For some physicians, big cities, complete with their many amenities, are the destinations of choice. But there are a number of smaller locations offering good positions, surprising family opportunities and - perhaps best of all - easy integration and heartwarming patient acceptance, not to mention state-of-the-art facilities.
Here are four welcoming examples: Ruidoso, N.M.; Wellsboro, Pa.; Crete, Neb.; and Ironwood, Mich.
Say but the word "skiing," and Jim Hubbard, M.D., is a happy man. "When we were kids in Washington State," he reminisces, "my folks would haul us up to the mountains four or five times a year, and we would cross-country ski." Now in Ironwood, Mich., this Upper Peninsula transplant says: "Now it can be four or five times a week."
The UP is well-known for its huge piles of the white stuff in winter. In fact, Yoopers, as the residents are nicknamed, like to define their climate as 10 months of snow and two months of poor sledding.
Ironwood conveniently offers no fewer than five ski resorts to accommodate enthusiasts like Hubbard and is also a link in the cross-country Wolverine Nordic Trail System. One resort, on Mount Zion, is owned and operated by the local Gogebic Community College, which uses it as a training facility for its ski area management program.
Hubbard’s route to this town near the Wisconsin border was, in a word, circuitous. The University of Washington School of Medicine, where he received his degree, focuses heavily on training physicians to work with underserved populations. After a residency in Tacoma, where this emphasis continued, he says, "I looked all over the country, including lots of places in the Midwest. In Ashland, Wisc., a recruiter told me, ’If you like this job, you should also look at (an opening) in Michigan.’ I had to get out a map because I thought the whole Upper Peninsula region was part of Canada."
In Ironwood, he says, "I liked the doctors, the area, the people and the hospital. They met all my professional criteria, and my wife really liked the area, so we came here."
After 12 years, he’s still enthusiastic. "Besides winter, it’s gorgeous up here with not too many people, and there’s no shortage of things to do," he says. "We also joke about there being traffic. There’s never any here, except for two or three cars on the road." Not only that; his wife has been able to start a chain of shoe stores (Superior Shoes, with a bow to nearby Lake Superior) with her brother in Indiana. With online sales, it’s possible for her to live in a small town.
As for Hubbard’s own professional progress, when he arrived, "a lot of patients were migrating out to have babies because of a lack of obstetricians. Now I personally do 90 to 100 deliveries a year, and my partner does the rest - a total of 150."
Hubbard’s employer is Aspirus Grand View Clinic. The Ironwood hospital is a critical access facility with full surgical center, urgent care, in-home physical therapy service, a sleep lab, the sole retinal specialist in the entire UP and specialty care including cardiologists, oncologist and physical/occupational therapist, with on-site radiology and lab services. In June, work will start on a major ER renovation.
Ironwood’s place on the map became important with the discovery of iron ore in the 1870s, but the lumber industry played a heavy part in the mix, thanks to the abundance of trees in the wilderness. The railroad arrived in the 1880s, and immigrants from locales such as Finland, Sweden, Germany, Italy and England began arriving to fill the job openings. Today the heritage persists (and so does a tasty food from Wales, the pasty).
In modern Ironwood, neither snow nor sunshine keeps residents from enjoying other forms of culture, such as performances by two theater organizations and the Ironwood Dance Company. With no professional sports within easy reach, local residents lend their cheers to the athletes at Luther L. Wright High School, especially when they meet Hurley High, one of the longest-running rivalries in American high school sports.
The field is larger for Hubbard, who takes off in his airplane during the summer to enjoy minor league baseball games in Ohio and downstate Michigan. The "local" team for him is in Appleton, Wisc. - four hours south by car but a mere hour by plane.
It was a cold, windy, snowy January day when the husband-and-wife team drove into Wellsboro, Pa., for the first time. Edmund Guelig, M.D., was finishing his residency at the Geisinger Clinic and, recalls his wife, physician assistant Daria Lin-Guelig, "We were looking for a (good) community to practice in." But on that day, she recalls with a chuckle, "it seemed like we would reach Neverland before Tioga County."
Their fortitude was rewarded. That was 22 years ago, and the trip is still vivid in her mind. "One spin down the gas-lit, snow-covered Main Street - the gaslights will do it every time - and I said to Ed, ’This is it. We can cancel the rest of the interviews. This is where we need to be.’"
Today they work together under the aegis of Soldiers + Sailors Memorial Hospital, itself a tribute to sturdy perseverance. In 1919, five local families filed a building application. The Great Depression literally depressed, but didn’t end, their plans. Twenty-three years later, on August 25, 1942, the hospital opened. In the next two years, some 4,000 patients were treated and 600 babies were born there.
After a number of expansions and upgrades, the hospital became part of the Laurel Health System, which was integrated into Susquehanna Health last October - providing greater patient access to a bevy of specialists and the 226-bed Williamsport Regional Medical Center. Also in 2012, Soldiers + Sailors opened a new emergency department and a same-day surgery unit. In keeping with the spirit of community friendliness, it provides a physical and aquatic therapy center, sponsors an annual golf tournament and supports a number of recreational programs in cooperation with Wellsboro Parks and Recreation.
