Family practice physicians in Alaska can count on treating the usual ear infections, urinary tract infections and rashes. But at any given moment, they also can find themselves the only pair of hands available to perform an emergency laparoscopic surgery for an ectopic pregnancy, talked through the steps via a gynecologist hundreds of miles away communicating into a headset.
Welcome to the true Wild West, an untamed landscape unlike any practice opportunities you’ll find in the Lower 48. There’s no managed care, few hospital-employed positions, and the biggest "fight" the 250 members of the Alaska Academy of Family Physicians faces this year is to encourage four-wheelers to wear helmets.
It was an atmosphere Katy Sheridan, MD, couldn’t leave. Born and raised on a homestead on the Alaska peninsula, she attended medical school at the University of Washington in Seattle, then fulfilled her residency in Bangor, Maine.
Eight years ago, she returned as a family practice physician, ready to set up a private practice in Soldotna. Since Anchorage is just 150 miles away, she says her stories of dramatic trauma moments don’t compare to her colleagues.’ On the other hand, how many family doctors deliver 40 babies a year and become president of their group academy for the state only eight years into their career?
If that sounds promising, there’s definitely a practice opportunity ready to welcome you with open arms. As of 2002, our 49th state had the sixth poorest physician-to-patient ratios, with just 1,350 doctors to cover a population of 644,000. And more than half of those physicians are older than 50, so groups like the AAFP foresee an even larger shortage looming.
"A lot of people like the idea of checking out Alaska because it has a mystique about it," says Sheridan. "A lot of people came here for the summer to work and never left. It doesn’t take people very long to know if they’ll like it or not."
The financial situation sways its share of interested professionals. Physician recruiter Rita McNeal, RN, who also doubles as the nursing supervisor at Valley Hospital in Palmer, brazenly touts the lack of capitated care here when making her pitches.
Thanks to the sparse population and the distances between health-care facilities (although two-thirds of residents live in the south central portion of the state), managed care isn’t even on the radar in the foreseeable future. At best, third-party payers like law enforcement, school systems, and government offices will negotiate discounted fees for service.
Doctors also receive higher Medicare reimbursements than elsewhere since the state’s senators went to bat in Washington for better pay in late 2003. Their argument hinged on the fact that in a state whose motto is "the last frontier," physicians can, and were, refusing to accept more Medicare patients, leaving nearly 47,000 folks out in the cold.
As for salaries, no matter what measure you use, it falls in the upper range, assures Lee Norman, MD, a former family practice and emergency room physician in Seattle who now uses his master’s in health-care planning and executive MBA to consult with medical organizations in rural Alaska.
McNeal rarely sees a physician’s pay drop below the 75th percentile. "Those that work the full five-day week and are reasonably intelligent about running their offices and keeping expenses down, and don’t spend an hour with each patient will do exceptionally well," she says. "Others choose to work only three or four days a week and they make a good enough living."
Not to mention most practices provide you with housing, which can present a problem in the bush. "It seems to be a lynchpin for maintaining one’s spirit," says Norman.
To top it off, Alaska imposes no state income or state sales tax (some localities do collect a two to three percent sales tax, but they cap it at $200 per purchase). In fact, the Permanent Fund, a unique investment program built on oil profits, actually pays dividends to folks for living in the state. The Fund returned more than eight percent from October through December 2004, increasing its market value by nearly $2.4 billion, reaching almost $30 billion as the quarter closed. It boils down to cash in everyone’s wallet.
Finally, many of the bush positions qualify as loan repayment sites, so young physicians can earn up to $20,000 a year toward educational loan repayments in addition to their salaries if they make a two-year commitment, plus $20,000 annually for each year they stay after that.
"This environment works very well for the entrepreneurial physician who wants to be in private practice," McNeal says. The average group practice involves two to five physicians, and these private partnerships far outnumber employed positions. "They can see the number of patients they want to see, they don’t have to kill themselves and rush people through like an assembly line. It’s a reasonable schedule and a good lifestyle."
