01/27/2012

Rural Health: Residency doctor chooses to return to rural roots
Tri-State Neighbor includes Jo Erickson of Falls Community Health

Dr. Jon Engbers, 27, is halfway through his medical residency but already knows where he's headed when he graduates in June 2013.

He'll be returning to his hometown of Rock Valley in northwestern Iowa, a place he never thought he would be working in when he left for medical school at the University of Iowa.

A student in the almost 40-year-old Sioux Falls Family Medicine Residency program that has helped produce about 300 doctors since 1973, Engbers said his interest piqued in the rural family practice field when he spent a month in Sioux Center, also in northwestern Iowa, when he was in medical school.

"I started seeing that as an option for my future," he said. "I'm really interested in developing relationships with my patients. I think that's one of the best practice settings that you are able to do that."

Engbers will be the fourth physician in Rock Valley, also joining a nurse practitioner and a physician's assistant.

"The community there is being really supportive. They are excited about me coming back and that makes me feel good about it," Engbers said.

Another resident, who will graduate this June in the 10-member class, is Dr. Wallace (Skipper) Fritz, who left the corporate world in 2000 and decided to pursue his dream of becoming a family medicine doctor.

Fritz, 36, won't be out in the middle of the corn and soybean fields when he graduates in June as he has decided to become the ninth member of a Sanford family practice clinic in Sioux Falls.

Although it isn't a more remote setting, it's still considered a rural position when using national statistical data, said program director Dr. Earl Kemp.

The University of South Dakota graduate has enjoyed his time in the Sioux Falls residency program, which is supported by both the Avera and Sanford health systems.

"It's a great program. There has been a lot of very diverse training opportunities," he said.

He'll be working in Madison, S.D., for a month in February, but has learned a lot by practicing at the Falls Community Health clinics.

"It's never a dull moment there," he said.

Owned by the city of Sioux Falls, the sliding-fee clinic contracts with the Center for Family Medicine with its office at Avera for physician services, according to resident program coordinator Jo Erickson.

Fritz said people think of Sioux Falls as white, middle class America.

"But we have our share of poverty, the homeless, an HIV population and truly under-served people," he said.

At the Falls clinic, the resident doctors follow their patients to either McKennan or Sanford, which is similar to what would happen in a rural setting, said Erickson.

Hospitalists often take over cases in the bigger hospitals, but in small towns the local family physician is often the only choice for a patient moved into the local hospital.

So Erickson said the program's 15-member faculty staff, most of whom trained or practiced in rural areas such as Nome, Alaska, or Canton, S.D., and have a vast array of rural experiences before moving to Sioux Falls, wants to give that similar experience to the residents.

Both Fritz and Engbers understand why some physicians don't want to go into remote rural settings. There aren't the big dollars that some specialists find in big cities, the Starbucks coffee shop or the luxury of not being on-call sometimes around the clock.

Fritz said another thing is in the remote areas there isn't that extra ear or camaraderie with other physicians that can help treat patients more efficiently as doctors can bounce patient ideas off each other.

"I think in some places it can lead to burnout," Fritz said.

On the other hand, the young doctors said there have been a lot of advances in the medical field and in air ambulances that have really boosted care opportunities.

High definition cameras, for example in the eEmergency systems now in place in many rural facilities, can provide a "wonderful outreach, especially given our large geographic area," Fritz said.

Engbers said the helicopters and highly trained flight crews also can be on the scene in rural areas quickly and he also noted how new heart monitors in all ambulances can send data back to waiting specialists at larger hospitals in a matter of seconds.

Kemp said he could see the future in rural America going a couple of directions.

"Being the optimist that I am I know there are people out there that want to do that and know that it's a nice lifestyle out there. And with the advancing technology there's a lot more stuff people can do at those rural sites. For example, even here in Sioux Falls, there are lab tests that we used to have to send to the Mayo Clinic before. But now with the availability of video conferencing and specialty involvement it makes it more doable. But there's still the challenges of getting (physician) families to connect to rural communities. For example, if they don't see a good school system," Kemp said.

Yet, a good share of the Sioux Falls residents end up in smaller communities across the Upper Midwest.

Kemp has pie charts showing that 80 percent of the program's graduates ended up in either South Dakota (48 percent) or adjacent states (32 percent). Also, 68 percent landed in communities smaller than 50,000 people, with 35 percent in towns under 5,000 in population.

Kemp said he did a study once that revealed a third of licensed physicians in South Dakota were graduates of the Sioux Falls residency program, one of two in the state. The other is in Rapid City. There are about a dozen rural residency programs in Minnesota, with six programs in Iowa, with the closest one in Sioux City.

Applicants who are accepted are mostly from the Sanford School of Medicine of the University of South Dakota, with the University of Minnesota Medical School (many of whom have completed their Rural Physician Associate Program) second on the list, although students come from all over the nation, with even a few foreign students. Kemp said he gets daily emails from medical students from foreign countries who are interested in the residency program, but he said many of those are filtered carefully and few make it into the program.

There are encouraging signs for the future.

This year, Erickson said there have been 42 applicants for the program that have met qualifications and are going to be interviewed to be a part of the class of 2015. That's a far cry from the late 1970s when there were as many as 80 finalists seeking a spot in the program. But the number has been steadily dropping with a low point in 2005 of only 18 interviewees. That was until the past two years, with an increased number of applicants showing an interest in family practice.

Over the years, Erickson said, they have been averaging interviews with about 20-25 medical school graduates.

"We take our mission seriously," Kemp said.

That is to provide an "excellent education that prepares physicians for practice in South Dakota and other areas of the mostly rural Upper Midwest."

Because of the increased applicants, Kemp said he has an item on the program board's next joint Avera-Sanford agenda to ponder the question of increasing the number of residents.

"We want to look at the question of how many we can take and do a really good job. We need to be comfortable in what we do," he said.

Another possible bright spot on the horizon is an effort by South Dakota officials to boost the state medical school budget by more than $1 million to try to attract additional doctors to work in rural South Dakota. This would increase the number of students in the medical school from 52 to 56 students and start a rural track as an option where the students spend lengthy training times in rural communities and hopefully then locate there.

Engbers said his time in a rural setting helped him to decide to return to rural northwest Iowa.

"I think there will always be people dedicated to working in the small community and serving a very small distinct group of patients. You really get a chance to develop relationships over the course of a career with your patients. The people you work with are your next door neighbors. You know all of the employees at the hospitals ... you have a working relationship with them that you aren't always able to develop in a bigger hospital setting," Engbers said.

Tri-State Neighbor - Barry Amundson