For the Gueligs, it was a good move indeed and their practice has been rewarding in many ways. "We had a vision of working together in a rural setting," he recalls, "where you’re not just in it for yourself and just for your career. You are truly part of the community." Lin-Guelig adds an interesting perspective: "Small towns are like spider webs," she says. "Our relationships are intertwined, and therefore stronger, more meaningful and more personal."
In 2011, Guelig was named Pennsylvania’s Family Physician of the Year. He’s also medical director of the Soldiers + Sailors hospice program - and a firm advocate of the "rewards and sense of gratification that come from being a family doctor in a small rural community. (Only in this setting can you have) the experience of treating three generations of a family in a small town," he says. His childhood experiences growing up in a small Wisconsin town (Waupun) played a big part in shaping his life, and they stayed with him as an undergraduate at the huge University of Wisconsin and then as a medical student at West Virginia University.
In Wellsboro, "intertwining" became part of their four children’s lives, too. "They got to experience real community life in a way that may be disappearing," Guelig says. "I delivered babies of their teachers, and I can’t go anywhere where you don’t expect to see people on three or four different levels." Although his now-grown offspring have scattered to cities across the country, he adds, "We reflect on what they took away (from their childhood experiences), and we know that a part of them understands human relations."
Another experience that he cherishes has been an offshoot of his woodworking hobby. Several patients operate the sawmills where he gets his wood. When he questioned one owner who undercharged him, he was told that it was his "doctor discount."
Wellsboro, about 120 miles east of Scranton and an hour’s drive northwest from Williamsport (famed for its annual Little League World Series), was named for Mary Wells, the wife of one of the 1806 town founders. To this day, it exudes the New England aura that captivated Lin-Guelig - wide boulevards, spreading elm and maple trees and, of course, gaslights, not to mention its historic district encompassing structures dating from 1835 to the 1950s. The mix includes early homes and grand 1890s mansions, as well as several churches and public buildings. About 600 are now on the National Register. As one city promoter puts it, "The district is among Pennsylvania’s architectural gems."
The area’s natural beauty hasn’t escaped the Gueligs, either. Three state forests surround Wellsboro, but the most notable feature, in Tioga State Forest, is the 47-mile-long Pine Creek Gorge, aka the "Grand Canyon of Pennsylvania," which descends at its deepest point to 1,450 feet and encompasses waterfalls and other scenic wonders. Canoeing and rafting are among the Gueligs’ favored activities, as well as hiking and bicycling. Enthusiastic winter visitors - and locals - can strap on their cross-country skis for a trek on the nearby Rail to Trail route - or zoom along some 800 miles of groomed snowmobile trails.
But the main "hobby" for this husband-and-wife team is a farm on the edge of town, complete with horses and chickens. "When the kids were young, we also raised lambs," he says. "There’s also an orchard, and my wife also does a lot of canning. (All in all) we feel that this is a nice complement to medicine."
Its bucolic atmosphere aside, the city is doing "quite well economically," says Mary Worthington of the Wellsboro Area Chamber of Commerce. Five nearby major highways help make it an attractive location for several small industries. Worthington notes that nine substantial employers attract an influx of workers. One of those companies, Osram Sylvania, is carrying on a long tradition. Wellsboro is the site of one of the first factories where light bulbs were mass-produced.
Ruidoso, New Mexico
High in the mountains of south-central New Mexico, the town of Ruidoso beckons to dedicated skiers and horse racing enthusiasts, not to mention hunters and fishermen. But, more than that, it offers residents and newcomers a captivating combination of mountain/forest surroundings, friendly togetherness and a certain urban sophistication.
For Gary Jackson, D.O., the skiing possibilities were too hard to resist. After growing up in Pittsburg, Kan., attending the University of Kansas and getting his medical degree from the Kansas City College of Osteopathic Medicine, he and his wife-to-be entered the Army. To complete his military commitment, he eventually became assistant chief of pulmonology at William Beaumont Army Medical Center in El Paso, Texas. The short distance from there to Ruidoso, N.M., (about 2 and a half hours) was too tempting to ignore, so New Mexico became the couple’s frequent snowy downhill destination. Before long, the lure of Ruidoso itself became too hard to resist.
Today, Jackson is the medical director of Lincoln County Medical Center and also provides coverage for four other area groups. The hospital itself is part of a unique partnership among the County of Lincoln, a local board of trustees and Presbyterian Health Services. The latter operates eight facilities in the state.
In the 1990s, the hospital was recognized by the Centers for Medicare and Medicaid Services as one of the top small hospitals in the U.S. "One of our big changes," Jackson reports, "was that we became a critical access institution. In the last two years we’ve been bringing on board a hospitalist system. Our ER is open 24 hours a day, seven days a week. We’re building a new physicians’ office building directly across from the ER, for both current practitioners and for outreach specialists such as cardiologists and neurologists."
One specialty is particularly important in a winter resort area: orthopaedics. With specialists from Alamogordo Orthopaedics and Sports Medicine, Lincoln can provide close-to-home joint replacements for visitors and residents alike. There’s also a strong in-house physical therapy program.
