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Interviews
Jeff Chappell, M.D.
Family Physician
Wayne Community Health Clinic
Interviewer
Will you describe the community of Bicknell and the surrounding areas?
Jeff Chappell
Sure. The communities in Wayne County are really referred to almost as one community and we refer to it as Wayne County and most of the people in South Central Utah or that are from here they'll say they're from Wayne County, they don't say they're from Lyman or Bicknell or Loa. They'll say they're from Wayne County. But it's made up of several communities along the Fremont River starting with Fremont, Loa, Lyman, Bicknell, Teasdale, Torrey, then Capital Reef and Kaneville and Hanksville and in that population there's probably 2200 people that are here full time. Now that population ebbs and flows. There are quite a few people that have second homes, especially in the Teasdale - Torrey area. On weekends the population will be high, especially in the summer with the tourism. We service a fairly sizeable patient base.
Interviewer
With that patient base - who are the kinds of patients that rely on this as their primary care?
Jeff Chappell
We have probably about, again about 2200 patients who this would be their medical home and that's a diverse population. There's quite a number of elderly and there's...it's a full spectrum of medicine. Everything from the geriatrics to pediatrics. I delivered babies for years in Richfield but obviously since I've moved over here I'm not delivering babies but yet I'll still take core...do a lot of well child care for the families and we do a lot of acute care for the people. We're the only clinic within gosh 100 miles and for some people, certainly within 60 miles we see a lot of people and you were asking what communities we service and I failed to mention that we are also the primary care medical home for most of the people in Eastern Garfield County. The people from Boulder come here. We also have patients come from Ticaboo down by Lake Powell and we have patients from Southern Emery County that come over and also from Koosharem which is Northeastern Piute County and we see a lot of the patients from those communities also. So we service a very broad, large geographical area, the patient base isn't...the numbers aren't large. But a lot of patients travel, some of them even two hours just to get to us and it's another hour on to the nearest hospital. In the summer there is a clinic in Bullfrog which the Ticaboo folks can see. But for a lot of people it’s not uncommon to travel an hour or more just to see us and then it's another hour on into Richfield if they need hospital care.
Interviewer
How about if a patient needs some sort of specialist care?
Jeff Chappell
I think we're very good in this clinic to providing primary care and urgent care. Specialty care is a challenge for these people because if you are seeing an oncologist or a cardiologist you have to travel. Happily there has been a group of Oncologists who have been coming to Gunnison out of Provo which, Gunnison is about an hour and 15 to an hour and 20 minutes from here which has saved a lot of travel time. But if they need to see Cardiologists, Provo is the closest which is 2 and a half hours away. We do have a surgeon in Richfield which brings up an important point in rural medicine where a lot of these communities have enough work to keep one specialist very busy but not quite enough for two and it's very hard for these lone specialists if you will in these small communities because they're on call all the time and sometimes...well there isn't anyone else that can cover for them. If they have patients in the hospital and it's time to go on vacation, they have to postpone or cancel vacations. We had an Orthopedic Surgeon in Richfield at one time and he was very busy and an extremely good Orthopedists but he just wore himself out and left and that's been about four years ago and we haven't been able to recruit another Orthopedists. Our current surgeon in Richfield's been there for several years, an excellent surgeon, very busy but again, he's busy to the point where he's wearing out. They're trying to recruit another physician, another surgeon but it's hard to recruit to these smaller hospitals in small communities. This surgeon's wife is actually from Tropic and he grew up in Provo, so they have some roots to South Southern/South Central Utah, but I fear if they can't get him some help he probably won’t stay for the long term either. We had an excellent internist in Richfield that developed cancer and had to retire and that's been about five years ago and we've been unsuccessful in recruiting another internist to Richfield. There's been...well when I left Richfield about three years ago to come and work full time in this clinic...When I left Richfield, well I had worked in Richfield for 11 years doing the full spectrum of family medicine, something that I'd always planned to do and it was extremely exciting and very interesting but also quite exhausting. I was delivering babies, doing minor surgeries, care center, ER, the full spectrum and I'd been coming here once a week and about three years ago one of the Physicians Assistants was leaving the community and they had staffed this clinic with two Physicians Assistants but they decided they wanted to hire a physician and approached me about it and having grown up here it just didn't seem right to have anyone else take care of these people other than myself.
