Oregon Story; Rural Medicine aka Country Doctors

Funding for production of the Oregon story was made possible through a generous grant from the United States Department of Agriculture--Rural Development. [water running] Sure it's a unique environment, and I think you have to be unique and have some quirks to practice out here. It's a different role, it's just, it's not what you train for, there's no training program to prepare for this. I think if you go to John Day or Burns or Lakeview, you're going to see the same type of person

practicing. I think we're all country doctors. So she was in labor, and fortunately grandma was there. And I did local anaesthesia, did my episiotomy, delivered a nice baby took care of the baby, handed it to Grandma who was plenty capable of newborn nurse and this guy was standing behind a curtain and the door. The bed was there, he was here, and after we, I got the baby delivered. I heard this thump on the floor, this guy had a double-barrel shotgun. Guess what was going to happen to me if I messed up? He handed me $64, says, "Thanks Doc." That was my first delivery. The practice of medicine in rural Oregon has always been and still is

a little different. A cowboy who worked for a rancher down by Princeton was well lubricated with alcohol one day, and he was demonstrating his prowess with snake-handling, and he picked up two rattlesnakes, one with the right, one with the left hand, and he was probably envenomated and bitten X number of times on both arms, and he got quite sick and he was brought to the hospital. They took about 10 days and about 20 units of anti-venom and surgery and he finally survived. [beeping] We have motor vehicle accidents, but our biggest source of severe head trauma is livestock. We see far more head injuries due to horse accidents. One thing that I've never seen before I moved here was a chainsaw accident. I was practiced in a bigger city but I've seen chainsaw accidents to literally every part of the body

and that was something I had to get used to, learn how to handle. Our population is a very stoic population. They are farmers, ranchers, loggers. They spend a lot of time taking care of themselves, are independent, and so they don't come to the doctor unless they really are in dire straits. A gentleman who was 94 came in with an MRI? his heart attack. It was the first time he'd ever been to any kind of a health care provider--and he wouldn't come in until he'd finished building the section of fence he was working on at the time. These loggers and ranchers would come in, and they'd just be almost dead why not. I said, "Look, you have to go see a specialist." "Not going doc." "Oh yeah, you're going." He said, "Oh no, hell no Doc, you can do it, come on."

But that was the attitude in that community. And so if we had somebody that was really sick or ill or whatnot, we had a waiting room out there that would seat about nine people. You'd go out there and you'd take the healthy as well and pull them in for your assistant. They always were willing. Out here, distances from one place to the next can be long. People do a lot of driving. Everything seems to take more time. One of the things that are the hardest here is is you know telling somebody they have a terminal diagnosis, but actually one of the big ones is just telling somebody they can't drive anymore, when they're in their 80s or 90s and they really shouldn't be driving anymore, and these people have been driving since they were 13, 14 years old, helping with the harvest and everything. Elevation here ranges anywhere from 10,000 feet to 12-hundred feet within the county. Some of our patients are an hour-and-a-half out, you know, [in] the

Greater Portland metropolitan area an ambulance response might be five, six, eight minutes. Ours oftentimes run to an hour-and-a-half down and an hour-and-a-half back, so it's three hours from the time that the event happens until these people actually see a doctor. If you wait for the ambulance to come and get you then that's He's got to make 130 miles down to get you and 130 miles back, and on the way there's lots of deer on the road. And the first three weeks the con?? I hit a deer every week coming home, three in a row. So rather than have all the anxiety of worrying about my $1700 Nova, I I just put a deer smasher on it. Doctors in rural areas tend to specialize in that most general of specialties: family practice. This is a fantastic place to live. The people here are great. You know, that's, that's that's part of the joy of family practice.

And they also tend to be very good. A bad doctor in a small town I think sticks out like a real sore thumb and I think that people get onto him very quickly. And he doesn't last long. By most accounts, these doctors, nurses, and dentists, as well as physicians' assistants and nurse practitioners are some of the finest health-care professionals in the state. Problem is they are in critically short supply. There are many communities in rural Oregon that have no physicians whatsoever. There are whole counties, in fact, that don't have physicians. ..something caught between a hitch and a bumper? Getting doctors, and keeping them, is an ongoing challenge for rural communities. The crisis is there's not a pipeline that we are filling fast enough to replace those, those openings. Even in places that do have doctors, soaring malpractice insurance rates are limiting the services they provide, especially prenatal care and childbirth, the field of obstetrics.

