chest surgery, and it was a very good practice," he reminisces. "We ended up doing a lot of innovative and exciting things. But (after 18 years) it got to be so all-encompassing that I couldn’t do anything else, so I decided to move." At the Helen Newberry Joy Hospital in Newberry, population 2,700, Wayne Hellerstedt, the hospital’s CEO, let him set up an ambulatory surgical practice. "We could perform all the routine things on an elective basis that are safe to do in this kind of environment." In return, he would not be on emergency call, there would be Thursday-to-Sunday weekends in summer, and eight weeks of vacation as well.

Low-key life meets technology

He remembers being "pleasantly surprised" at the hospital’s high-quality technology. "It’s a very nice hospital in a nice little community," he adds. The move illustrates another happy possibility for some UP physicians. They’re sometimes able to find work that doesn’t require a 24/7 commitment, although Armstrong isn’t sure that would be a good plan for a young surgeon eager to build an exciting career.

"We live in this little island of relative medical sanity in an insane country," he says.  "When I talk to my friends who practice in urban areas, they’re tearing their hair out. They want to quit, (but) I really like what I do, and the patients like me. I come home, and we’re happy, and it’s great."

The new life means he has time to take his 13-year-old daughter to school, where she immerses herself in music and drama opportunities. "(And, the family) can have dinner together and ski together in winter," Armstrong adds. In summer there are long weekends at a log home on a remote lake. Other Yoopers, as UP residents like to call themselves, revel in such winter activities as snowmobiling and, like those "Grumpy Old Men" from Minnesota, ice fishing.

There are cultural possibilities, too. Community theater, photography, and arts groups have sprung up in the area, and there’s a large country club at nearby Manistique.

Farther west, according to Tom Nemacheck, director of Michigan’s Upper Peninsula Travel & Recreation Association, the large Marquette General Health System and Northern Michigan University not only drive the economy but inspire a thriving cultural scene. The nationally known Pine Mountain Music Festival offers summer concerts, drama, and other shows in several cities. Farther north, on the Keweenaw Peninsula, other entertainment venues include the historic Calumet Theatre in Calumet and the Rozsa Center for the Performing Arts at Michigan Technological University in Houghton. (Locals nickname Keweenaw "the Upper Peninsula’s Upper Peninsula." It juts north into Lake Superior.)

Nemacheck admits that cultural possibilities tend to drop off farther east, but Armstrong has a ready "cure." He points out, "One of the great advantages of making enough money to be able to travel is that, if we want to, we can go to big cities like Chicago and Minneapolis. You immerse yourself in tremendously big places, then come back where things are quiet and you can actually have a life."

Lessons from the locals

A "life" is a prized possession for many UP residents. Possibly inspired by early, hardy immigrants from Cornwall, Finland, the British Isles, and other European countries, they revel in the uniqueness of the place and the self-reliance that equips them to cope with harsh winters when the snowfall, at least on the Keweenaw Peninsula, can reach 300 inches. And they enjoy demonstrating their independence. That includes a joking kind of patois, a hand-me-down from Finnish and Slavic immigrants. One sample: "Say yah to da UP, eh?" Translation: "See you at the UP. Okay?" Yoopers also like to twit residents of "that other part of Michigan" by calling them Trolls. That’s because the Lower Peninsula folks live "under the bridge" - the Mackinac Straits Bridge connecting the two parts of the state - as in the fairy tale "The Three Billy Goats Gruff."

Finlandia University, in Hancock, founded in 1896 by Finnish immigrants, is the United States’ sole higher education institution associated with their culture. Still-popular UP foods include the Finnish nisu (pronounced niss-oo), a sweet bread with cardamom seasoning, and the Cornish pasty (pronounced past-ee), a hearty turnover filled with ground meat and vegetables. Early miners pocketed and ate them for lunch while on the job.

What "miracle" was it that turned the 1800s skeptics into believers - and made the UP a prized property instead of a poor stepchild?

Tahquamenon Falls

A lucrative fur trade had begun soon after European explorers arrived in the 17th century, but it was a young New York doctor who spurred discoveries that led to America’s first great mining bonanza.  In 1830, Douglass Houghton arrived in Detroit. Inspired by reports of a huge, pure copper "boulder," he was eager to scour the UP for treasure from the land. Soon, "lower peninsula" Michiganders, contemptuous about the Toledo strip tradeoff, would rethink their attitudes.