That lifestyle actually attracts more physicians than the dollar side, in McNeal’s experience. For starters, public schools turn out excellent scholars, thanks to the smaller class sizes and personal attention. "Then, when they start applying to Harvard, they get in," she says. And it’s hard to top the outdoor experiences when it comes to everything from dog sledding to snowboarding.
Ultimately, the biggest choice comes down to where a physician prefers to work: on road (meaning the big city), off road (affectionately known as the bush), or something in between.
If you like to shop at Nordstrom’s, enjoy sunlight five hours a day during the "dark" winter season, and visit art galleries on par with Portland, Oregon, or Seattle, then cities like Anchorage hit the mark. "There are a couple of restaurants here that to me are New York quality, with wine lists right out of Wine Spectator," says Laura Screeney, a consultant to the office of physician recruitment for Southcentral Foundation in Anchorage. "Yet you can walk in there wearing your hiking boots and fleece."
Southcentral Foundation is one example of a health system the native tribes bought back from the federal government’s Indian Health Service. Screeney’s primary-care arm oversees the Native American population in this city of a quarter million people. Unlike most images the word "clinic" conjures up, this service on the campus of the Alaska Native Medical Center - the main tertiary care facility for the state’s native residents - runs with incredible efficiency.
"As a doctor, you’re not restricted," she notes. "You’re not worried about malpractice because our physicians, like those at the Veterans Administration, are covered under the federal policy for malpractice insurance."
In this organization, each physician has an RN case manager and either an LPN or medical assistant on his team. All three share an office, the better to deal with the same patient panel. So in many cases, the RN case manager can take care of prescription refills and follow up on patient education for medication instructions. To the physician, it means not shoving a stack of pink notes in your pockets to deal with in a spare moment.
There’s always a big push for family medicine physicians in this setting, as well as psychiatrists. "They can name their bucks right now," Screeney says. Over at Fairbanks Memorial Hospital, in another "large" city of 82,000, medical staff recruiter Paul Allen is also on the hunt for internists, pulmonologists, neurologists, and orthopaedists. In the future, they could be in the market for a cardiologist, but it’s a rare subspecialty that finds an audience in this state.
"We just don’t have a large enough population to support two," Allen explains.
Alaska boasts just one family practice residency program, so even recruiters in the urban settings can’t rely on this relationship to feed their programs. They have to sell the opportunities in the Lower 48. "This also means that if somebody’s an academic person, with a curriculum vitae 48 pages long to include all their publications, it’s not the place for them," Screeney says bluntly.
But the remark Allen hears most often: "This is the best place I’ve ever practiced."
Valley Hospital in Palmer serves an area the size of West Virginia, running from the base of Mt. McKinley on the west side, to Lake Wasilla in the east, with parts of the Denali Highway included in between. Wasilla hosts an 80,000-square-foot urgent care and surgery center, but the hospital sponsors zero medical clinics in this region. In a nutshell, patients find their way into the 40-bed hospital in Palmer when they need medical attention.
Although the size of a state, this area is considered suburban to Anchorage. Like many American suburbs, the borough is jumping with a 4.7 percent annual growth rate since 2000. Home Depot opened in November 2004, followed by Lowe’s in December. The Wal-Mart here is the busiest location in the discount chain’s West Coast properties, and it sells more Duck brand duct tape than any other Wal-Mart in the United States.
Still, folks like Rita McNeal wouldn’t mistake this area for Anchorage. She owns a 2,500-square-foot home on 13 acres, a spread that includes a 5,000-square-foot barn and a stream where salmon spawn at the bottom of a mountain. Bear, wild sheep, and moose wander into her yard, blending in with the breathtaking mountain scenery in the background. She owns horses, dogs, and pigs while still living just a 15-minute drive away from Wasilla or 20 minutes to Palmer.
"We grow awesome gardens," she brags. "Because of our length of sunshine, our vegetables here have more sugars in them. So our carrots are really sweet, peas are packed with flavor, and my corn last year grew just fine."