Right now there are five physicians in John Day and three of them have quit doing obstetrics altogether. In Hermiston, they had 13 OB providers-- five of them just quit because their malpractice went up 400 percent this year. I predict that there's going to be some communities in rural Oregon, they're going to lose all obstetrical care. So women are going to have to travel 100 miles, 150 miles, maybe 200 miles to get to someone to deliver their baby. And that's just a recipe for disaster with people potentially having trouble in transport. Rural doctors earn substantially less than their urban counterparts, likewise for hospitals. Most rural hospitals in Oregon need outside funding to stay open. And for doctors and institutions, the situation is getting worse because rural patients are increasingly older, needing more healthcare than ever and relying on Medicare to pay for it. Rural populations at large are becoming poorer, more dependent on Medicaid,

here called the Oregon Health Plan. These government insurance programs already reimburse hospitals and doctors at a low rate, and those rates are actually dropping. Our reward for taking care of these people now they're cut another 4 and a 1/2 percent this year, and that doesn't really compute, you know, eventually it really affects one salary. If the cost of living goes up but reimbursement goes down. OK I think we're gaining. We haven't gone to refusing to see Medicare patients or refusing to see obstetrical patients, we just keep taking care of people. [In background: "There's still a little crackle there but--] Where does it end? I don't know. [Heart muscle's pretty weak but we can get a little more mileage out of it so. Another lap or two? Yeah, there you go. You get to the point where you can really wonder about can you afford to practice? And none of this helps the recruitment of new doctors to rural areas. For a ten-year period I think we interviewed, if my memory serves me

well, about 16 doctors, not one came here. But they came here to look it over and we showed 'em our practice and our books, and their question was, "Why are you doing this?" Ultimately, one overall concern may be the most important. Tough economic times have plagued rural Oregon for years, so that now, if these communities hope to see economic recovery, and in some cases if they are to survive at all, the last thing they need is a healthcare system in trouble. But that's exactly what they have. We know that we will compound the hemorrhaging of this community if we do not aggressively continue to better our healthcare system and be better. It will only get worse if we don't. Bob Morrison is a rare bird out here. He's a doctor, and unlike just about everyone else, he grew up in what's often called the Big City: Portland.

I decided that after I finished medical school I wanted to come to Bend, or go further east, because I like the outdoor life, hunting and and fishing. Clear as a bell. It's kind of a religion here. And I thought that country medicine and my particular likes and training were quite compatible. Went to Bend and I thought they had too many doctors then and there were too few in Burns and Burns looked quite good. We've been here forty-four years to date. That's quite a few. Bob retired from his practice in Burn several years ago, but a couple of times a month he and a nurse still take to the road with the county's mobile clinic.

Today's destination is Fields, population 12. Two hours from Burns. As remote as Fields is, some of today's clinic patients have themselves traveled dozens of miles to get here. So the first one is a....?? OK. How long do you think it is? I think it might be a half-inch banter?? OK. All right, we'll fix it. What were you doing when you got that stuck in? Running [ ] into a chute A lot of injuries happen out in the mountains, out on the, on the desert. So you just pull out your own first aid kit and you try and do the best you can with it. I tried to get it out myself but after the layers of skin, you know, you start getting into the

nerves and stuff and it's a little too painful. Oh. It was a little bit deeper than I could handle and nobody around was willing to to cut into my hand to pull the sliver out. From my house it's about an hour and a half drive to the nearest town, which is Burns. So when we get the flyer saying that there's going to be a doctor in Fields or French Glen, then you try and make time to come out and do that, that. Do you want to watch him do this or not? No you'd better just look-- I want to but-- Because rural healthcare care is not a profitable business, Oregon is quilted with rural healthcare care districts in which the local people tax themselves to subsidize hospitals, clinics, and mobile clinics. We had to start a tax base, not a very popular concept, amongst rural people, but we thought that if we could explain it and show our presence, that it might be accepted. And that's the way it turned out.

There you are. There it is. That's it, that's the culprit. I'm going to put one stitch in. This clinic loses money, but it's good public relations. A visible example of taxpayers' dollars at work. I'll have you check this out in about three or four days. No problem. And all you need to do is lift up with your tweezers and cut once and pull it, and I know you know that. Do it yourself is just the way things get done out here. My aunt sewed a guy's tongue on one time, he was riding a bucking horse and they went through a chicken yard and it had a two-by-four around the top of it to keep the magpies out, and he hit it with his chin and cut his tongue [ ], and my aunt sewed it back on and sent him to Winnemucca. What's the other guy looks like? Hey, I'll tell you what. Okay. Pretty rotten...? ...I could have jumped up too quick, you

know that. Yeah. Young fellow like you oughta learn better, shouldn't he? I always go to see Dr. Morrison when he's down here because he knows everything about me and and I want to talk to somebody I can talk to him. Any sore throat? No Oh it's a little tender I guess. He's going to need a flu shot. I have known this man about 16 years, and his illnesses have been things that could have proven to be fatal. But he's still here. I can't really tell these other doctors what, they probably think that this silly old man don't know what the hell he's talking about anyhow. Have you had any unusual dizziness? No. This is an inhibitor for your blood pressure, like Vasotec and Alperil. Same as this, huh? Yeah, same thing. Last argument I had with him was using the calendar,

