Editor’s note: With the national debate continuing over rising health care costs and the future of the Affordable Care Act, The Country Today staff writers dug a little more into some of the issues associated with making health care more affordable and accessible for rural Wisconsinites for this installment of “Country Matters.”
Phoebe Devitt has always been a country girl at heart. Raised outside the village of Soldiers Grove, in the Driftless Region of southwest Wisconsin, a young Devitt enthusiastically explored the trout stream, woods and everything nature had to offer on her parents’ 50 acres in the country.
“I liked it, but there were times I resented being in the country when I was in high school,” she said. “It was a bit more difficult to socialize — no malls, no movie theaters. I just knew I wanted to go to the city. That’s why I went to Milwaukee for college, because it was the big city.
“But it didn’t take long for me to realize I wasn’t a city girl. I really missed the country. I missed being able to go outside and go for a walk without running into people or being stuck in traffic. I love the country, but I had to go to the city to realize it.”
Now, life is coming full circle for Devitt. After earning a bachelor’s degree from UW-Milwaukee and a medical doctorate from UW-Madison (as an alumna of the institution’s Wisconsin Academy for Rural Medicine), Devitt recently completed her residency in California and is returning to her hometown. Starting Jan. 1, she will live in Soldiers Grove and serve as a family medicine doctor in nearby Viroqua at Vernon Memorial Hospital, where she’ll combine her love of rural life with her passion to help people.
“These days, so many people are moving to the cities, and there aren’t as many people to take care of the rural communities,” she said. “And sometimes when a medical professional comes in from outside the community and it’s not someone people know, it can take a while to develop that trust. But I think we’re in a special place, because the community knows us and trusts us. A lot of people know my dad and my mom and me, and I think it will allow us to take better care of the community.”
Her husband, Joel Charles, a Green Bay native whom she met at medical school, is moving to the area too. He will see patients in Soldiers Grove at a clinic where Devitt’s father, retired physician Timothy Devitt, once worked.
Charles said it’s a win-win for Devitt and the community: “Her desire to serve comes from growing up there and knowing the people and respecting them. She really has a passion for what she’s doing.”
In many ways, Devitt is following in the footsteps of her parents, who faithfully served the community as medical professionals for decades. Her father was a doctor for 46 years, including 31 years in Soldiers Grove. The bonds he formed with the Amish community are so strong that even after retirement, he continued receiving requests for house calls. As a young girl, Phoebe started tagging along on those house calls with her father.
Meanwhile, her mother, Emily, still works as a nurse at Vernon Memorial Hospital. Her nursing career has spanned 47 years, including 38 years in rural areas.
Phoebe Devitt’s first health care-related position came at the age of 15, when she worked as a dietary assistant at a nursing home while attending North Crawford High School. At UW-Milwaukee, she worked as a certified nursing assistant at a group home and nursing home, and at the hospital in Viroqua.
“I didn’t know for sure what I wanted to be in high school or even the beginning of college, but having my own experiences in the medical field made me realize it was the right fit for me,” she said. “My parents never pushed me to go into medicine — it’s just something that proved to be the right fit for me.”
After earning her bachelor’s degree at UW-Milwaukee, Devitt returned home for a year and a half, working as a nursing assistant alongside her mother at Vernon Memorial Hospital. From there, she enrolled in the Wisconsin Academy for Rural Medicine, a rural education program within the Doctor of Medicine Program curriculum at the UW School of Medicine and Public Health in Madison. WARM’s goal is to help increase the number of physicians who practice medicine in rural Wisconsin and improve the health of the state’s rural communities.
Her first summer at medical school, Devitt participated in a Spanish immersion program in Ecuador, where she spent half of each day with a Spanish instructor and the other half with a local physician providing basic health care to rural residents.
After receiving her medical degree from UW-Madison in 2014, Devitt, along with her husband, spent the past three years completing a residency in Santa Rosa, Calif. Now, they’re spending a few weeks traveling before officially planting their roots in Soldiers Grove and immersing themselves in the surrounding community.
The doctor is in?
An often-heard complaint of the rural health care system is that there are not enough doctors available to fill openings in rural facilities. John Almquist, director of hospitalist services for Ministry Health Care in Stevens Point, told The Country Today last December that the U.S. will be short 90,000 primary care physicians by 2020. It is a dismal prospect for Wisconsin, where the current availability of new doctors coming out of school is roughly one every other year, Almquist said.
For Ministry Health Care, one of the ways to fill the gap is to turn to technology and nurse practitioners. Ministry is using a $432,258 grant from the U.S. Department of Agriculture to connect 15 medical care sites across Clark, Forest, Lincoln, Marathon, Portage, Vilas and Waupaca counties with hubs where supervising physicians and specialists can hear, see and talk to patients and their nurse practitioners in real time via Internet connection and a telemedicine “cart.”
Carts are equipped with an electronic stethoscope, onboard video camera, speakers, visual display and handheld camera. Almquist said the hospital system will eventually have 24 connected facilities across the state with nurse practitioners managing the on-site patient care.