Physicians here really break out the "big boy" toys, indulging in boats, skis, and dog-sled teams. Some subdivisions even accommodate private airplanes, so doctors can park their wings at the house. (One Valley Hospital doctor literally commutes by air since the Palmer Airport is adjacent to the hospital.)
Soon, they’ll have an impressively equipped 75-bed facility, now under construction. "At the very least it will have the best view of any hospital in the country," McNeal says of this boutique hospital designed to face a glacier, three mountain ranges, and the Pacific Ocean in the form of Cook Inlet. Physicians, of course, appreciate the MRI, PET, and CT scanners they’ll be able to get their hands on.
"One of the doctors I recruited two years ago told me, ’You’re better equipped than the major hospital in Denver,’" she laughs.
Perhaps the best news is the list of specialty physicians McNeal needs to staff this new building. Obviously, there’s room for family practice, but she puts internists and nutritionists higher on the list. She has needs in cardiology, thoracic surgery, pulmonology, breast surgery, gastroenterology, and psychiatry.
Maniilaq Health Center, located above the Arctic Circle, takes care of the Native American population spread out over a 30,000-square-mile territory that includes one city of 3,200 people and 11 villages with anywhere from 75 to just under 1,000 residents. The 17-bed hospital facility in Kotzebue, in the center of this network, has no operating room, so emergencies are medevaced 2.5 hours south to Anchorage. They average two a week.
Yet it’s not a pitiful situation to practice in - in fact, just the opposite for Patricia Clancy, MD, who, after 10 years in nursing in the Philadelphia area, headed off to medical school when her four children reached high school age.
But long before she hit the books to study internal medicine, Alaska had captured her imagination. Fired up by long-ago letters from her brother stationed there during the Cold War about grizzlies chasing jeeps, she seized the chance to complete a month-long rotation in the state during her residency in 2001. She learned to cast, helped out at a delivery, and spent an 11-hour day flight-seeing over the state for an insider’s glimpse.
"I was hooked," she said simply. By 2002, she was back to stay, for a few years at least. And no, she hasn’t seen grizzlies chasing jeeps, although she has seen the shaggy beasts in their natural environment. "I’ve poked a 12-inch hole in the ice and pulled up fish. I’ve been out on snow machine rides and four-wheeled down the beach. I’ve been along when people found mammoth teeth pulled out of the dirt.
"There’s no escaping that you need an adventuresome soul because you have to provide your own entertainment up here. Alaska seems to self select for pretty laid-back, easygoing people, so it makes for great working conditions because whatever the problems are, everybody just fixes them. We figure duct tape cures all," Clancy jokes.
Take, for instance, the medical care delivery model. Each village has a clinic run by someone from the Community Health Aid Program, CHAP for short. These CHAP administrators are residents of the community and must have a minimum of sixth-grade education and receive basic training in six-week didactic courses over the period of two years so they have skills in assessment, suturing, splinting, and administering medication. These clinics helped change lives in the region after the program was launched in the late ’70s.
According to the State of Alaska Epidemiology Bulletin, life expectancy of Alaska Natives in 1950 was somewhere in the mid-40s. By 1980, that life expectancy jumped to the mid-60s.
Each clinic has a cart equipped with a digital camera, an EKG machine and an otoscope camera so the CHAP can take pictures of patients’ complaints and e-mail them to the physicians in Kotzebue. The clinics also boast two-way video systems in the event a doctor wants to walk a CHAP through an exam or test with the patient while she observes.
"They have fancier digital archiving and radiology transfer than we see in a lot of metropolitan areas," says Lee Norman, who works with Clancy in her role as medical director of the Maniilaq Health Center. "I’ve seen sophisticated academic medical centers that do not have the capabilities they have in the Arctic."
This means a typical day for the primary care physicians at headquarters consists of either covering the emergency room from 8 to 12 or 12 to 6, or sitting in the radio room for a shift responding to the telemedicine reports. Four to six times a year, each physician visits an assigned village for a week to work with patients face to face. (Specialty physicians like rheumatologists mainly fly in from the larger cities for clinic summits on a quarterly basis.) Usually just the paramedic and an EMT or nurse handle the medevac runs, but in cases of a premature labor or severe trauma, the physician hops aboard as well.
