No Doctor in the House
February 25th, 2019 by Drew Myron

Physician Assistant Sharon DeHart meets with Lou Melius, a patient at the Deschutes Rim Clinic in Maupin, Oregon, where she is the only medical provider in a vast and remote rural area.

Rural communities struggle with shortage of medical providers

As the head of the only medical clinic for 50 miles, Physician Assistant Sharon DeHart tends to the needs of more than 250 patients who live across a wide landscape of farms, ranches and a smattering of small towns in north-central Oregon.

At 69, Sharon is roaring toward retirement—if she can find her replacement.

For 10 years, Sharon has served as sole medical provider and administrator at the Deschutes Rim Health Clinic in Maupin, Oregon, and the job has taken a toll. The paperwork is immense, and processing complicated insurance reimbursements and claims is consuming.

A limited support staff and a population that has twice rejected votes to increase the health district budget have only increased the burden.

“The days of a quaint country doctor are over,” Sharon says. “We’ve had a terrible time recruiting.”

She’s not alone. Across the nation, rural communities suffer from a shortage of medical providers. Clinics in isolated areas operate on thin margins, limiting their financial ability to recruit new medical personnel.

Though she served for years as president of the Central Oregon Independent Practice Association and was recently named a Rural Health Care Hero by Oregon Health & Science University, Sharon hopes to partner with a hospital or medical group to gain administrative and management assistance.

“I don’t think it’s possible now to remain an independent clinic. I’m tired of trying to do all this myself,” says Sharon, her voice weary with frustration. “We can’t recruit to get additional providers and resources.”

When a rural physician moves or retires, it can create a health care crisis for the community, says Brock Slabach, a former rural hospital administrator, now senior vice president for member services at the National Rural Health Association.

“Physicians are disappearing from the map of rural America,” Brock says.

About 60 million people live in rural America, according to the U.S Census Bureau. That means one in five Americans live in a uniquely challenging health-care delivery environment.

“You have an elderly population, a sicker population and a low-income population,” says Alan Morgan, CEO of the National Rural Health Association. “Yet you have the fewest options available when it comes to seeking care.”

Rural clinics are often headed by nurse practitioners or physician assistants like Sharon. Both are advanced-practice providers, and in remote areas, they are increasingly filling roles traditionally filled by doctors, including making diagnoses and prescribing medication.

Nurse practitioners and physician assistants account for one in four medical-care providers in rural clinics—an increase of 43 percent from 2008 to 2016, according to a report in Health Affairs journal. While telemedicine is helping rural providers meet their communities’ needs, the need for more advanced-practice providers persists.

The average salary for a rural health clinic provider is roughly $100,000, According to the U.S. Bureau of Labor Statistics. But recruiting requires generous incentives beyond a six-figure salary.

Even the smallest clinics are stepping up to pay student loan debt, offer hiring bonuses, cover relocation costs, pay for malpractice insurance, and guarantee weekends off and few on-call hours.

Despite all of those incentives, rural communities still struggle to bring providers to the frontier. Small towns and remote areas are now working to create their own pipeline for health professionals.

“A trend we’re seeing in every rural area is the challenge of keeping your local people with viable work options,” says Julie Manning, communications director for Samaritan Health Services—a network of hospitals, clinics and physicians serving six mostly rural communities in Oregon.

In 2013, Samaritan partnered with Western University of Health Sciences in Pomona, California, to create a second medical school in Lebanon, Oregon, a former timber-based town of 15,000 people. With 400 students on a 50-acre campus, the College of Osteopathic Medicine of the Pacific-Northwest (COMP-NW) is the first new medical school in Oregon in 100 years. Graduating 100 students each year, the nationally accredited school has doubled the number of medical degrees in Oregon.

“We wanted to recruit and retain medical professionals for our region and state,” Julie says. “A key for many in rural areas is access to education. COMP has really been an incredible asset.”

The medical school receives more than 4,000 applications a year, and more than half of its graduates are from the Pacific Northwest. Upon graduation, most complete their residency training in Washington, Oregon, Montana, Idaho, Utah and Wyoming.

Julie says physicians tend to stay in the region where they completed medical training and residency.

Another program at the University of Washington School of Medicine integrates medical, science and clinical education with rural training to encourage more health professionals to learn and work in medically underserved areas.

“WWAMI is the UW School of Medicine’s one-of-a-kind, multi-state medical education program,” according to the UW Medicine website. WWAMI stands for Washington, Wyoming, Alaska, Montana and Idaho—the states served by the program.

Of the five states, Washington is the only one with medical schools. UW Medicine partners with universities in the other states, allowing students to complete a large portion of their studies in their home states and complete clinical rotations within the five-state region, where they gain practical experience in rural and underserved settings, such as trauma centers, migrant communities and remote areas.

U.S. News & World Report ranked the UW School of Medicine as a top medical school for primary-care education, as well as family medicine and rural medicine training. The school attributes the ranking to its WWAMI program.

The school’s physician assistant program, known as MEDEX Northwest, is another regional program that focuses on primary care with an emphasis on underserved populations.

Christina Rust grew up in the small town of Sandpoint, Idaho. After earning her doctorate in physical therapy from Creighton University in 1996, she returned to Sandpoint to open her own practice. After raising four children, she attended UW’s MEDEX Northwest program in Spokane, graduating as a physician assistant in 2018.

Last year, she became the primary care provider for the Sherman County Medical Clinic in Moro, Oregon—a small farm and ranching community of about 325 people.

In many ways, Christina is the ideal country doctor. Raised in a small town, she appreciates rural living. Her mother was a nurse and her father a family doctor. She recalls fondly that he would sometimes trade his medical visits for cords of wood or handmade doll clothes.

“I like small towns,” Christina says. “I’m not a big-city girl.”

Christina says she prefers the outdoor activities that are abundant in rural settings, such as biking, hiking and skiing. With the move to Oregon, she’s within a few hours of her siblings. In nearby Goldendale, Washington, her sister, Ann Rust, is a doctor. Her brother works in Hood River, Oregon.

The challenge for rural clinics is that people like Christina are a rarity.

As administrator of the Sherman County Medical Clinic, Caitlin Blagg spent a year trying to recruit someone for the job Christina ultimately filled. In promoting the position, she highlighted the “spectacular exploration opportunities, breathtaking mountain views, multitude of wind turbines and infinite amount of outdoor activities.”

“I felt like a real estate agent,” Caitlin jokes. “You can’t paint a rural community in a way that is not accurate. There’s no night life, and there are not a lot of singles. I have to say, ‘Cows roam freely around here.’”

Despite the challenges, Christina says rural communities have a distinct advantage over more densely populated areas when it comes to recruiting medical providers.

“In a big city, you end up practicing medicine but not helping people,” she says. “But here, I can really help people.”

About the series: This Ruralite-produced initiative spotlights health challenges in rural communities, efforts to address them and the unsung heroes behind the work. The series receives support from the M.J. Murdock Charitable Trust, which funds projects and programs in Alaska and the Northwest. The sponsorship helps fund journalism that makes a difference. We welcome story ideas at gro.etilarurnull@swenhtlaeh.

For the record: This story has been updated to clarify that the University of Washington School of Medicine is one of two medical schools in Washington state. The other is Washington State University’s Elson S. Floyd College of Medicine. WSU’s medical school, accredited in 2016, was opened to draw more doctors to Eastern Washington and less served communities.