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‘Backbone of rural America’: One clinic’s efforts to keep health care in Idaho communities

Dr. Marilou Gonzalez, left, with WWAMI medical student Maryam Karim, who worked with Gonzalez at her clinic in Plummer over the summer (Courtesy of the University of Idaho).
Dr. Marilou Gonzalez, left, with WWAMI medical student Maryam Karim, who worked with Gonzalez at her clinic in Plummer over the summer (Courtesy of the University of Idaho).

Doctors partner with students from Idaho’s medical school to encourage new talent

As someone who grew up in Hawaii, one of the most jarring realizations Dr. Marilou Gonzalez had when she started working in rural health care was just how much driving people had to do for basic necessities. Like people who come to her clinic in Plummer but shop for groceries an hour away in Coeur d’Alene — and take care of a lot of other errands too.

“People pack coolers in their cars here when they go shopping, because they’re going to Best Buy, then Costco, they’re getting their tires changed, they have a dentist appointment,” Gonzalez said. “It is amazing how much I took for granted living in an urban setting versus a rural setting.”

Gonzalez is a family medical doctor and the medical director at Marimn Health, a clinic of six doctors that serves citizens of the Coeur d’Alene Tribe as well as non-tribal members in North Idaho. She is a member of the U.S. Public Health Service stationed with the Coeur d’Alene Tribe under an agreement with the Indian Health Service. She has been stationed there for the past six years, but prior to that worked in Bethesda, Maryland, and on the Crow Reservation in southern Montana.

Idaho ranks near the bottom of states in the country for number of active primary care physicians, and 49th for active physicians overall. According to the Idaho Department of Health and Welfare, nearly every corner of Idaho, or 98%, has a shortage of primary care physicians, and every county has a shortage of mental health care professionals. Approximately 94% have a shortage of dental health care workers.

According to the Idaho Department of Labor, 88% of Idaho’s land area is located in rural counties, and it’s where 28% of the state’s population lives, which makes Idaho a low density and highly rural state. The Idaho Department of Health and Welfare says residents in those rural communities tend to be older, lower income and are more likely to be uninsured or underinsured compared to urban areas.

And according to the Indian Health Service, the life expectancy of Indigenous people as of 2017 was four years less than the general population of the United States, with higher death rates from diseases such as chronic liver disease and cirrhosis, diabetes-related injuries and chronic lower respiratory disease.

It’s all part of why Idaho celebratedNational Rural Health Day on Thursday, recognizing rural health care providers and the critical services they perform.

“Family medicine is pretty much the backbone of most of rural America,” Gonzalez said.

University of Idaho student studied at Plummer clinic over the summer

About an hour south is the Washington, Wyoming, Alaska, Montana and Idaho Regional Medical Education Program, known as WWAMI, at the University of Idaho. It is Idaho’s only medical school that is partially funded by state dollars, and the medical school that produces the most rural physicians for the state, with incentives available for those who decide to practice in a rural area of Idaho.

One of its students is Maryam Karim, who is in her second year of medical school and worked for Gonzalez in Plummer over the summer at Marimn Health. Karim was born in Afghanistan and lived in Turkmenistan when she was young, before moving to Boise at age 11 with her family as a refugee in 2005. Because of her unique background, Karim speaks five languages — Farsi, Russian, Turkish, Hindi and English.

She remembers first hearing about the WWAMI program while she was still at Boise High School and thought it would mesh well with her own values.

“There’s a lot of emphasis on diversity at the WWAMI program, and as somebody who comes from a very diverse background, I needed that type of acceptance for me,” Karim said. “They are very concentrated on research, and they just want students to stay in their home states, and I would like to come back to Idaho and practice (here).”

The program is part of the University of Washington’s School of Medicine, but every applicant who joins the Idaho branch is an Idaho resident. The school admits about 40 students per year.

Karim said she enjoyed working at the Plummer clinic with Gonzalez, and it strengthened her interest in working for a rural clinic in the future.

“I really like the fact that they are able to create these long-term relationships with their patients that can carry on for years,” Karim said.

She hopes to become a vascular surgeon, a specialty of surgeons who manage the veins and arteries of all parts of the body except for the brain and heart.

“That’s something that is very scarce in rural areas, there are not many surgeons,” Karim said. “And that was what I noticed in Plummer, they didn’t even have an ultrasound to complete those diagnoses and confirm something. They had to send those patients out to Coeur d’Alene or Spokane.”

Staff shortages hit rural clinics harder, Idaho doctor says

Rural health care has been particularly interesting during the pandemic, Gonzalez said, especially among the Coeur d’Alene Tribe. When the COVID-19 pandemic began in February 2020, the clinic staff recognized they would need to perform their own contact tracing for its 7,500 patients.

“We were one of the first locations to get COVID (test capability) given to us, so we were able to start the screening process, and we were trained by Panhandle Health District to start our own contract tracing, and we were able to do it within hours of a positive test,” Gonzalez said. “That itself just represents how quickly the tribe can put plans into action to protect the community. I’ve only been here for six years, but the way they’ve been handling medicine is just phenomenal.”

Gonzalez said her clinic is also seeing an uptick in patients as a result of the pandemic, because people who don’t usually sick got COVID and were instructed to follow up with a primary care provider.

“So we’ve just been growing here as a clinic, absorbing new patients every day,” she said.

But that doesn’t mean the staffing levels are there to support all of the new patients. Like many health care organizations, Marimn Health has a shortage of nurses, pharmacy technicians and nursing assistants, but she said shortages are felt more acutely in a small area.

“One person makes a difference everywhere, but even more so in rural medicine because you wear so many hats,” she said. “… You’re asked to do other duties almost every day.”

Marimn Health has also been understaffed for many years, dating back to the 1990s.

That’s why Gonzalez is happy to partner with the WWAMI program, because she knows those students can make a significant difference in rural health care in the future if they stay in Idaho, especially as current medical providers age.

“If you don’t invest in the future, you’re not going to have providers to take over when people are retiring,” she said. “You need to create relationships with the medical students, because studies have shown that yes, a medical student will likely stay in the region they train in.

… The WWAMI program is doing what it needs to do to attract medical students to rural America and finding places like our clinic, finding preceptors who are willing to teach and share their time is what’s going to keep those students here.”

The Idaho Capital Sun is a nonprofit news organization delivering accountability reporting on state government, politics and policy in the Gem state.