But Jackson and his wife had other reasons for settling in Ruidoso 22 years ago. "I think we moved because we wanted a nice environment for our children to grow up in and a good educational opportunity for them as well." Sierra Blanca, 7,000 feet high and frequently living up to its "snowy mountain" name, is another plus. "I appreciate it every morning, and when I travel I really am eager to
get home," he says.
]Not only that. "We’re a friendly area, with a community spirit that I think is unique to Ruidoso. Community members hold together to help each other."
When winter disappears, the recreation of choice is horseracing at the Ruidoso Downs Race Track. The Hubbard Museum of the American West, unique gift shops, interesting restaurants and children’s attractions also attract visitors to the area.
The odds are heavy that anyone breakfasting on Corn Flakes or munching on Fritos can trace them to the Crete, Neb., area cornfields - and the local Bunge Milling Co., whose roots date to 1869 - two years before the town was officially organized.
It was one of the first corn processing operations in the U.S. As early as 1878, its goods were being shipped to points as distant as Scotland.
Leon Jons, M.D., surely has treated a good number of Bunge employees during the 22 years that he’s been practicing family medicine with Saline Medical Specialties, a practice affiliated with Physicians Network, which in turn is part of Catholic Health Initiatives. Jons arrived in Crete in 1990 after earning his degree and completing residency at the University of Nebraska Medical Center in nearby Lincoln, where he now lives and where his wife is a teacher.
As for his own choice of work area, he reports that University of Nebraska medical students were encouraged to consider rural locations. He ran a private practice for nine years, then joined the Saline group, where he finds much satisfaction. "Practice in a rural community is much different than in the city," he says. "Over the years we’ve worked with complicated obstetrical patients, done some of our own surgery, taken care of our own hospital patients and done a lot of public relations work." He’s also found that patients are more cooperative.
But there are other advantages. "I think that financially, rural physicians do better than physicians working in the city. We’re a rural health clinic where Medicare and Medicaid reimbursements are much higher." Another reason: "Rural physicians tend to do a lot more procedures, with much higher reimbursements. Also, there’s a malpractice cap, so insurance rates are low. Another advantage is that we have a great deal of autonomy and a lot of leeway in what we practice and how we want to practice."
Jons’ idea of recreation is relaxing at his cabin on the Missouri River, but he also enjoys exercising and spending time with his family. All in all, "the quality of life in rural Nebraska is really good. I think people shy away from rural areas thinking that there’s nothing to do and they’re too far away from entertainment (and other city attractions). I find that not to be the case. I think that most doctors find that wherever they are they can have a vibrant social life if they want one."
There’s also room for innovation. The city’s hospital, Crete Area Medical Center, is Exhibit A. In the last three years, it has become one of the nation’s pioneers in embracing a new philosophy and system of health care - the "patient-centered medical home" initiative. So far, it’s the only recognized program in Nebraska outside of Omaha, according to CEO Carol Friesen. "In the U.S., 75 cents of every health dollar is spent on chronic disease care," she says. "We made the commitment to spend time working with patients to achieve better control of the three biggest of them - diabetes, hypertension and hyperlipidemia. Today, for instance, the national average of uncontrolled diabetes is 36 percent. Ours is under 6 percent."
By encouraging patients to carefully monitor blood sugar, for instance, and contacting them often to make sure they’re complying and following other healthy practices, doctors and nurses help prevent repeated hospital stays, thus reducing health care costs. "We don’t think it’s right to take patients’ money or insurance unless we’re giving them the best care possible," adds Friesen.
A second aspect of the medical home program is open access. "We will take care of every sick patient today," she says. "We believe that health care is where you need it and when you need it. That has always been our goal." So that local residents can get more complicated treatment close to home, the medical center brings in 20 to 25 specialists each week from Bryan LGH Health, its parent in Lincoln. In the meantime, the hospital provides several services beyond what might be expected in a 25-bed critical care facility, such as surgical suites, imaging, emergency and rehab departments, an in-house lab and a pharmacy. All of the above probably played a part in its 2012 National Rural Health Quality Award from the National Rural Health Association.
Even though Crete is a mere 25 miles from Lincoln, Neb., Mayor Roger Foster notes that "Most of the community is surrounded by farmland, and probably 40 percent of the kids in school have some sort of rural relationship."
It’s a population mix that has become unexpectedly diversified in the last 10 years. Over the years, the immigrant stream has included many Eastern Europeans, and Crete became what Janet Jeffries, the spokesperson for Crete’s Doane College, describes as a "hotbed of Czech culture." More recently, there have been new population influxes. In fact, according to Foster, minority groups comprise about 50 percent of students in the school system.
Physicians at Saline Medical Specialties are now seeing a large Hispanic influx. "I have learned a little Spanish as the years have gone on, and it’s a good thing. I do about 30 percent of my visits in Spanish, and we also have four people in the clinic who can translate," Jons reports. "I’ve enjoyed learning how to deal with these patients culturally."
Eileen Lockwood is a frequent contributor to PracticeLink Magazine.