"The biggest thing is to know yourself," advises Norman. "I’ll be in an area where I’m very isolated as their caregiver, so what are the things I can do well, and what do I have to relinquish even though it’s expensive to get them down the road to Anchorage?" Trauma offers the perfect illustration. Clinicians must get good very early at recognizing whether they can treat the patient on the spot or simply stabilize and transfer.
"There’s a temptation at times to say, ’No, let me get a definitive diagnosis and see if this is something that can be managed here.’ That’s a tough one, especially for young physicians because they may not have enough gray in the temples to have done that sort of thing before," he says.
To further compound the challenge, the native population wants to stay as close to home as possible for treatment, whether it be rheumatoid arthritis or chemotherapy, so the city hospitals try to push everything as far out as they can. In Norman’s experience, that alone can really challenge one’s creativity.
But in exchange, physicians get to address more than the predictable coughs and colds. "If you like hands-on medicine, this is an excellent place," says Clancy. She’s removed toenails, set bones, debrided skin lesions, and performed D&Cs. Some of her colleagues have trained to perform colonoscopies. "It would be hard for me to have a straight internist doctor who didn’t see pediatrics or obstetrics," she notes.
The patients in this part of the world come from a non-confrontational culture, which on the flip side means things tend to move rather slowly. It also requires physicians to tune in to subtle, non-verbal cues; a little wrinkling of the nose or a slight shake of the head is akin to an Italian throwing his arms up in the air and yelling. Sentences are compact, often one or two-word answers. "I had to relearn the value of silence," Norman admits. "When I say something like, ’Alan, do you think this is a good idea?’ I have to shut up while they ponder," he says. Occasionally, he goes so far as to prod the patient with "Now this is the part where I’m silent and you talk."
But after you earn their trust, the wealth of family history and information at your fingertips amazes many doctors. And their generosity is overwhelming, says McNeal, who has lived all over Alaska in the 22 years since she moved here - one physician at her hospital has an entire wall decorated in artwork given to her by grateful patients. "You don’t need to go fishing yourself because the patients bring you fish, and smoke your salmon for you, too. Patients love their doctors," she adds.
It’s not uncommon for physicians in the bush to hang it up after two to three years, so administrators like Clancy constantly seek fresh interest. Clancy arrived to a full house, a pattern the group maintained until August 2004. But at press time, she was scrambling to bring on more family practice doctors to replace those who left.
It’s an understandable reaction. After all, areas this remote do foster a feeling of isolation. And although doctors enjoy liberal vacation time, a snowstorm on Tuesday could ground you just long enough to miss the cruise boat in Honolulu.
"If you like to have dinners with Mom and Dad every Sunday, you better bring your parents up or don’t come to Alaska," McNeal says.
The natural answer to the shortage would be to foster more Alaskan Native clinicians - a drive that’s in the works but still needs time to bear fruit. For example, in 1971, only 2,000 Natives in the entire state held high school degrees. By the turn of the millennium, that number increased to 60,000. The improvement is commendable, but it hasn’t yet reached the point of producing physicians and nurses. So for the time being, the Lower 48 remains the feeder system.
Even Clancy is uncertain how long her days in the Arctic will last. With children and grandchildren building lives 4,000 miles away, she feels torn between her two loves. Job-sharing in six month increments could provide the perfect answer - as soon as she can find someone willing to swap the same patient list, apartment, and vehicles. "Then I could see me staying for 10 years, easily," she says. "I just need to find somebody else out there with a restless heart."
That shouldn’t be difficult in Norman’s estimation. "It’s a National Geographic experience," he says of his past year in the bush. "Some people open the pages and say, ’My gosh, it’s bleak, it’s cold, it’s dark for 63 days - how could I exist there?’ Others see a culture unlike anything they’ll ever see again and a chance to care for folks amid a natural wonderment that is unlike anything on Earth."