And I said well, I'll use it once a week. He said, you'll use it every day. I said, I'll use it every two or three days. He said, you'll use it every day. Then he said, when your kidneys quit working, don't come crying to me. Go ahead. For a while it was hurting me and I couldn't sleep. Yeah, I don't work very fast unless I have to because I don't see that there's any gain and I get to know people better if I'm slower around them and I give them a chance to tell me what's really on their mind. They're rural people and they know how much time it takes to do things. You know I think you want to avoid getting down on the kneecap and irritating it, which I don't think you do anyway, do ya? Not if I can get out of it [laughs]. Only if you go to church, you know? [both laugh] Because they're always needed somewhere, rural doctors often just

semi-retire, like Doc Morrison. Others retire very late. Dr. Lee Harris finally retired from his practice in 1990, at age 75. Until then he worked at the hospital in John Day and with his wife Eva ran a clinic in their home in nearby Canyon City. For a while, they even operated their own mobile clinic. One day, we're rounding this curve, and here is a bunch of cattle in the road. So we pull up Tough-looking guy hadn't shaved for a week or two, he says, "You the doc?" Yeah. Pull over there. I pulled over, I didn't ask any questions. So Is this -- can I help you? He says yeah, we got this cowboy over here that's got this thing in his neck. And here comes this guy with a swelling

a big lump the size of a lemon, right over there, and they'd been out two weeks Anything. So, can you fix him up? I say, yeah, I can fix him up and I'll listen to it so it's not an aneurism from a neck or anything like that, it's, you know, not full of blood. So I stuck a knife in it and the pus just, she was holding a can there, filled it up After a while he said, I can talk better now Doc, it sure as hell feels good, thank ya [laughs]. Then they took the cattle out of the road and I could go where I was going. That's the kind of stuff you run into. Our phone was listed. We were available 24 hours a day whether Lee was on call or not. When patients didn't have the cash, Lee and Eva were open to alternatives. I'm sitting at the reception desk,

and I see this little VW bug come up the driveway, and here's this little fellow sitting in it and beside him are eight naked legs sticking out and over the years they've received everything from firewood to livestock in payment for services. The best goat meat I've ever had. It was so tender and wonderful. These days, airborne medical services like Air Life serve most of rural Oregon and provide vital emergency transport to major hospitals. But 25 years ago the quickest way from John Day to a big-city Medical Center was in Lee and Eva's airplane. She's an EMT. She's a commercial pilot, and I'm a pilot too, so so if we get a difficult case, I'd be stabilizing the patient and call up Evie and say, "Get up and get the plane ready, we're going someplace." So, by the time I got the patient stabilized, she would have the plane warmed up and ready, we get the

ambulance and put him, so I could get my patient to Bend or to Portland or Eugene faster than they could get here. If the patient were really critical, I would take care of it and she would fly. Or if the patient weren't too critical, she would take care and I'd get to fly, you know, so it was the best of both worlds. One thing that was fun about country living in small communities is that sometimes I was off downtown doing other things. So he couldn't call me. But the word would go out and I would be found. Somebody would just walk up to me and say, "I think your husband needs the airplane." And, you know, I never really knew what the chain of communication was that it got to me wherever I was but that was not uncommon. [background noise] Life in a small community can be a little like living in a fishbowl.

Everybody in town knows who you are, everybody in town knows your habits, everybody in town knows what you do and what you don't do. But the flip side is they really know you and when something isn't going well they're right there to help you. It's one of those things you either really love or you don't. There are certainly people who would find having that kind of exposure all the time uncomfortable. Lisa Dotson administers rural health programs at Oregon Health and Sciences University in Portland, but for seven years prior she had been a family-practice physician in John Day. One partner that we had in our practice, after two years really decided she could not deal with the fishbowl effect, and really didn't like going to the grocery store and having everyone know what she bought and feeling like she had to leave town in order to be able to have some privacy. So I think for some people that is a problem and an issue and the more small and isolated a community is the more of a problem that it is. On the other hand, it's a wonderful way to connect to communities and I really felt like I knew

a lot about my patients. We had a fire out here. And we have four engines. You know one of those boys came up here to take care of this fire. One of them said, "Hey, remember this elbow Doc?" Pretty good elbow. or you, I almost cut my throat off and you fixed that up. I put a power saw across my knees and you fixed it, look at me, I'm working! That sort of thing has been greatly rewarding to me, all the time that happens. For people who like that sense of connectedness, there is no better place to practice than a small town. How are you? Fine, Yeah? Doing pretty good. Looks like you're doing very well. Yeah even without a prostate. Haha OK. Lisa Dotson left John Day for Portland, largely because the urban environment offered more opportunities for her husband, an engineer.

