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Medicine in a Small, Small Town

When 86-year-old Dallas Gaines of Scobey, Mont., woke up with the classic symptoms of stroke last October, the only doctor in the county was out hunting whitetail bucks on a sea of prairie stretching from one horizon to the other. Donald Sawdey, M.D., had just lined up his shot when the emergency call arrived from the clinic. Even out in the great beyond, deer know to run when they hear a ringing cellphone. “Next time I’ll keep it on vibrate,” the doctor says.

Sawdey hustled back into town and treated Gaines within 20 minutes. An hour after that, Gaines was on a 50-minute medevac flight to Billings, the closest town with a fully equipped hospital. He’s lucky the plane was available; it’s about 360 miles to Billings by car, a trip that few critically ill people could survive. Fortunately, Gaines got to the hospital in time. Within days, he was on his way to a full recovery in his hometown, a place that puts the “rural” in rural health care.

Health care access has become a vexing problem all over the country. But the challenge of connecting patients with the right medicines, tests and procedures becomes even more complicated the farther you get from the medical hubs of big cities. A 2008 study published in the journal PLoS Medicine found that life expectancies are actually declining in large swaths of rural America, a trend largely fueled by upswings in diabetes, cancer and chronic obstructive pulmonary disease.

Many of these illnesses could be managed or prevented with proper medical care, but the 77 million Americans who live in rural areas have just 10 percent of the country’s doctors. As much as we idealize the country—clean air, hard-working people—there’s no doubt it can be hazardous to health.

Sitting in the northeast corner of Montana, 15 miles south of the Canadian border, Scobey (population about 1,200) is surrounded by land that’s too dry and windy for trees but marginally suitable for wheat fields, cattle, horses, deer and coyotes. The local radio station runs individual funeral announcements alongside ads for good-tempered bulls. You can drive through town in about two minutes, a trip that takes you past a single flashing traffic light, the Daniels County Courthouse and the medical clinic, a nondescript two-story brick building that makes the rest of Scobey possible. “Without the clinic, this town would disappear,” Sawdey says.

The Scobey clinic—which draws patients from a 200-square-mile area—has 24 hospital beds, 30 nursing home beds and about 90 employees. Everyone in town knows someone either staying or working there. They all know Sawdey, a tall, talkative native Californian who settled in Scobey three years ago with his wife and two sons. He set up shop here partly for the challenge, but mostly because he wanted to raise his kids in a quiet, safe town populated by trustworthy people. By the clinic’s standard, he’s almost an old-timer. “They’ve had a new doc here every year or year and a half,” Sawdey says. That kind of turnover, he says, “destroys the health care system.”

The shortage of physicians in rural areas certainly hasn’t gone unnoticed by the federal government. In 2009 Congress earmarked $500 million for the National Health Service Corps, a program that helps pay the student loans of doctors who spend at least two years in “underserved” areas, most of which are rural. In March, federal officials estimated that it would take nearly 17,000 more physicians to fill the gaps nationwide, including 87 in Montana.

The new health care reform law takes aim at the problem with measures that include a 10 percent bonus to doctors who treat Medicare patients in rural areas, and more money for rural hospitals.

Still, it’s easy to see why small towns have trouble keeping their doctors, says Craig Klugman, an associate professor at the University of Texas Health Science Center in San Antonio. Rural primary care doctors tend to make about $20,000 a year less than their big-city counterparts. And while country life may seem laid-back and relaxing, rural medicine can be incredibly stressful, he says. “You’re always on the clock. It’s hard to get vacation time. And people will walk up to you at the grocery store to have you look at a rash.”

A bigger problem: Rural health care is performed without a safety net. Sawdey’s nearest colleague lives 40 miles to the east in Plentywood. The two have talked by phone but never met in person. And both know that they can’t count on a surgeon or cardiologist to show up when things get complicated. Sawdey’s one and only physician’s assistant recently quit, leaving him scrambling for a new one. “You don’t have any backup, and it can be really scary,” he says.