Thanks to Houghton’s reports - and beating the California Gold Rush by about five years - prospectors streamed in to share the hoped-for riches from mining the "red metal."

By the 1860s, UP mines were producing 90 percent of America’s copper supply.  According to Angus Murdoch, author of "Boom Copper: The Story of the First U.S. Mining Boom," the Keweenaw Peninsula still holds the record for the "immense amount of copper from an infinitesimally small piece of the earth." It was in the purest state ever discovered, and at one point there were no fewer than 112 "discernible mining corporations" in just one county.

The UP’s economic history can probably be summarized in eight words: fur, timber, railroading, copper, iron, fishing, shipping, and tourism. Some, such as copper, came as booms and all but disappeared; others, such as timbering, are still viable. Iron/taconite mining in the Marquette area is thriving, thanks greatly to strong demand from China and other emerging countries.

"The Newberry area," says Armstrong, "was the big timber baron (headquarters) at the turn of the century to about 1930. They clear-cut the UP. There are pictures in Marquette showing hills completely bare." The timber companies have since replanted millions of pines and other trees, and dense stands abound once again, especially in three national forest areas.

For some physicians, "Upper Peninsula" spells "freedom," but with it comes a caution. "When you are going to be a rural physician, you had better be very sure of yourself and a really good doctor," says Carl Velte, CEO of Munising Memorial Hospital on the north shore of the big peninsula.

Challenges and changes

Now an independent practitioner in Hancock, on the Keweenaw Peninsula, Sigurds (Sig) Janners, MD, typifies the happy "loner" and embraces the "really good doctor" concept. Born in Latvia, he was brought by his family to America, grew up in New Jersey and attended the University of Virginia School of Medicine, followed by a residency in Ann Arbor, Michigan. He agrees with Armstrong about the lure of unspoiled nature. "The beauty of the UP is hard to deny because we’re right on Lake Superior," he says. "My first time to interview was June 1974. I came in on the last plane. The sun was just setting, and I thought, ’Is this real?’ The first place they took me was the overlook to the Portage Lake Canal. It was just so peaceful and beautiful!"

The possibility of "a variety of activity," mostly generated by the two area universities, Finlandia and Michigan Tech, made the place doubly attractive to him.

For the local hospital, now the Portage Health System, the timing for hiring new doctors was crucial. "The reality," Janners recalls, "was that medical care was atrocious. The hospital was run by the Sisters of Carondolet, who were very generous, but they were in debt up to their ears. They left within a year-and-a-half of when I came. The number of practitioners dropped precipitously to about five of us in primary care for awhile, and there was no ER.

It was like a pressure cooker," he remembers. "The downside was that it was very challenging. The upside was that you were doing a truly broad range of services and you were really needed."

Today there are 38 doctors on the active medical staff. "I’m one of the few not employed by the hospital," he reports, citing several advantages: "If you are employed, you are going to use the services of the hospital, such as physical therapy, and especially outpatient care. (For instance), I have a lab that turns (tests) around in half an hour. At the hospital it’s six hours." Best of all, in his opinion, "I’m not beholden to anyone else except my patients. They can call anytime, and I make house calls. I try to be what patients want as a doctor.

"The fun of being an internist is taking care of the tough stuff and knowing where the edges are and that the patients will trust you. What makes life interesting as a practitioner is the variety of cases."

He does admit to an occasional "complication," though. A favorite anecdote: "Blue Cross & Blue Shield once sent me a note that it would drop me as a provider. I didn’t match up with other servers they could find. They didn’t realize that I was saving them money."

For Terry Kinzel, MD, Janners’ partner for several years, freedom means he can choose an "unusual" lifestyle. Now limiting his practice to about half-time, he has found other satisfying activities, although he and his wife still enjoy biking, hiking, walking in the woods, and skiing.

Echoing some of the more extreme baby boomer trends, he admits that "my wife and I are pretty left of the midline. One of the things that concerns us is how we feed ourselves," such as inordinate amounts of corn fed to cows and the great distances to transport food items. "We raise geese and chickens and mostly trade for meat and eggs. We had some sheep, but that didn’t work out so well. I couldn’t slaughter them, so they’re pets now."