“We need to do something,” Almquist said. “We have to think about how we are going to provide care in rural communities if we can’t hire doctors, and the way to do it is to hire nurse practitioners.”
Technology is one option, but the National Health Service Corps is focusing on the real thing when it comes to getting doctors into underserved communities. NHSC and its Students to Service Loan Repayment Program will cover up to $120,000 in student loans to doctors who commit to providing primary health care for at least three years in a designated shortage area.
Neil Cox is taking advantage of the program. After getting his medical degree from Wayne State University in 2014, Cox started his residency in Baraboo and then moved to Black River Falls in August, where he serves Black River Memorial Hospital and the Ho-Chunk Health Care Center.
Some doctors have said no to the loan relief program with the belief that they would make less money — loan repayment notwithstanding — in rural communities, but Cox said that premise may not be correct: “If you look at the average doctor’s salary in a rural community vs. an urban community, I believe it is slightly higher in rural communities.”
He referenced a 2005 study reported on physicianspractice.com that said rural doctors make 12.7 percent more than their urban counterparts after incomes were adjusted for cost of living. A 2012 report by the Medicare Payment Advisory Commission said doctors in rural settings make “slightly more” than their urban counterparts.
Cox, who grew up in suburban Detroit and whose wife is from Minneapolis, came to love rural life while serving in the Peace Corps. He said the loan forgiveness program is “icing on the cake,” but there are challenges for doctors who serve in rural communities. They work long hours.
“For example, I see patients in the hospital, I see patients in the clinic, I deliver babies, and many doctors nowadays are looking for a 9-to-5 job, and that’s not something that is as on-offer in rural areas,” Cox said.
Rural patients often have lower incomes, which may impact their health care. It isn’t a question of paying their bills, Cox said, but they may not have ready gas money to get to their appointments.
“So it’s harder to manage their chronic conditions, and doctors worry about those sorts of things,” he said. “If you see a person, you start them on medication, you tell them to follow up and they don’t, then they show up in the (emergency room), and now I’m seeing them in the hospital instead of the clinic. We want to make people better, and it’s frustrating that for social, or economic, or whatever personal reasons, they can’t or don’t follow up the way we hope.”
Taking a bite out of tuition
James Younan and his wife, Kia Moore, share a passion for improving dental care for underserved populations, so when they heard about the Students to Service program now being made available to dental students, they jumped on the chance.
“Dental school can be really expensive. ... It was a win-win situation for us,” said Younan, who, with Moore, has been seeing clients at Family Health Center in Ladysmith, an affiliate of Marshfield Clinic Health System, since August.
Ladysmith is one of more than 380 Health Professional Shortage Areas in Wisconsin, and Family Health Center has a HPSA score of 26, which is the highest score a dental site can receive to designate the severity of the provider shortage in the area. There are 124 dental HPSAs in Wisconsin.
Younan and Moore met at A.T. Still University, the Arizona School of Dentistry and Oral Health, and were notified of the Students to Service program during their third year of coursework. Both have their Masters of Public Health degrees. While similar programs have been available for other health care professionals in the past, this was the first year that a Students to Service program has been offered to those entering the dental field.
The need is great: A 2013 Pew Charitable Trust study found that almost 72 percent of children in the Wisconsin Medicaid program did not receive dental care in 2011, and patients who do receive care often travel an hour or more for an appointment.
Moore said they were drawn to Ladysmith because they had heard good things about the area and the people from fellow students who had visited there as part of a rotation through rural areas of the U.S.
Younan said the Rusk County area faces a severe shortage of dental providers, and some of their patients drive a couple hours to see them. Many of them have had minimal dental care in the past, and he finds it rewarding to educate patients about oral health and hygiene. Many people in rural areas aren’t as exposed as urban residents to crucial information about prevention and the link between oral health and conditions elsewhere in the body, such as diabetes and high blood pressure.
Serving in the Ladysmith clinic also has helped both Younan and Moore gain new skills, such as modifying certain procedures to foster a stronger patient-doctor relationship. Only half of it is what the dentist does in the chair, and the rest of it is what the patient does at home.
Moore said she and Younan could have chosen to go into private practice, where care is more elective and “almost taken for granted,” but they want to make a bigger impact and help people who need it most. Also, they’ve fallen in love with northern Wisconsin.
“The people are amazing; everybody’s ridiculously nice,” Younan said.
Younan, a California native, and Moore, who’s from Arizona, said they plan to stay in Ladysmith longer than their three-year Students to Service obligation, and they’re bracing for their first Wisconsin winter. They said they look forward to enjoying outdoors activities such as snowboarding, hunting and ice-fishing.
Since its inception, the NHSC community has grown to more than 50,000 primary care providers. There are about 230 NHSC clinicians in Wisconsin and about 10,400 active members across the country. The current application cycle for the Students to Service Loan Repayment Program closes Oct. 26. For more information, visit www.nhsc.hrsa.gov.