Interviewer
With that, you see a lot of people that you know. Can you talk a little bit about maybe the economic makeup of the community? What do people do for work around here? I know you have some people that have second homes and come down here for vacations, but the guy that's working at the gas station or the rancher that has property here and runs his ranch operation; can you talk a little bit about that? The financial makeup of the community?
Jeff Chappell
Most of the families that live here permanently do more than one job if you will. A lot of them are third or fourth, even fifth generation people and a lot of them will have a small farm and a few cows or sheep but then they'll work either as a school teacher or for one of the government agencies - the BLM, the Forest Service or the Park Service and there aren't very many families that just make their living on agriculture anymore even though there a lot of families that are involved in agriculture. There's a wilderness program - Aspen Wilderness and Passages to Recovery who employ a large number of people and they also have a residential program called Aspen Ranch and they employ quite a large number of people and that's been some new jobs that's been available. Then the schools will employ a fair number of people and then there are some of the service industries - tourism certainly has become much bigger over the last 20 years, especially if you move into the Torrey area. There are a lot of people that do tourism. The timber industry was fairly significant when I was growing up here but that's really...there's not much timber industry going on. There is one sawmill that employ's some people here locally but most people; interestingly they have two or three different jobs.
Interviewer
If you have two or three different jobs to make ends meet for your family, what's the makeup of your population that is covered with insurance?
Jeff Chappell
We are somewhat unique in that because of the many government school and educational jobs, a lot of these people do have insurance which is a real boon for a lot of these folks. I would guess probably maybe 15 to 20 percent are Medicare; we have a fairly large population of Medicare. Those without insurance probably make up the same percentage and then we have a few...a small Hispanic community, not quite as large as I was seeing in the Severe Valley but we do see a fair number. But we actually have a fairly high percentage of insured. More so I think than other small communities of comparable size, just because we're surrounded by National Forests and the National Park.
Interviewer
What would you say is one of the biggest challenges of practicing rural medicine?
Jeff Chappell
I think probably one of the biggest challenges is that you see and at least treat initially every infirmity known to man, truly. We may not sense it very often but we will see major trauma that we have to try to stabilize as best we can and move on to the bigger facilities. We see a full spectrum of complex elderly patients. Again pediatric patients, newborns...pretty much a full spectrum and it is challenging. I think it's a bit intimidating. I'm glad that I worked in Richfield for a few years before I came here where there were at least other physicians that I could bounce things off and visit with. Then after the challenges of caring for such a broad population base I think is the challenge of providing on-call coverage. That's a challenge. My cousin was a Physician Assistant here, he was actually the first provider in this clinic when it was first started in 1979 and he did it alone for many years. He was a medic in Vietnam and when I was in medical school and as I began to appreciate the challenges of being on call, I would ask him "are you okay?" and he would say, "well it's not as bad as it was in Vietnam". Well eventually it burned him out and he ended up moving to the Wasatch Front and they brought in two Physician Assistants to take his place of one so that they could take call for each other. Now there's another...I work with Brett Hilton who is a Physician Assistant and he and I share call and so you're on call half the time but at least half the time you're off. While the call...you may get called down every time you're on call but you are very limited, you can't leave town. It's a bit tough to be in the middle of some of the most beautiful places in the world to go hiking and sightseeing and half the time you can't leave time. But that's a challenge, that's a challenge. And that's a big challenge again for the specialists, especially for example as we try to bring more specialists into Richfield which is our closest hospital. There's enough work for one but not enough for two and without having two to help cover each other it's very difficult for them to stay.
Interviewer
I'd like to talk about retention and recruiting of providers kind of generically. Do you know any issues involving that?