His wife volunteers with the Network in Solidarity with the People of Guatemala (NISGUA) and makes frequent trips to the Central American country, an interest sparked when she traveled there in 1976 to help earthquake victims.

You could say Kinzel inherited a "relationship" with the UP. His grandparents lived there but relocated to Detroit for work when the UP copper mines began closing. Decades later, Kinzel graduated from Michigan Tech. After medical school at the University of Michigan and residency at Michigan State University-affiliated hospitals, he rediscovered Keweenaw’s beauty.

He, too, winces as he remembers the dearth of practitioners in 1978 when he arrived. The expectation was that he and Janners would refer "tough cases" to a bigger hospital. "We received complicated patients and took turns on call for emergencies," Kinzel recalls. "There was no emergency room then. The practice was really quite, quite consuming."

Kinzel’s eventual "salvation" was to move into geriatrics and community mental health. He’s also medical director for the hospital’s long-term care facility and, most recently, has been working with the Veterans Administration Hospital in Iron Mountain.

Kinzel does lament the fairly recent arrival of "civilization." He says, "Now we’re on a strip complete with Wal-Mart and other big box stores in an area southwest of Houghton and Hancock. If you were transported blindfolded you would think you were almost anywhere, except for the cheaper construction." But area tourism people are proud of their designation by National Geographic magazine as one of the top 10 outdoor adventure spots in the United States. There are hundreds of miles of hike/bike trails, lakes and harbors for boaters, many trails or loops for snowmobiling, and - almost unique to the area - scores of shipwrecks for SCUBA divers to explore.

In fact, Sean Ley at the Great Lakes Shipwreck Museum says victims of Lake Superior’s all-too-frequent "temper tantrums" now number 550. At least 200 wrecks have happened near Whitefish Point, today’s museum site and one of the UP’s most treacherous areas. Over the years, professional divers have salvaged several of them.

Although practitioners like Janners and Kinzel have maintained their independence, they have by no means shunned the vast array of new patient tests and treatments. Neither have the UP’s five acute care and 15 critical access hospitals. While small, with less than 25 beds each, the 15 handle a multitude of outpatient cases.

Hospital care in the UP dates back to a time when the area’s reputation for "healthful air" attracted tuberculosis and hay fever sufferers. Early "care centers" were private homes, but today’s Marquette General Health System, the UP’s largest hospital, dates to 1896, a time when, among other lacks, there was no elevator. The superintendent carried patients upstairs on his back. Today’s large complex offers many specialties, and a number of its doctors act as consultants in other UP hospitals.

The modern face of UP medicine includes an exponential number of doctors, state-of-the-art diagnostic and other technology, available help from organizations such as the Michigan Office of Rural Health, the Upper Peninsula Health Care Network and the Telehealth Center, with 42 sites. It links local internists with specialists around the world, allows physicians to "attend" professional conferences and tune in on pharmacy and therapeutic health committee meetings without leaving home. "This builds efficiency like crazy," says Telehealth’s program director Sally Davis.

Thanks also to the State Office of Rural Health, "the hospitals have gone from isolated to a complete network," says Angie Emge, the hospital programs manager. The organization oversees group purchases of supplies, facilitates rural health clinics, monitors legislative activities, and advises on strategic opportunities for rural health improvement.

Some communities are starting fresh with state-of-the-art replacement buildings. Exhibit One: Munising Memorial Hospital opened in March. All 11 homelike patient rooms have scenic views of Lake Superior. "It’s like a shopping mall," says Velte, its CEO. "Once you’re inside you don’t have to leave the building," a huge advantage, especially for elderly patients who will no longer have to cross - and cross back again - an often snowy, icy parking lot.

The new building is a special triumph for him. "(Other administrators) can’t believe that we built a 60,000-square-foot hospital for $9,200,000," he says. Thinking toward the future, Velte also insisted on a wood-framed building so that interior walls could be quite easily reconfigured if the need arose.

Exhibit Two: Bell Hospital in Ishpeming, 15 miles west of Marquette, a Single-level, 102,427-square-foot building and the third incarnation of a 1917 structure built mainly with area iron miners in mind. The new facility focuses on patient convenience and staffing efficiency, and comes with an attached medical office building. With some 90 resident and consulting doctors, it can now handle many surgical procedures once farmed out to bigger hospitals.