For most positions, spouse issues are a concern. Most physicians are married or attached to other professionals of some description and that can be really challenging to find things that keep them happy and moving along in their careers. If you are in a really small location. Lisa's position in John Day was soon filled by a new doctor, David Graham. Spouse approval is the number one thing that drives doctors out of rural practice, whether they're a male physician or a woman physician. I think the reason I'm able to survive here and my wife is able to survive here is she grew up in a small town so she knows what rural life is about. Practicing out here gives David the opportunity to do something that few urban physicians can. Once a week he makes house calls. I do these house calls because I can figure out a lot of things about a patient and what might be further impacting their disease process and further making them not get better by going to their house. If I am

I'm not sure why their diabetes isn't getting better and I go to their house and peek in their cupboard and they've got a bunch of Ho Ho's and Twinkies, then I know the answer. A lot of people out here drive a pick-up truck and it's pretty hard to get someone who can't lift themself and is overweight and/or immobile up into the cab of a pick-up to get up into a visit. So the options are really limited. And there you go. If I can see them at their home and just have them recline on their couch to examine 'em, it's easier on them. [dog barking] Oh here we go. And you can look at their pill bottles and see who's prescribed 'em, and what prescriptions that they may be taking that you didn't know about, or old prescriptions that may be expired that they're still taking. Boy I'd like to eliminate some of those, Bill, even as I just went through each one of 'em. It's just nice to be able to see people in their environment and come to them to serve

them instead of having to make a hardship on them and whisk them in and out of the office. I've got to where I don't mind spilling the peas and picking them up again and stuff like that. that. But if we could get that shakin' to the point that you don't drip your peas off your spoon, you'd like it. That would be darn nice. OK, all right. I can't even sign my name anymore. more. Okay. OK, It's getting that bad. Yeah. OK. Train, cut that [?] I think the quality of care is a big issue and a lot of people bring it up not just as an issue for rural practice but for family medicine and they say how can you know everything about everything and my answer to that is always always I don't know everything about everything. Somebody focuses only on diseases of the left hand, they're going to be a lot better at treating the left hand than I am but I'm, I'm going to be better at taking care of that person as a whole person. And I know my limitation of when to call somebody else, and we do tend to refer a lot of things out of town. But we also can do an awful lot here that keeps people in town and not having to

travel. One of the questions becomes, Bill, at what point do we work on more time with the motorized chair and a better way to [fades out]. Transportation is a big issue for people that have physical disabilities, especially in a rural town. The Americans with Disabilities Act says you have to have you know wheelchair accessible ramps at all of the crosswalks intersections. Well, in a town where there's one main road and a few cross streets that's not that many places. And off the beaten path is usually gravel roads, dirt roads, or unimproved driveways, and that makes it a lot harder for people. I know of about five people I've taken care of through the time here at home who go from their motorized wheelchair to a old riding lawnmower that they can then get up and down the hills and the rocky gravel driveways. You've got a spot there under your eye. I'm going to measure that thing Harley, because by the color of it and the shape of it, I'm a little concerned about that one, I think we should try and find a time where we can take a biopsy of that and make

sure it's not a skin cancer. [background noise][knocking] Come in. Hello. How's everybody doing today. Good, how are you? I'm doing just great, thank you. How are you doing, Mary? Pretty good. How are you getting around, are you getting around the house pretty well? Yeah. I fell once in a while, but that's it. Mary suffers from failing kidneys, an ultimately fatal condition if not treated by dialysis. Dialysis is readily available in Bend and Portland, but both are too far from home for Mary. She has chosen to stay here, close to family and friends. Rural communities typically have older and poorer populations which creates a practice dilemma for providers there because they typically have fewer patients that are covered by standard commercial health insurance and they have a larger population of older, sicker and poorer patients

in Medicare and Medicaid being the primary payment mechanisms, and that then adversely affects their bottom line because they're being less well reimbursed for a larger percentage of their patient population. When I get back home I'm fine to use my room. I know how I got there. K, well, I don't want to chain you to your bed Mary, I want you to get around and doing things. I want you to be as active as you can be. Mary's treatment is covered by Medicare. Many urban doctors to stay profitable restrict their numbers of Medicare, Medicaid patients to no more than 20 to 25 percent of their total patients. In our situation, 65 to 70 percent of our practice is either Medicare or Medicaid. It makes it hard. Bye bye. 16 of my deer have been hit on the way home from Condon, and I have hit six deer in other

