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VOL. 41 | NO. 7 | Friday, February 17, 2017

Rural, low-income practices a hard sell for young doctors

By Jeannie Naujeck

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Clinica Medicos opened in Chattanooga two years ago and is part of the Tennessee Rural Partnership. Dr Philip Sutherland, who is also the clinic’s assistant director,  monitors the heartbeat of Elvi Morales Zunun’s baby while her husband Misael Reynose and 6-year-old daughter Anahi Reynoso entertain themselves with a video game.

-- Alex Mcmahan | The Ledger

There’s a great temptation for doctors completing their training to follow the money.

More than half graduate from medical school with more than $200,000 in student loan debt, a burden that might lead a new doctor to sign a lucrative employment contract with a large urban hospital.

But Matthew Campbell was different.

Though he came out of med school and residency with more than $300,000 in debt, he wanted to establish his practice in a small town like his North Georgia hometown, which had fewer than 2,000 people and no local pediatrician to serve them.

“I knew it would mean less money and definitely less prestige, but it’s where my heart was and my wife’s heart,” Campbell says. “We wanted to raise our kids in a small town like where I grew up, and help people.”

When it comes to recruiting new doctors, most rural areas can’t compete on pay. That’s why the Tennessee Rural Partnership was formed – to help match people like Campbell with rural and underserved communities where they can do the most good, and to help make up some of the salary they give up by doing it.

TRP awarded Campbell a stipend that allowed him to establish a pediatrics practice in Tullahoma, a town of 18,000 that Campbell and his growing young family now call home. The practice, Kazoo Pediatrics, a part of Tennova Healthcare, has become a vital part of the community. He’s taken on two partners, and Campbell and his wife are building a house with their third child on the way.

“The grant money changed my life,” Campbell points out. “It offset the loans and allowed us to focus on getting a house, getting a car that worked and building our family. They really helped me get settled here, and we’re planning on staying here probably for the rest of our lives.”

Hospitals shut down

Access to health care is an acute problem in large swaths of the state. Tennessee’s rural population tends to be older, have less income, more likely to be on TennCare and Medicare, and in poorer health than their urban counterparts.

They are also significantly less likely to live near medical services, resulting in a higher rate of preventable deaths from diseases like cancer because patients did not get an early diagnosis when it was most treatable.

Part of the problem is the closing of small and rural hospitals due to financial pressures.

Tennessee has had eight closures since 2010 – the second-highest number in the country. And more are at risk: 48 hospitals in the state are currently losing money – most of them small and rural, according to the Craig Becker, CEO of the Tennessee Hospital Association.

Some hospitals have been replaced by rural health clinics, community health centers, Department of Health Clinics, private clinics, and freestanding emergency departments.

Other rural hospitals are surviving by eliminating inpatient beds and cutting specialties like obstetrics, forcing women to drive long distances to deliver their babies.

Less money for recruitment and physician salaries also means more medical care that physicians used to provide is now being delivered by “mid-levels, including nurse practitioners and physician assistants.

Tennessee has only one primary care physician for every 5,625 residents in its most severely affected counties in. The ratio is one to 1,397 residents in counties with the most doctors.

The ratio is much worse when it comes to mental health providers, a critical need.

Jolley

“Trying to recruit physicians to a community without a hospital is extremely important; increasing capacity around primary care is especially critical,” says Bill Jolley, executive director of the Tennessee Rural Partnership.

“We continue to recruit in those communities because if a community cannot sustain a full-service hospital, it’s important that they do maintain a medical presence, even though delivery of medical services may look a little different.”

Tennessee Rural Partnership helps bridge that gap by offering stipends to physicians, nurse practitioners, physician assistants and psychiatric nurses who practice where the need is greatest.

Residents in a primary care field – generally family or internal medicine, pediatrics, obstetrics and gynecology, and psychiatry – may receive a stipend of $35,000 per year for up to four years that they can use for living expenses, loan payments or anything they need. When they finish residency, they are obligated to work at a TRP-approved site – one that serves a high percentage of TennCare recipients – for an equal number of years.

Cecilia Ramirez Geronimo holds her daughter Esil Velaquesz Ramirez still while Dr. Philip Sutherland performs a check up on the 9-month-old.

