Rural remedies

Growing up, Liz Stuhlmiller spent long summer days working in her family’s wheat and barley fields near Reardan.    “I’ve had to work ever since I was 12, and if you’re from a small town that’s a lifestyle you understand – but it’s also something a lot of people haven’t been exposed to,” said Stuhlmiller, who now is Dr. Stuhlmiller and in her final year of family medicine residency in Spokane. “A lot of people think small towns don’t have much to offer, but I think it’s what you make of it.”

Among physicians, Stuhlmiller is a statistical minority.

She’s preparing for a career as a small-town doctor, a choice studies show at least 65 percent of America’s physicians are unlikely to even consider. Her path from high school to physician residency illustrates what some believe could become a key strategy in combating rural physician shortages: recruit more medical students from America’s small towns.

“We need more rural kids to go to medical school and get that training,” Stuhlmiller said. “One of the best ways to know if you can make it in a small town is to try living in a small town, and we’ve already done that.”

Three hours away, in the town of Tonasket, another experiment in addressing rural physician shortages is being studied as well.

The tiny Okanogan County community has invested in its public schools, civic amenities and development of a broad range of social activities. Tonasket now has guided nature hikes, a vibrant community theater, and a lecture and concert series that packs a renovated former Packard auto dealership on many weekends.

Something that Tonasket doesn’t have is a physician shortage.

“We can sell a lifestyle,” said Dr. Douglas Wilson, who moved to Tonasket from Southern California about 11 years ago and just took on another partner at his family practice clinic. “Probably the most amazing thing is my wife has let us stay this long.”

As the state’s two leading universities prepare to battle it out in the Legislature over whose vision of physician training is best for Washington’s needs, new studies indicate social dynamics may have more to do with America’s rural doctor shortage than the number of medical schools or curriculum.

Put bluntly, rural communities tend to lack the kind of opportunities sought by highly educated professionals and their families.

‘Social geography’

Researchers call it “social geography,” and in the case of doctors it’s compounded by the fact that 55 percent have highly educated spouses who generally are looking for high-end career options as well. Another 10 percent of America’s physicians are single.

The two groups are statistically the least likely to practice medicine outside of urban settings, yet represent the fastest-growing physician demographics, according to research compiled by Dartmouth College professor and economics department Chairman Douglas Staiger.

Washington State University and the University of Washington both contend they have training, curriculum and recruitment models that can help overcome that challenge.

The two universities parted ways last month over UW’s existing physician training program in Spokane, which used WSU facilities. Differences over the best training model for rural care is what sparked the split.

The University of Washington wants to double its existing physician training program in Spokane to 80 students per class, eventually climbing to 120, and bolster its network of clinical training sites, many of which already are located in underserved Washington communities. It is regularly ranked as one of the nation’s top medical schools for primary and rural care, and backers say it’s the most cost-effective option at $70,000 per student each year – about $40,000 from taxpayers and $30,000 in tuition and fees.WSU wants to establish its own Spokane-based medical school enrolling 120 new students and emphasizing primary and rural care through training and targeted recruiting. Rather than build a new teaching hospital, which is the traditional model, WSU wants to partner with existing hospitals in underserved communities statewide to develop community-based training centers for third- and fourth-year students.

Backers say WSU’s approach would help build and bolster professional networks not only where the centers are located but within surrounding communities as well.

“As you develop these community-based training centers, you create a culture where physicians want to practice,” said Ken Roberts, dean of WSU’s new College of Medical Sciences at Spokane’s Riverpoint campus. The idea, he said, is the training centers would also support the other nearby small towns, making them less isolated in a professional sense.

Recruiting rural students

University of Washington officials say they’ve launched aggressive student recruiting and training efforts to improve the number of physicians willing to practice in rural communities.

Among them is a program created seven years ago that dedicates 10 medical school slots per year to students from underserved regions of Washington.

“They have to come from a rural background to even be admitted” under the program, said Dr. Tom Norris, chairman of the UW Family Medicine Department.

Within the medical community, there’s a lively discussion about whether it’s a doctor shortage or a doctor distribution problem.

“If you look at Washington state, almost all smaller communities have a primary care shortage,” Norris said. “Urban areas on both sides of the state are fine.”

About half of Washington’s doctors are in King County, which is home to 29 percent of the state’s population. Figures compiled for WSU suggest the state will need an additional 1,695 primary care physicians by 2030 as population grows.

The final prong of doctor preparation is graduate training, and both universities agree that more residency programs are needed in Washington to help keep medical school graduates here. Of the 1,600 residency slots statewide, just 100 are located in Eastern Washington.

In Colville, Dr. Mo Campbell is in one of Eastern Washington’s residency training slots. She’s a second-year resident in a program operated by Providence Family Medicine Spokane, which is working with Empire Health Foundation and WSU to expand residency opportunities and has a partnership with Providence Mount Carmel Hospital in Colville.

“It’s a good setup,” said Campbell, who also grew up in a small town and wants to practice in a rural community after finishing her residency. “We do everything we get to do down in Spokane but it’s in a critical access environment,” a term used by the federal government to describe small, rural hospitals.

She and Stuhlmiller, the Reardan native, acknowledge that in medical school most of their colleagues were uninterested in rural practice, for various reasons ranging from perceived lack of social activities appealing to their interests to the availability of career options for spouses and questions about the quality of schools for their children.

“I had always lived in a small town, and when I thought about what I’m looking for I realized that’s the kind of environment where I’m comfortable,” Campbell said.

But even among those who want to practice in rural settings, they’re still looking for communities that have social and other activities enabling a healthy balance for work and personal life.

Also, they want an established medical community enabling on-call and other duties to be rotated, facilities where cesarean sections can be performed and more than one doctor in the region able to do the procedure.

Creating vibrant communities

In Tonasket, Dr. Walter Henze is credited with recognizing the need to build an established medical community and a vibrant rural lifestyle that could help alleviate feelings of professional isolation to lure more physicians.

Wilson was among those recruited by Henze and remembers traveling to Tonasket initially because he would be eligible for having some of his medical school loans forgiven. Once there, he discovered an inviting, close-knit town with a collegial physician community and plenty of social opportunities for him and his family outside of work.

Despite being three hours or more from the nearest metropolitan center, Tonasket has a small hospital and three family practice clinics. Okanogan County is among the few in Eastern Washington that has enough doctors to keep it off the critical shortage list.

Wilson and others credit the community’s commitment to fostering and supporting activities that give Tonasket a lifestyle that appeals to a variety of families.

“This community has a tradition of coming together around common interests,” he said, noting that in addition to providing a varied lineup of activities throughout the year, it commits a lot of time and effort to providing great educational opportunities for kids. “The school is a point of pride for the community and it was definitely a factor when I was being recruited.”