Jeff Chappell
Yeah, it's a challenge. I grew up here and have you know more than just the job and the beautiful area to bring in though it's a wonderful area to live in and it's truly great I think for me to be able to live here and to have a good job and a professional opportunity to live in this wonderful place. But the Physician’s Assistant here that also grew up here in Bicknell and I think the people that have ties to these areas are much more likely to stay. But it is a challenge and especially the opportunities for family physicians and general surgeons and internists - the kind of people that we need in these rural areas - there are so many opportunities right now in other...you know along the Wasatch Front, in St. George and elsewhere that it's pretty tough to compete against them because for the same amount of pay or probably less, they work less hours, they have more family time, they don't have to take very much call and it's difficult. When I left Richfield three years ago we tried to recruit another family physician to take my place and were unsuccessful. We were able to bring in a Physician’s Assistant to fill that spot but another physician just left Richfield this winter and they had been two years filling another position and they had another one that they were trying to fill and now they have two positions and they are recruiting...I don't know who it's going to turn out and it puts a great burden on those who remain because suddenly the emergency room coverage becomes more burdensome, the numbers of patients who need to be seen increases and so it's a challenge. I think the big challenge is there's a lot of very good employment opportunities in...If you will, more desirable places to live. You've got to really like living in the country to want to be here.
Interviewer
With that maybe can you fold in the concept that a lot of medical students leave school with huge debt?
Jeff Chappell
That is very true. That is very true. It does play into it. I know it's not uncommon to have a 250,000 dollar debt or even more coming out of medical school and that is a challenge. When I came out of medical school I was fortunate to go to the University of Utah where I didn't have as big of a debt but at that time the state had a program where they would pay for my loans up to 50,000 at that time for a certain number of years serving in a rural community. That worked out very nicely for me; fortunately my loans were less than 50,000 dollars. But it works somewhat to our advantage in that there are some rural sites that have fairly large federal loan repayment programs so it helps in recruiting. Some of those doctors stay, most don't. Which is kind of the downside.
Interviewer
The focus of this show is on barriers to health care. How is remoteness or geographical distance a barrier to access to health care?
Jeff Chappell
It's a challenge for patients to get into the clinic. Yesterday I was in Hanksville which is a clinic...we have a clinic there that we service once a week. I go there once a month, our Physicians Assistant goes there the other weeks and that's 60 miles away and I was visiting with an elderly lady there who I see occasionally up here and she said with the price of gas going up she just can't afford to come up here anymore. Travel is a big expense. It's something that I didn't really appreciate until I moved over here three years ago but we put over 35,000 miles on our car in one year and that's just one of our cars. We must have traveled 50,000 in a year. Granted my children have music lessons in Richfield, but people travel a lot in these communities already and especially for specialty care. I mean we're here and we're fairly central to the area but it's not uncommon for people to travel like I said - 60 miles from Hanksville, 25 mile from Koosharem and 10 miles from Torrey so it's not a big problem but the miles add up. It's a challenge when people are in a crisis. We rely heavily on the EMS, it’s a volunteer ambulance service and they do a marvelous job. It's a challenge for those who are vacationing in the remote parts of the state in that a lot of times they are at least two to three hours away from our facility and then they're another hour away from Richfield or another two and a half hours away from a major trauma center. So it is a challenge, it's...I think having this facility here has been such a huge help to these people as far as being able to get care here at home. A lot of people...unfortunately they will say "well doc if you can't handle it then I'm just gonna...I guess it just isn't going to work" and a lot of them really don't want to travel.
Interviewer
So you have this level of trust that you have built up among the community. How would you build this level of trust especially with some of your older patients?
Jeff Chappell
I think taking the time to understand really what their concerns are. Again a lot of these people are the parents of the people I grew up with or my old Sunday School Teacher or Basketball Coach, Baseball Coach...these are people that I've known, a lot of them for all of my life and I'm generally concerned about them and I think they sense that concern and I truly try to do my best by them and if I can't or if I've done all I can do then I try to be very honest with them and I think they trust me and that's a great feeling.