places and one bull elk, one pig and countless porcupines. Every Tuesday since 1985, Mike Dess Jardin has driven from John Day to the town of Condon and back. A 250-mile round trip. Doctor Mike, as just about everyone calls him, is a dentist. He's arrived in Condon this morning to a problem. Some remodeling in his rented clinic space has somehow stopped the flow of water to his equipment. This is nothing he can't fix. It's just part of country dentistry. Barbara Starr to find out what.[??] Parts they got. It used to be, in the 40s or 50s, the average man could take and put a roof on his garage and change the spark plugs in the car or work on the plumbing, and I grew up around people like them, as far as when things break down I've been able to fix them, when things need to be installed, I know how to put 'em in. It's made a big difference in my practice. My

first office I installed all the chairs and hooked them all up, and then that way if some something breaks you know where to look, how it was done. There's no reason in dental school why they shouldn't be giving these dental students rudimentary courses on dental equipment, how it works. I can't pull this joint loose because it, it, this thing has to turn, so He drives here each week because this county, Gillum County, has no dentist of its own. See you got hot, cold water through here. I'm only one dentist for about 3800 people, you know, one dentist one day a week for 3800 people isn't hardly cutting the mustard. We're graduating dentists at 1964 levels right now and you have 2.7 retiring dentists for every dentist graduating from dental school, so that that creates a real problem with there being enough practitioners. I think it's about all dry, Nelly. In better

Better economic times Condon had as many as three practicing dentists, since then preventative care and hygiene education have fallen way off. I had a kid the other day, 21 years old, looked in their mouth and couldn't find any cavities, took X-rays and ended up doing five root canals on that kid, and all from interproximal cavities, nobody had ever talked to him about flossing. We did, I think, a much finer job, you know, 20, 30 years ago about those kinds of issues than we do today. Now we're running around, you know, we're largely putting out fires on people's teeth, and oftentimes the only time we see 'em is when a tooth's so bad that it has to be pulled. What really should be going on is they should be getting in on a more routine basis and their routine fillings and routine health should be addressed. I think there There are very few truly unique rural health problems, the problem is that they sometimes are more magnified in a rural community. Here in Condon, David Jones, the fellow in the chair, and his partner Dennis Bruneau operate the clinic that houses Dr. Mike's office, and they too

see many of the same problems found in the rest of the U.S., though sometimes with a rural twist. We have tremendous obesity, a huge increase in diabetes with that and, and our lifestyles are just a mess when it comes to our diets and habits and so on. We've had a lot of problems and still do with alcohol, in kids, because there's has not been a lot for the kids to do and that's their parents did it and their parents don't see anything wrong with their kids doing it. And that just, that and, and chewing tobacco, you know, I mean the parents buy it for the kids. And just, it's enough enough to really drive you nuts sometimes. The Gillum County Medical Center is an award-winning clinic. We're about a third subsidized by the Health District. And it's run so efficiently that it often returns much of the county's annual subsidy. How much does it hurt? I'm just wondering. Hmm, not as much as

your allergy shot, I don't think. The clinic is operated continuously since it was founded by the men and their wives, Karen and Cindy, more than 22 years ago. It's an impressive feat, especially given that none of them is a doctor. Keep breathing, keep breathing. Was it okay? M-hm. It didn't hurt as much either. Our county, the county to the south of us, the county to the west of us, there are no physicians in those three counties. Just breathe normally and listen to your heart here. David and Dennis are physicians' assistants or PAs, supervised by a doctor in Hermiston, 90 miles away, who visits once a week, but they too wear some of the many hats common to rural health practitioners there and hold it. [DENNIS BRUNEAU]: You have to be multi-discipline, you know. I take my own X-rays, I do my own EKGs, sometimes I do my own lab work. I see patients you know I do my own paperwork.

I write my own charts and so you have to be efficient and that keeps costs down because what kills real health clinics is economics. Why don't you just leave the gun on the case. I goofed up. OK OK David and Dennis insisted on coming as a pair a package deal to avoid the burnout they know would accrue to a sole practitioner and well aware of their spouse's needs to be active and challenged in the small town environment. The men hire their wives to staff the clinic. So far for 22 years at least the plan has worked well. A while back David and Dennis even reigned as national rural physicians assistants of the year. Tada. [NARRATOR]: A prestigious award, but fortune did not follow fame for the two P.A.s And I would be ventured again. We're pretty darn close to still the lowest two paid in the state especially with 22 years experience. The clinic gets enthusiastic local support because folks out here remember

life before it opened. People here suffered no health care for about three or four years. They had no doctors no no practitioners here they had to go to the Dalles 70 miles through all kinds of weather and the risks of delayed care and all that. And so they know that it's well worth it, it's money well spent, and they see the results. But as fine a job as this clinic does the local population still has no obstetric care. No surgical services and no doctor. The rural shortage is applied to nurses too. And the so-called mid-levels nurse practitioners and physicians assistants. A lot of the rural physicians or mid-levels are older and they're getting to the point where they're getting just tired and they're they're going to retire and move elsewhere. You're not getting the young folks out as much whether it's mid-levels or physicians because the income levels here don't

