A majority of Montana counties face primary care shortages

The gap in health care access is particularly acute in rural areas.


This story is part of The Montana Gap project, produced in partnership with the Solutions Journalism Network.

Montana is ailing from a chronic shortage of doctors and mental health providers. In such a rural state, the lack of physicians means patients must often drive hundreds of miles for medical care. What’s being done to recruit and keep more doctors in rural areas?

Transcript below:

With its wide open spaces, Montana is still geographically more rural than urban. Across much of the state it’s common for people to drive hundreds of miles to stock up on groceries or go to a doctor’s appointment. 

“Fifty-two of the 56 counties in the state of Montana are primary care shortage areas or under served as how the government says,” says Louie King, president of Teton County Medical Center. “In fact, nine counties do not even have doctors.”

Like the rest of the country, Montana is facing a growing lack of physicians, nurses and dentists. But the problem is especially acute in rural areas. “We have one of the oldest physician populations in the country,” says Martin Teintze, Montana State University WWAMI Director. “So we’re facing a wave of retirements.”

The shortage is even more severe when it comes to mental health professionals. Except for Yellowstone County, the entire state is considered a mental health shortage area.  At the same time, a recent state report found one in five Montanans deal with depression.

Part of the doctor deficiency has to do with health care education: Students from rural areas are less likely to apply to medical school, possibly due to a lack of role models because there are fewer physicians around them. Montana also does not have a traditional medical school to educate the hundreds of students it would take to alleviate the doctor shortage. 

Despite these challenges, Montana is seeing growing success with a medical school program that targets students who want to work in rural areas.  “And it’s really important for us to be able to educate new physicians who want to go practice in these areas and the best people to do that are the ones who grew up there,” says Teintze.

The program is called TRUST, or the Targeted Rural Underserved Track. It’s part of the larger WWAMI program, which Montana has been a part of for decades. WWAMI stands for the states Washington, Wyoming, Alaska, Montana and Idaho that work together to offer students from rural areas without medical schools training under the University of Washington’s prestigious medical school. 

Studies show that students who are from rural areas and train in rural areas are more likely to return there to practice. And the TRUST program has helped launch Montana to the top among states in keeping newly trained physicians in the state where they trained. 

“About a third of all the graduates of that track have come back to practice in a really rural area, which is substantial because nationally fewer than five percent of all physicians started their practice in a rural area,” says Teintze.

That’s good news, but that’s sort of like putting a bandaid on a broken arm.

“We’re going to have to do everything we can and run as fast as we can just to stay in one place. In terms of the number of physicians per capita in rural areas it’s a real challenge,” says Teintze. “I don’t think we want to give up on that, but it’s going to be really hard even just to stay at the level that we’re at, let alone to improve it.”

Doctor Christina Marchion is an example of a small town Montanan who chose to stay and work in a rural community. The Anaconda native went through the WWAMI program and now has her own obstetrics and family medicine practice in Lewistown. “It’s everything,” Marchion says. “It’s intimidating and terrifying and awesome and fun. And I don’t think I would want to be anywhere else.”

She told us one of the biggest factors in her decision to practice in a rural hospital was having a mentor. She trained under doctor Laura Bennett, who has spent 25 years working in Lewistown. “I mean she had a reputation and I thought back then, if I want to be the doctor that I want to be, if I want to provide cradle-to-grave care, full scope family medicine, the real deal out in the middle of nowhere and still have a marriage and be able to pull off being a mom, it’s pivotal that I find somebody who could role model that for me,” Marchion says.

And she did that. She raised three kids, she’s still happily married, she exercises.

Central Montana Medical Center is one of three Montana hospitals where medical students can get a Rural Integrated Training Experience. Bennett oversaw the rural training program for nearly two decades and has since passed that torch to Marchion.

“Students keep you on your toes,” Marchion says. “They remind you why the heck you did this in the first place. They ask important questions and they’re really smart.”

“The big advantage to being in a small town is that you’re the only medical student there and everybody knows that you’re there,” Teintze says. “And they they call you into all the interesting cases and you get to do a lot more hands on training. And when you land that, if you want to do [obstetrician] rotation, do it in a small town. You don’t get to deliver half a dozen babies in your six week rotation if you do [obstetrics] in Seattle. All you get to do is look over somebody’s shoulder – you’ll never actually touch a baby.”

Offering more on-the-job training in the form of medical residencies is one way other states are trying to recruit and retain doctors. But it’s a solution Montana has yet to expand investing in.

“Most people decide to settle where they do their residency program, because for most people you’ve been in undergrad, you’ve been through med school and now you’re in residency. You have a husband or wife – you want to start a family,” says Kelsie Delaney, a TRUST student. “And most people like to just settle wherever they do their residency. And so it would be a huge help if we could get more residency programs in Montana.”

Each year thousands of medical school grads apply for just 78 resident slots. During the 2017 state legislature, lawmakers rejected a $400,000 request to fund more residency programs, citing a budget crunch. The money would have expanded training for doctors in rural areas and a create a psychiatric residency. Montana, Wyoming and Alaska are the only three states without one.

There are federal programs to incentivize new doctors to return to work Montana’s rural areas and dozens of states, including Montana, offer grants and stipends to help pay off huge medical school loans to students willing to work in underserved communities. A new state law now requires WWAMI graduates to return to Montana after residency to work for three years or pay the state back $165,000. 

Monetary motivation may help bring more doctors to the state, but the life of a rural doctor isn’t for everyone.

“Sometimes it’s lonely even with Dr. Bennett or the people around you,” Marchion says. “Sometimes you just realize you’re two hours away from anywhere and sometimes in the winter it doesn’t matter how close it is if they’re down the street. You’re stuck with an emergency and it’s all on you, and there’s nobody behind you patting you on the back saying ‘yeah we gotcha.’”

“I think getting physicians into rural practice requires more than just a financial incentive,” says Teintze. “It requires a program that actually recruits the right kind of students and nurtures them along and provides them with the training and the opportunities that help them actually establish that rural practice and that’s what we’re trying to do with the TRUST program.”

The small town of Choteau, Montana, is long on views of the Rocky Mountain Front, but short on health care providers.

“One of the challenges that we see is that there’s really no specialty care here at all. Even something as simple as prenatal care you can’t receive in Teton County so women have to travel,” says Melissa Moyer, Teton County’s public health director. “Pregnant women have to travel to Great Falls to do all of their prenatal visits, which is a big challenge.”

“When I got here I was fortunate that we did have an M.D., but she is just recently retiring. She’s backing off from having a full practice here. So basically the future of our hospital is going to be run by advance practice clinicians,” says King. “Most people know advance practice clinicians as either nurse practitioners or physician assistants, but they do a great job. And they’ve been around for a long time in primary health care.”

Like many rural hospitals in Montana, the Teton Medical Center has had to adapt to keep its doors open. In 2016, Benefis Health System in Great Falls purchased the facility and the monetary backing of the larger hospital has given the center some financial life support. The same thing is happening across the country, with rural clinics being forced to partner with bigger health systems to survive. And all too often, the survival of a small town can depend on whether or not there is quality medical care nearby. Hospitals are often the largest employer in a rural area and a vital part of the local economy.

“I love this rural community. But without this hospital, this rural community is going to have a real problem staying the same because it is the economic engine for this community,” King says. “A lot of high-paying jobs, you know like I said: 65 employees. But one thing we do here is we save lives. We’re here for that golden hour after a heart attack, or a stroke, or a car wreck. We’re here to stabilize you. And if it’s life threatening, we’ll put you in an ambulance, or if we need to get you to Benefis quicker we’ll put you in a helicopter. We save lives here.”

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