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Editorial


Front Page - Friday, February 17, 2017

Low-income clinics a tough sell for young docs




Cecilia Ramirez Geronimo holds her daughter Esil Velaquesz Ramirez still while Dr. Philip Sutherland performs a check up on the 9-month-old at Clinica Medicos. The clinic opened two years ago at 1300 E. 23rd St. and is part of the Tennessee Rural Partnership. Dr. Sutherland says 80-90 percent of the clinic’s patients only speak Spanish and 60 percent do not have health insurance. - Photograph by Alex McMahan

When new doctors finish their training, there’s a great temptation to follow the money.

Over half of them graduate from med school with more than $200,000 in student loans, and that kind of debt burden might lead a new doctor to sign a lucrative employment contract with a large urban hospital.

Philip Sutherland wanted to go in a different direction. 

After graduating from the University of Tennessee College of Medicine and going through residency and a fellowship, Sutherland also wanted to start his family medicine and obstetrics practice in a rural area. Tennessee Rural Partnership was there for him.

The agency offers stipends to physicians, nurse practitioners, physician assistants and psychiatric nurses who practice where the need is greatest. 

Residents in a primary care field –generally family or internal medicine, pediatrics, obstetrics and gynecology, and psychiatry – may receive a stipend of $35,000 per year for up to four years that they can use for living expenses, loan payments or anything they need. When they finish a residency, they are obligated to work at a TRP-approved site – one that serves a high percentage of TennCare recipients – for an equal number of years.

The TRP also offers incentives to nurse practitioners and physician assistants in training - $7,500 the first year and $10,000 the second. Those practitioners are required to do a rotation in a rural area first.

Sutherland didn’t settle in small town. Two years ago a med school acquaintance approached him about starting up a clinic for the Hispanic population in Chattanooga. Sutherland decided to change course.

He now works at Clinica Medicos, a bilingual clinic focused on serving a population that is one of that region’s most underserved and under-reached, due to language barriers and access to care issues. Despite being inside a city, the clinic fits TRP’s mandate.

“Even though we are in a city that has all these resources and specialties, when a patient has no insurance their access to those resources is extremely limited,” Sutherland says.

“So in many ways it’s a lot like the country, where those resources are hours away, and it takes significant effort to overcome the barriers of getting there.

“A lot of it comes back to what we do there in the office. I think that’s one of the reasons I’m so satisfied with it.”

Sutherland says at Clinica Medicos he gets the high-touch experience of a small-town doctor. He also has greater autonomy as a physician than he would have at a health system. And while he may not make as much as some in his med school cohort, he is highly involved with his colleagues and his patients, giving him what he calls “spiritual revenue.”

“For my colleagues, they punch in and they punch out. It’s a job for them,” he adds.

“The thing that’s so unique about where I work is, it’s not really a job. It’s really a calling, a pulling together with a team to provide excellence in care to the people we serve, and being a part of that community of people.”

“When you look in the eyes of a dad and mom and hand them their baby, to have cared for them during their pregnancy, to deliver this baby and know we are going to be a part of that family through these life-changing experiences, it’s really humbling and amazing.

“We are blessed to have found that sense of connectedness to a community here in Chattanooga, with a population that really needs the opportunities of care that we are providing.”

Even though Sutherland and many other physicians are continually bombarded with recruitment offers, he’s not interested in leaving Clinica Medicos. Two years after it opened, the clinic is flourishing to the point where it can afford to pay the doctors more.

In fact, Sutherland has been offered the opportunity to become a partner in the clinic. He and his wife have decided to take it.

“When you’re looking around at the job offers and someone wants to pay you significantly more, it’s tempting to put the money ahead of your heart,” Sutherland says.

“My salary is lower than what it would be at many places with the same training that I have, but the Tennessee Rural Partnership really enabled me to take that job, and I’m still getting a good solid start.