approach what they can get in the cities. Seems to me we're due for a blood test in another week or two. PAs much to my dismay a showing a declining interest in rural health. There are more PAs being produced today because there are more schools. But the problem is is that they're not preparing PAs for positions like this. (music) In just about all the areas of health care the training of people to fill the many vacancies is running behind. There are too few future doctors, nurses, mid-levels and dentists are in the pipeline. But in Oregon at least some solutions are in the works. The salvation for rural Oregon and Rural Practice is going to be training programs like we have here. The thing that attracted me to coming here was the rural experience I had in my training. When I could go to enterprise and spend a few months there and really see what it was like to be a rural doctor and that solidified my desire. (music)

In our county's demographics have changed. There used to be a lot more families. Not as many jobs. The timber industry is basically gone, and the population here stayed around 7000 in the 30 years I've been here. Right now there are a lot more elderly people and a lot fewer families. Lowell Euhus is an avid hiker and mountain climber, but his real passion is the practice of medicine. For 31 years he's been a family practice physician here in Enterprise. Rural Practice is very broad. It has to be by it's very nature, because we don't have all the specialists available. (Door opens) Hello, Carolee. Good morning. how are you? I do some surgery. Actually, quite a bit over the years. I've done a lot of obstetrics. I'm the county medical examiner, investigating deaths that are unexplained or out of the ordinary or whatever. One day we're pretty sick, coughing. Let's start off that that flu they've been telling us about.

One day I delivered a baby did a hysterectomy and put in a temporary pacemaker and that was an exciting day. You and Lee both have come through pretty well this year on you're testing [cut off] I've been behaving myself everything except weight. although you'll know that I've lost about 10 pounds since I was here last. Fantastic. Thanks to the flu. To the flu huh. Back in the 1980s as Lol pondered his eventual retirement he realized that there might be no one to replace him. The nineteen years prior to that Oregon Health and Science University had produced just one rural family practice doctor. So they really weren't training rural doctors, family practitioners end up in bigger cities by and large. One of the things that we know about medical centers in general is they attract urban students to urban places and so if you take urban kids from urban universities and put them in urban medical schools you don't produce rural doctors unless you really set out to do that. OK. thanks doctor Euhus. You bet. See you later. So Lowell and a partner help create

what may well be the salvation of rural medicine in Oregon and now every medical student at OHSU spends a mandatory six weeks in a rural clinic or hospital. Residents and family medicine spent an additional three months. David Graham is a product of this program. So is Lisa Dotson who now helps run it. When we first started the programs there was some concern among the faculty whether the rural faculty out there could really actually teach the students anything. And I think it became quickly apparent that not only can they teach them they teach them things that are much more valuable in real life than we can in Portland. lots. [LOWELL EUHUS]: Another little trick I've developed -- I haven't done it in my new book but I put the scale on my book here. Oh OK. I can just pull my book out and check it right. I don't have to think very hard. OHSU you resident Dr. Mark Harvey has just begun his rotation at Wallowa Memorial Hospital under the supervision of Lowell Euhus and others.

The anterior towards septal towards then lateral. Yep I agree. The best way to help a doctor even imagine him or herself in a rural setting is to provide the experience of working in one. That is the goal of this program. Before I came out here, I thought there's no way I'm ever practicing in a rural area, and now I'm open to it. I'm not saying that I'm going to, and I have no idea if I will or not, but at least now I really can see the advantages to being out here. I think the patients get great quality care maybe even a little bit better since they're their neighbors if they're taken care of so they really care about them a whole heck of a lot. Yeah, this is Gwen, one of my favorite patients. Well over here at the hospital. Some urban health care professionals though not many, do find their own way to rural areas. Emergency room nurse Mary Riley is one. I worked at a level one trauma in Portland for 16 years. It was the day after

day of people swearing at you and trying to hit you and and being confused and wanting drugs and you start to think that the whole population is made up of people that are not nice. I've never been up here and when I came to see the hospital I just kind of laughed and walked in here, instead of having 20-30 beds and patients in the hall we have two beds in this room and one we have room and it just was almost comical to me, and I thought, oh, what did I get myself into. But Nurse Riley stayed and has been at Wallowa memorial for five years now. [RILEY]: It's a joy to be a nurse again. It really is very rewarding, and it's kind of like going back in time and people up here are so appreciative of anything you do for them. Did you feel like that today? Did you feel nervous upset? Today Mark Harvey finds himself the doctor in charge of the hospital emergency room. It sounds like you're pretty low risk for stroke. It is really an eye opening

