Dr. Heidi Korstad is standing in the two-bed emergency room at Bigfork Valley Hospital, describing in her rapid fire manner the health care system in this town of 450 people.
"Small communities are misrepresented sometimes," says Korstad, a family practice doctor who runs emergency services for one of the most highly rated hospitals in the state. "Everybody thinks we're treating ear aches and sore throats because we're not the Mayo. Where do you think people around here go when they have a heart attack or major car accident or a stroke or cancer? They don't go to the Mayo. They go to us. And we may pass them on for specialty care, but we have to take care of everything that walks in the door."
It's not easy to be always prepared in a small town, where specialists are hard to come by and patient volume is low. So Korstad, who works for Scenic Rivers Health Services, the clinic inside the hospital, conducts what she calls monthly treasure hunts. Each member of the ER staff pulls something from a bag, something they haven't used for a long time, like a jet ventilator, which keeps a patient breathing during tracheal surgery. Then they must pinpoint where the item is kept in the emergency room.
"This is the rural health care story," says Korstad. "The quality has to be higher than in the city because there is nobody to bail me out. The quality has to be greater, but the volume is tiny."
Outstate communities are finding it increasingly difficult to land doctors who can do it all, like Korstad. Across the country, fewer medical students are choosing to become family practitioners, instead opting for specialties that pay more and afford shorter working hours. According to the American Academy of Family Physicians, the number of students going into primary care has dropped by more than 50 percent since 1997. Rising medical school costs exacerbate the trend.
That's on top of an long-existing shortage of physicians in rural Minnesota. While around 12 percent of state residents live in its most rural areas, the Department of Health estimates that fewer than 5 percent of doctors practice there. The primary care doctor-to-patient ratio in Hennepin County, for example, is one to every 508 people, according to a recent report measuring health statewide.
In rural counties, however, the ratio can run closer to one for every 2,000 people. Five rural counties have no primary care providers at all.
The shortage, combined with shifting demographics, a tight economy and health care reform pressures, is contributing to concern that the strain on rural hospitals and clinics could get worse.A waning supply of doctors could contribute to a collapse of services in some parts of the state.
LURING DOCTORS TO SMALL TOWNS
Korstad's clinic in Bigfork has been trying to lure a physician for nearly four years. The town's school kids even wrote pleading letters to medical schools in crayon, to no avail. To fill the gaps, Scenic Rivers hires rent-a-docs, or locums. "We're really remote," says Korstad. "There is no Wal-Mart within 50 miles. There is no movie theater. We don't have some of the amenities. We will find somebody, but it will have to be the perfect person." And it'll have to be soon, she adds, because at least one existing doctor is planning retirement.
There are various ways to counter this longtime trend. The National Rural Health Resource Center in Duluth helps clinics and hospitals recruit doctors with advertisements, surveys, and even "recruitment readiness assessments." Executive Director Terry Hill, who acknowledges the uphill nature of the battle, says "Our recruiting program is one of the best one or two in the country ... But there is a shortage of primary care physicians. It's harder and harder to recruit physicians into this area."
Some medical systems use financial inducements to draw doctors to small town settings, paying off hundreds of thousands of dollars worth of medical school debt. Karrie Schipper, a recruiter for Sioux Falls-based Avera, says the money is given up front as a loan and then forgiven over five years. "The amount in loans students have coming out of residencies averages $160,000," she says. "Sometimes we'll pay for the entire loan amount."
"Our primary focus," continues Schipper, "is we want to make sure it's about retention and the fit. We really look for ties to the area." She says that even after the five-year commitment expires, Avera doctors tend to stay. "They are vested at that point."
Dr. Curt Louwagie, an Avera ophthalmologist in Marshall, took advantage of the program. He grew up in nearby Cottonwood and has loads of family in the area, including his parents. Two years in, he says he plans to stick around. "That's the fear, that they'll dangle a pretty check in front of you and then you will leave." It can happen, he says, "if you have somebody who has never lived in a small town. They can't take the personal nature of a small town. Every Saturday I go to church and I see half a dozen patients there. They come up and talk about their eye surgery. A lot of doctors don't like that."
"But it doesn't bother me," he continues. "It's part of growing up here. Everybody is in everybody else's business. There is a sense of concern for what's going on with your neighbors. I don't have any plans to go anywhere."