Patients in rural areas can’t necessarily count on access to the latest technology, either. Sawdey looks forward to finally getting a CT scanner—purchased with the help of silent auctions, private donations and a federal grant—but he doesn’t have many of the instruments considered essential for modern medical care. “We are grossly underfunded,” he says. “I’d be able to do a lot more if I had more equipment. It’s tough to fix the windows around here, let alone get new things.”

A fundraising thermometer out front shows that the clinic is still a tad short of its $10,000 goal for a new ultrasound bladder scanner. He doesn’t have any anesthesia, doesn’t perform colonoscopies and isn’t set up to deliver babies, although babies aren’t always aware of that policy when they decide it’s time to be born.

He does have one piece of equipment that makes Scobey a little less isolated than it used to be. A new telemedicine monitor—a 26-inch screen mounted with a camera—lets patients talk face-to-face with specialists in Billings without making the 360-mile drive. “I can’t send an 80-year-old grandma to Billings when there’s 2 inches of ice on the road,” Sawdey says. “For some of these people, the trip would be more dangerous than their illness.”

Patients who need a checkup from a cardiologist can drive to Plentywood, a slightly larger town where the telemedicine machine is equipped with a stethoscope. The doctor or physician’s assistant in Plentywood places the stethoscope, and the doctor in Billings can hear the beats and murmurs of the patient’s heart as clearly as if he or she were standing in the room.

Sometimes, a small town can even be a good place to have a health crisis.

“No one ever waits to get into our emergency room,” Sawdey says. The ER, with two beds, is usually empty, but it’s ready for emergencies: Tony Lantz, 57, a maintenance worker at the Scobey clinic, suffered a heart attack last summer. The doors of the clinic were locked shut, but Sawdey was across the street at the Catholic church attending a health fair. Within minutes, Sawdey was giving Lantz the clot-busting drug that saved his life. Lantz was flown to Billings to have stents implanted. Still, he says, he doesn’t worry about being away from big-city medical care. “I like living here,” he adds. “And I couldn’t have gotten to a doctor any faster in a bigger city.”

Rural doctors have to deal with surprisingly diverse problems—from “the guy with the runny nose to the grandma whose chart weighs more than I do,” Sawdey says.

Many health problems in rural areas can be chalked up to simple demographics. People living on farms or in small towns tend to be older than urbanites, according to the National Rural Health Association, so they face all the illnesses associated with aging. They also tend to have less money to pay for such things as health insurance. Insurance or no, people living and working on ranches have a tendency to ignore things like their blood sugar, blood pressure or cholesterol levels until they’re looking at a crisis, Klugman says. “Being sick is considered to be a moral failing,” he says. “They aren’t likely to see a doctor or worry about their health unless they are unable to do their chores.”

Such attitudes can be costly. A study published in 2009 in the Journal of Public Health Management and Practice found that rural Americans spent over $9 billion on hospital bills in 2002 for problems—like hypertension and asthma—that could have been nipped in the bud with basic medical care. Sawdey certainly has had trouble bringing patients into his clinic. He estimates that his caseload could increase by 70 percent if everyone in the area who needed medical care made an appointment. “Preventive health is a hard sell,” he says. “They wait until they just can’t go anymore.”

For people who do go to the clinic, rural medicine can be a small blessing. Greta Stentoft, 82, says her sister used to drive to Billings every three months to see a specialist for her diabetes. With Sawdey’s help, her blood sugar is under control and she hasn’t been to Billings in over a year.

Dallas Gaines and his wife, Maxine, 82, catch flak from their kids for living so far away from a city. If the kids had their way, the two of them would pack up and move to Portland, Ore. The couple agree Portland is a nice town—but it’s no Scobey. “We’re going to stay put,” Maxine says. “As long as the doctor is here, we’ll be here.”

Chris Woolston is a freelance health writer whose work has appeared in the Los Angeles Times and Reader’s Digest.