experience for many medical students whose experience otherwise has been standing third deep at the operating room table trying to peer over the top of the senior resident and the junior resident and the senior student and the junior student. And so the chance to go out and actually experience what they consider to be real world medicine has been very very valuable. So I want you to cover one of your eyes. It doesn't matter which one you look right in my nose. I'm going to ask you to tell me how many fingers I'm holding up. But I'm I gonna kind of put it out here, but I want you to focus on my nose OK. OK. So no cheating. Ready. Two. I think you learn more out of each patient coming in than you do back in Portland. You're the emergency room doctor. If that patient needs to be admitted and stay in the hospital you admit to yourself. So you take care of them the next morning when they're finally ready to leave the hospital, and you send them home and want them to see somebody in clinic the next week to see how they're doing. They're seeing you. You're there for every single step of the patient's care. I think that's

invaluable. There's no way you can duplicate that in urban medicine. Then I'm going to want you to close your eyes. I'll catch you if you fall. Don't worry. [NARRATOR]: Rural doctors value the "whole person" patient care that they can practice here. But there's a financial downside to wearing many hats. Insurers won't reimburse for more than one or two. If someone goes into an E.R. in Portland the E.R. doc sees them and gets to make a charge and then the admitting doctor gets to see him and make a charge and then their regular doctor gets to see him the next morning and make a charge. Well if that's all the same person then you can't make three charges so the same work gets done for less overall cost to the health care system but also less reimbursement to the physician. So it is harder for doctors in rural communities to make it. You know the stroke and the TIA are a lot more serious. So we're going to make sure first that you don't have any of the serious things. Rural areas face unique challenges in providing emergency medical services,

E.M.S., because of the long distances and limited resources. Bruce Womack runs the E.M.S program at Wallowa Memorial and was recently awarded the title of Oregon E.M.S. administrator of the year. About 85 percent of my patients are over 65 years old [background noise] so we know we do a lot of chronically ill, elderly patients. We see a lot of hip injuries, abdominal diseases, respiratory ailments, just all the things that are typical with an aging population. But we have elderly people out on ranches and in the middle of nowhere. (music) We have retired people who move to Wallowa county and then find the most remote location they can to live and then fall down, can't get up or become chronically ill after they've purchased a residence 20 miles up the Wallowa river.

[LOWELL EUHUS]: The distance makes a difference when we're spread out. And if you're injured way out in the woods 40 miles away gaining access to emergency care can be slow. And there's only so many things EMTs and paramedics can do in a field and transport to an emergency room. So yes there is a built in jeopardy for living out here. I tell people that all the time when you live here a couple things you probably don't want to get one is a severe head injury that needs immediate neurosurgery. And other's a severe chest injury that needs immediate chest surgery. There's supposed to be a golden hour of trauma care which you have to stabilize them and get them healthy enough to survive and unfortunately a lot of times the golden hour in Wallowa county is gone before they ever see an ambulance or ever ever make it to the emergency room. Some of our worst things don't come in by ambulance. Some of them come in in the back of the pickup and all of a sudden, someone's really hammering on the emergency room buzzer and they've got someone in the back of the pickup who's bleeding badly and having trouble breathing.

This is actually where I was born, I was born in this room. Gail Johnson is the assistant hospital administrator and a full time registered nurse here at 50 year old Wallowa Memorial. This is brand new equipment it's as good of equipment you can find anywhere. And this is done a lot of it with Hospital Foundation funds from our community. That we're very proud of our lab and our lab capability. So we're happy with this. Wallowa Memorial consist of both a hospital and a residential senior care center. I could be circulating in surgery. I could be doing patient recovery after surgery. I could be doing chemotherapy or I could be doing an I.V. infusions or teaching. Good morning Arlene, how are you? The most wonderful thing about rural nursing is taking care of people that you know and you love. And having said that I will tell you it's also the very worst thing about rural nursing. An example of that and maybe my hardest example in my

life is my dad was in a horrible car accident in which he and two other people who were involved. And the other two died outright. My dad came to the emergency room it was very very very difficult. I wouldn't have wanted anything else other than to be there but it was very hard. Folks who work here may be in for harder times ahead. Because despite a remarkable level of community tech support, donated equipment and even donated ambulances. Wallowa Memorial's financial health continues to worsen. Lean forward. On three, one.. The demographics are that we do have a lot of older people that are a lot sicker and needing a lot more care. And reimbursement for that is going down. And then because of the economics of our community the a lot of young people can't work here the people that would have private insurance if they had jobs they can't be here because there's no job for them so we don't have that offset of the private insurance to be able to offset the Medicaid, Medicare.