UMD A HOTBED FOR TRAINING RURAL PHYSICIANS
One of the more successful recruitment efforts comes out of the University of Minnesota Medical School's Duluth campus. If you ask Dr. Jim Boulger, who runs the campus's department of Behavioral Sciences and the Center for Rural Mental Health Studies, the solution begins with medical school. Nationally, fewer than 10 percent of graduates become family physicians and an even smaller sliver put out a shingle in a small town. Yet, 51 percent of the University of Minnesota-Duluth's graduates become family doctors and 45 percent of graduates practice in rural communities, a greater portion than from any school in the country.
"That's not an accident," Boulger says. "We select [students] for that." The university recruits future doctors who hail from small towns and thus are more likely to want to live in one. "People don't go into rural family medicine for money," he says. "If you don't get the people in who want to do this, you will never get them out to do it. We'll have 1,300 applications for 60 spots. We'll ask, 'Where did you grow up? What was that like for you? What is your experience taking care of others? What is your philosophy of life in terms of helping others?' Everybody has the smarts. There are 4.0s who can't tie their shoes. They are not going to get in here. We will take that kid who boot strapped himself off the farm, who took care of the crops and the animals."
Boulger directs the university's family medicine preceptor program, which matches students with small town doctors who show them the ropes. Sometimes, the students even stay in the doctors' homes. "We take them from smaller communities, train them in smaller communities, and we've got them out there in the communities," says Boulger. "It's all conscious. It's all horribly time-consuming to try to engineer this stuff."
FROM OUTSIDER TO COMMUNITY LEADER
Korstad is a product of the University of Minnesota's Duluth campus. She's originally from Braham, a town of 1,800 people north of the Twin Cities. "When I came out of residency," she says, "I drew a line at Duluth and looked at everything north. That was a lifestyle choice."
She started in Bigfork in 1983 and was the town's first female doctor, which she says was "challenging" at first. "There were some issues, though people here were very open and honest about the fact that they hadn't had a woman physician before. That made it easier for me. A guy would come in and say, 'Whoa, do you know what you're doing?'"
Korstad met concerns head on, as is her style, and since she was one of only three doctors at the clinic at the time, all rotating shifts, patients had no choice but to get used to her. "It wasn't like if you cut your hand on a Friday night, you could go to somebody else," she says. "I was the only show in town. It was easy for me to prove I was as competent as the men."
Judging by Regana Richter, a patient of Korstad's for 18 years, the community's feelings toward the doctor border on affection. Richter suffers from chronic myalgia, or severe muscle pain. "I come here for everything," she says at Bigfork Valley one Tuesday in May, after a check-up.
Bigfork Valley ranks tops in the state in overall patient satisfaction. When patients were asked in a national survey whether they'd "definitely recommend" the hospital, 94 percent said yes, compared to the state average of 72 percent.
After Richter's granddaughter died, Korstad came to the funeral. When her grandson needed special education, "Dr. Korstad got an occupational therapist to come from Grand Rapids to see him." Richter recalls a time she had pneumonia and called to set up an appointment. "They said, 'You need to come in right away. You don't sound good.'" She didn't have a ride, so "They picked me up. That's the kind of care you get here."
Richter is covered by MinnesotaCare, but there have been times when she had no insurance. The clinic charges on a sliding scale (its doctors also work on salary, rather than on a per-service basis), so she paid what she could afford. When she didn't have prescriptions, "Sometimes Dr. Korstad would give me samples for months."
Guiding patients through the health care system is something "small town rural health care providers are uniquely good at," says Korstad, who sees more uninsured and under-insured people every day. She often has to be creative to get patients the services they need, tapping into a program for free or discounted mammograms, for example. "It's the burden and the joy," Korstad says.
Nearly 30 years after arriving in Bigfork, Korstad is rooted. She's raised three kids and helped build a state-of-the-art community theater called the Edge, where she runs the lights during performances. She's integral to the hospital and clinic.
"I came for the lakes and trees and stayed because of the partners," Korstad says of her co-physicians. "We have an unbelievable team. If you're in the soup, you can call anybody at home and they'll run in to help. I feel supported. Sure it's lonely. Sometimes I wish had a bunch of subspecialists in my pocket that I could go to in the next room. But it's what we do."