“The program doesn’t set you up for your whole career, but it can take the edge off of that transition and let you go where your heart is by helping reduce some of that financial pressure while your new position is growing. I’m just really grateful for the opportunity it gave me to land in a place where I’m able to serve and have a job that I love at the same time.”

Hospitals shut down

Access to health care is an acute problem in large swaths of the state. Tennessee’s rural population tends to be older and have less income. They are also  more likely to be on TennCare and Medicare and be in poorer health than their urban counterparts.

They are also significantly less likely to live near medical services, resulting in a higher rate of preventable deaths from diseases like cancer because patients did not get an early diagnosis when the disease was most treatable.

Part of the problem is the closing of small and rural hospitals due to financial pressures.

Tennessee has had eight closures since 2010 – the second-highest number in the country. And more are at risk: 48 hospitals in the state are currently losing money – most of them small and rural, according to the Craig Becker, CEO of the Tennessee Hospital Association.

Some hospitals have been replaced by rural health clinics, community health centers, Department of Health Clinics, private clinics and freestanding emergency departments.

Other rural hospitals are surviving by eliminating inpatient beds and cutting specialties such as obstetrics and by forcing women to drive long distances to deliver their babies. Less money for recruitment and physician salaries also means more medical care that physicians used to provide is now being delivered by “mid-levels” – medical professionals like nurse practitioners and physician assistants.

In the most severely affected counties in Tennessee, there is only one primary care physician for every 5,625 residents – compared to one for every 1,397 residents in the counties with the most doctors. The ratio is much worse when it comes to mental health providers, a critical need.

“Trying to recruit physicians to a community without a hospital is extremely important; increasing capacity around primary care is especially critical,” says Bill Jolley, executive director of the Tennessee Rural Partnership.

“We continue to recruit in those communities because if a community cannot sustain a full-service hospital, it’s important that they do maintain a medical presence, even though delivery of medical services may look a little different.”

 TRP is funded by the four Tennessee medical schools with primary care residency programs: The University of Tennessee, Meharry Medical College, East Tennessee State University, and Vanderbilt University. Over the past ten years, the program has placed 128 providers, Jolley says.

“One of our main concerns is making sure the people we place are a good fit for rural because we want them to be comfortable and stay there,” says Julia Hall, recruiting specialist.

“It takes a very special person to work in a rural community. You have to be very autonomous and quick-thinking and you have to have a heart for the work.”

A third program awards grants that can be used for recruiting to sites trying to lure medical professionals.

“If we get a doctor into a small town and they stay there for five years, they’ve made a huge impact and touched a lot of patients,” says Dr. David Maness, chairman of the TRP’s board of directors.

 “If we get lucky and they stay there even longer, then they’ve impacted one or two generations, maybe three generations of families over time and that’s priceless.”

Small town doc

Though Matthew Campbell came out of med school and residency with more than $300,000 of debt, he wanted to establish his practice in a small town like his north Georgia hometown, which had fewer than 2,000 people and no local pediatrician to serve them.

“I knew it would mean less money and definitely less prestige, but it’s where my heart was and my wife’s heart,” Campbell says. “We wanted to raise our kids in a small town like where I grew up, and help people.”

When it comes to recruiting new doctors, most rural areas can’t compete on pay. That’s why the Tennessee Rural Partnership was formed – to help match people like Campbell with rural and underserved communities where they can do the most good, and to help make up some of the salary they give up by doing it.

TRP awarded Campbell a stipend that allowed him to establish a pediatrics practice in Tullahoma, a town of 18,000 that Campbell and his growing young family now call home. The practice, Kazoo Pediatrics, a part of Tennova Healthcare, has become a vital part of the community. He’s taken on two partners, and Campbell and his wife are building a house, with their third child on the way.

“The grant money changed my life,” Campbell points out. “It offset the loans and allowed us to focus on getting a house, getting a car that worked, and building our family. They really helped me get settled here, and we’re planning on staying here probably for the rest of our lives.”