They're still required to provide that level of care. We talk about a commitment to your community, this isn't a somebody I don't know, this is my first-grade teacher. (music) The Care center is losing a lot of money and the hospital has to subsidize that but generating enough income and funds to do it is getting tougher all the time. This here is our critical care unit. I don't have any of our monitors...Small hospitals have fewer patients and lower revenues than larger medical centers but have many of the same fixed costs to pay. If a big city hospital has four ORs and they're operating 10 hours a day. That pays a lot of salaries and a lot of equipment. Our little hospital, y'know, four or five a week it's hard to pay for the anesthesia machines are very expensive and all the equipment is needed. Francis we may use our defibrillator once every six months I don't really know how often it's used but not very often, but that piece of equipment is expensive, and it doesn't really pay for itself except by saving a life. Well, what's a life worth. But somebody has to pay for

that. Give me a good squeeze. Squeeze. Squeeze. Squeeze. OK. Offering a full range of diagnostic services helps keep patients here in town as paying customers keeping the hospital alive. But these services often entail costly equipment. We have a brand new C.T. scanner and it's a wonderful state of the art equipment it's excellent. But our entire population of our county is 7000 people and you don't have the volumes going through to purchase that. But you still are responsible to make sure you're operating your equipment. (music) The financial woes of rural hospitals and doctors have set the stage for more and more long term problems too because routine, non-critical patient care -- that is, preventative medicine -- is vanishing. I feel really very good for a guy that's supposed to be dead five and a half years ago. (laughter) Personally I think there's a tremendous wealth of untapped money that could be saved by preventative medicine. And if we spent more money trying to keep people well, and not

so much treating the acute phases. If we can somehow help with her medication so that they stay on them so they don't not take them because they can't afford them, or that we do aggressive health management I think we would save money in the long run. But we're certainly not there when they're ?conning? the absolute nuts and bolts of health care there's certainly no money for prevention OK Bee we're going to move you. Yeah okay On the count of three. I like to go places. [RENEE GRANDI]: OK. One, two, three. She came from one of our foster homes, which we have quite a few of, that help care for elderly that can't be at home. Do you remember anything that just happened to you? We're worried about a stroke and the goal we have is to get them in here and get them assessed if they need one we can get a head CT pretty quick and if there's anything that's obvious that we would need to contact an outside hospital for We do that quite rapidly. You get that experience of taking care of both ends of the spectrum from rocking chair to rocking chair. I'm gonna have you look up there

Look at that ceiling for me. You do get to do it all. You get to have a relationship with so many different people. It's it's very magic. "We know there that the butt works. You made it. You survived." She's a big baby how much does she weigh? I don't know we haven't weighed her yet. I have known the great grandmother there, I've known her all of my life and I've taken care of her family through the years in the hospital. And I grew up with her children. We have been friends and now her grandchildren are now having children. So it's pretty remarkable I think that's the real, wonderful thing about being in nursing in in a rural setting is that you have the opportunity to know all ages and know them well and to be intimate with a whole generation generation generation. With so many young families having moved away. Baby Lily will be one of only two births in the hospital this month. Obstetrics is not a lucrative practice here. We don't make money on the births. We have a long term commitment to our community and so that's why we're

committed to providing the birth experience here. But a lot of facilities in Oregon are not providing that any longer. And multimillion dollar lawsuits continue to push insurance rates through the roof. I think that you know we really need to do something about those jury awards. We're a society that thinks that you're guaranteed a perfect outcome or somebody is responsible but as a sheep ranchers wife we had a lot of sheep and they didn't all have perfect outcomes that's just not the way life is. (music) The prognosis for these communities is uncertain but the task ahead is clear. The hardworking folks who live here will have to work harder still to attract and keep quality health care for their families. Communities have to be really actively involved in keeping their professionals there. That means all professionals: lawyers, doctors, nurses, hospital

administrators because there's always going to be opportunity for them to go elsewhere and they need to be given the services and support that they need to practice well and keep their families happy here. And that's always going to be a challenge for rural communities. You not taking any other medicines are you? Ok. Just once in a while you have a cigarette? Yeah. That's my medicine. (laughter) Ok. All right OK. I don't want to say ? . No that's all right You gotta sneak out behind the barn sometime. You don't need a psychiatrist Deloris you're fine. you're a great doctor you see. (laughter) OK. The bull buck for Heinz lumber company over here in the woods. A tree fell on him. a tree. So they brought him in here. His forehead and his eyebrow are hanging down over his face.

He had crushed chest. He had a fractured pelvis. He had a broken leg and he had a broken little toe. So I worked about six hours on that guy. Picking the dirt out of his brain. Suturing the dura of the scalp over that, then suturing his skull. And months later he'd say Doc you did a pretty nice job on me. But that damn toe still hurts. That's a logger's humor. You never let me forget that the toe still hurts. Funding for production of the Oregon story was made possible through a generous grant from the United States Department of Agriculture Rural Development.