Exhibit Three: War Memorial Hospital in Saul Sainte Marie, on the eastern end of the UP, bordering with Canadian sister city Saul Sainte Marie, Ontario. War Memorial just finished a new 30,000-square-foot rehabilitation center, helping the hospital double in size within the last eight years.  The hospital’s wish list for specialty physicians includes OB/GYN, internal medicine, ENT, dermatology and urology.

Searching for Dr. Right

But even with an exponentially increased number of fellow professionals, state-of-the-art facilities and ultramodern communications capabilities, Wayne Seibert, human resources vice president at OSF St. Francis Healthcare System in Escanaba, worries about recruiting certain specialists. The hospital, on the warmer Lake Michigan side, is one of the UP’s five acute care facilities.  Tiny-niche specialists seem reluctant to wear the generalist hats required at smaller hospitals, says Seibert. It does seem there are more than enough hospitalist wannabes but fewer internists, and recreational considerations are more prevalent than in the past.

"When we’ve had candidates here, they often are quite surprised at the level of our technology. But getting them here is the thing," Seibert explains. Among recent arrivals, though, are an OB/GYN from Lower Michigan and an orthopedic surgeon. Seibert’s search for "outdoor-oriented, four-season-oriented" practitioners continues.

Mark Povich, DO, is a family practitioner rather than a tiny-niche specialist, but the UP was a very soft sell for him. "One of my classmates in medical school was from up here," he reminisces. During an Air Force stint, he and his family frequently drove home from North Dakota to downstate Michigan, stopping to visit the old UP classmate.  "When the time came for me to look for a practice, there happened to be an opening in Escanaba. While doing my residency in Lansing - not the worst part of town, but not the best, either - we’d be awakened at night by police helicopters shining big searchlights, looking for the person who had just robbed the convenience store up the road. This, I thought, is not the right kind of place for us, with its crime and heavy traffic.

"North Dakota had been a breath of fresh air. There are places in the world where there’s not much crime, a lot of outdoors and not much traffic. The UP had the taste of a different quality of life, which was on our criteria of places to go. We grew up in the Midwest, so the snow didn’t make a difference to us. If you are going to be up here your mindset is either that you’re a prisoner of winter or a participant in winter. Good snow makes winter all the more doable."

That’s what the season has been for Povich, who enjoys cross country skiing and snowshoeing. His take on the cold season: "There’s hardly a day all winter long that I can’t dress appropriately for something outside."

In a multi-specialty group practice, he says, "I think we are at an advantage because it’s part of the OSF corporation that has many resources we can tap into. A big part of that soon will be having electronic medical records integrated into the hospital system. Patients can flow from office to hospital to home and home health. Everything will be connected." This, he adds, will be a first in the UP.

For Dickinson County Healthcare System in Iron Mountain, recruiting Michael Merig, MD, was also an easy sell. Growing up on the Gulf Coast, Merig, a pathologist, remembers "two snows, in 1972 and 1977" in Mobile. Two factors played a role in his UP arrival. "The older I got, the more I didn’t like heat in the 90s. The summers are pretty bad in the South, and the humidity is high. I had always wanted to come somewhere up north, and, the way this job happened, it worked out."

After completing education and residency in the South, he decided this northern locale was his favorite place. In fact, "(my family and I) had all anticipated seeing snow so much that we just couldn’t wait." Still, he adds, "I wanted to be involved in all four seasons." Not only that; "the summers are very nice here."

For recreation, he has switched from the deer hunting he loved as a boy to duck hunting.  He’s done some skiing and enjoys snowmobiling. "When the temperature goes to zero or below, that’s not fun for any activity," he groans, "but, honestly the winters haven’t been that bad. Just because the weather is 10 degrees outside, doesn’t mean you stay inside. It just means you add more clothes before you head out the door." He’s been in the area for 10 years. In summer, he says, "I’m heavily involved with my youngest boy, who plays soccer and baseball."

As for winter, he still pleads guilty laughingly to a first naïve snow removal effort - with a leaf blower. He still says it works when there’s a tiny dusting, but, in the meantime he’s prepared himself very well. He now owns a four-wheeler ATV - complete with plow on the front!

Eileen Lockwood lives in St. Joseph, Michigan, and has vacationed in the Upper Peninsula several times.  She is a frequent contributor to PracticeLink Magazine. Have a suggestion for a city or region you’d like to see us write about? Share with us on Facebook.com/PracticeLink.



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