-- Alex Mcmahan | The Ledger

The TRP also offers incentives to nurse practitioners and physician assistants in training - $7,500 the first year and $10,000 the second. Those practitioners are required to do a rotation in a rural area first.

“One of our main concerns is making sure the people we place are a good fit for rural because we want them to be comfortable and stay there,” says Julia Hall, recruiting specialist.

“It takes a very special person to work in a rural community. You have to be very autonomous and quick-thinking and you have to have a heart for the work.”

A third program awards grants that can be used for recruiting to sites trying to lure medical professionals.

TRP is funded by the four Tennessee medical schools with primary care residency programs: The University of Tennessee, Meharry Medical College, East Tennessee State University, and Vanderbilt University. The program has placed 128 providers in the last 10 years, Jolley notes.

Maness

“If we get a doctor into a small town and they stay there for five years, they’ve made a huge impact and touched a lot of patients,” says Dr. David Maness, chairman of the TRP’s board of directors.

“If we get lucky and they stay there even longer, then they’ve impacted one or two generations, maybe three generations of families over time and that’s priceless.”

Chattanooga’s country doc

Philip Sutherland also wanted to start his family medicine and obstetrics practice in a rural area after graduating from the University of Tennessee College of Medicine and going through residency and a fellowship.

He and his wife decided to change course, however, when a med school acquaintance approached him two years ago about starting up a clinic for the Hispanic population in Chattanooga.

Sutherland now works at Clinica Medicos, a bilingual clinic focused on serving a population that is one of that region’s most underserved and under-reached, due to language barriers and access to care issues. Despite being inside a city, the clinic fits TRP’s mandate.

“Even though we are in a city that has all these resources and specialties, when a patient has no insurance their access to those resources is extremely limited,” Sutherland says.

“So in many ways it’s a lot like the country, where those resources are hours away, and it takes significant effort to overcome the barriers of getting there.

“A lot of it comes back to what we do there in the office. I think that’s one of the reasons I’m so satisfied with it.”

Sutherland says at Clinica Medicos he gets the high-touch experience of a small-town doctor. He also has greater autonomy as a physician than he would have at a health system.

And while he may not make as much as some in his med school cohort, he is highly involved with his colleagues and his patients, giving him what he calls “spiritual revenue.”

Dr. Sutherland and scribe Simey Emerson, left, discuss and enter medical data collected on one of his patients. At right is Jennifer Ortiz, a 17-year-old Chattanooga State Vet Tech student, who also has an interest in health care for humans, was shadowing the health care workers at Clinica Medicos. Ortiz says she found the clinic to be “an enviroment filled with compassion and interest in the patients.”

-- Alex Mcmahan | The Ledger

“For my colleagues, they punch in and they punch out. It’s a job for them,” he adds.

“The thing that’s so unique about where I work is, it’s not really a job. It’s really a calling, a pulling together with a team to provide excellence in care to the people we serve, and being a part of that community of people.”

“When you look in the eyes of a dad and mom and hand them their baby, to have cared for them during their pregnancy, to deliver this baby and know we are going to be a part of that family through these life-changing experiences, it’s really humbling and amazing.

“We are blessed to have found that sense of connectedness to a community here in Chattanooga, with a population that really needs the opportunities of care that we are providing.”

Even though Sutherland and many other physicians are continually bombarded with recruitment offers, he’s not interested in leaving Clinica Medicos. Two years after it opened, the clinic is flourishing to the point where it can afford to pay the doctors more.

In fact, Sutherland has been offered the opportunity to become a partner in the clinic. He and his wife have decided to take it.

“When you’re looking around at the job offers and someone wants to pay you significantly more, it’s tempting to put the money ahead of your heart,” Sutherland says.

“My salary is lower than what it would be at many places with the same training that I have, but the Tennessee Rural Partnership really enabled me to take that job and I’m still getting a good solid start.

“The program doesn’t set you up for your whole career, but it can take the edge off of that transition and let you go where your heart is by helping reduce some of that financial pressure while your new position is growing. I’m just really grateful for the opportunity it gave me to land in a place where I’m able to serve and have a job that I love at the same time.”

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