Interviewer
With that too, what's the...you know it's beautiful country out here. What's the advantage of living in a rural area?
Jeff Chappell
Oh again the marvelous beauty of nature around us is great. But I think even more than that there's a friendliness or sense of community. You might notice as you're driving through, people wave at everybody even people they don't know they wave. I've just gotten in the habit of waving at everyone because I don't want to offend anyone by not waving. A lot of people know me and I may not recognize them. People look out for each other, they're very friendly, they're very open. It's a bit of a slower pace if you will there isn't the pressures to have as many things. There's not the pressures to have big homes and fancy cars and a lot of these people...this is where they grew up. This is where their parents grew up and this is where their grandparents grew up. They look out their window at night and they see Thousand Lake Mountain, there's a sense of 'this is home', this is where they belong. And having grown up here then moved away and come back, it is a great place to live, it really is. The people are great and it's just a very nice place to live.
Interviewer
Can you see any disadvantages of living in this part of the world?
Jeff Chappell
The disadvantages I think are the remoteness and the need to travel. It's quite expensive to travel especially with the price of gas and also if you need healthcare in a hurry, we can use helicopters and airplanes to come in but the best case scenario, you are three hours away from tertiary care. There's been a lot of emphasis recently on seeking care quickly when you've had a stroke because of new treatments that can be given and patients come in and they ask me about that and I say, "well you really need to get care within about three hours and we probably can't get you to a tertiary care center and get the workup that you would need in time to get inside that three hour window to receive care". So I tell them, "let us know as soon as you can, but living here you're probably not a candidate to receive the new treatments for stroke".
Interviewer
With that too, how about medical imaging? They are incredible devices but...an MRI machine - where is the nearest one?
Jeff Chappell
There's an MRI truck that comes into Richfield I think once or twice a week, so that's about 60 miles away. We do basic x-rays here and they're electronically transmitted to a Radiology group in Salt Lake who read them and then fax us the report back. So we have that tele-radiology if you will... But you're right, if you have to have more sophisticated x-rays...we have some basic lab but more sophisticated lab we cannot do here. It's not uncommon for example last night I talked with a patient, they were having symptoms that required workup beyond our ability to do for example ultrasound, CAT scan, more sophisticated blood tests and we had to refer them to Richfield. So it's gotten better, we're able to do more things than we could three years ago as far as our lab and x-ray but still a lot of people who come in, we have to send them on, especially again for surgical consultations, cardiology, oncology, those things.
Interviewer
How about tele-medicine? Does that help the situation? The internet?
Jeff Chappell
Yes very much! We have...they brought in some high speed internet just in the last year and we have access to Intermountain Healthcare Databases, their 'How-To' databases, their 'Help2' system which has been wonderful. It's been really good for us. We are implementing electronic medical records. Right now we have a web based program that is okay, hopefully in the next few months we'll be doing a full electronic medical record and hopefully be able to interface that with a statewide system that I know the Utah Medical Association is pushing towards so that all the physicians in Utah will be able to access the records, labs, consults etcetera of the patients that we see and that would be a huge boon for us because we see a lot of people...for example I mentioned the people that come down and spend...have summer homes if you will weekend homes in the area, they receive a lot of their primary and tertiary care in Salt Lake or elsewhere and when they come in to see us, if we could access those records it would be really nice and the same for the tourists who are vacationing in the area.
Interviewer
How do you provide care?
Jeff Chappell
I think optimally is to have the patients come here to the clinic. We have lab, x-ray, nurses, our pharmacy - which something we should really talk about too is our pharmacy services. But we do not have an extended care facility or nursing home facilities if you will in the area. The closest is in Richfield and so we try the best we can to keep patients in their home, home health has a big role in that and they're a huge help and a big part of the care for the elderly here in Wayne County. A lot of these folks can't come to the clinic, they're home bound, bed bound and I'll try to go to their homes as needed and do house calls and that's different. But it's actually quite rewarding to see them in their homes, you get a better sense of how they're doing, how they're managing their medicines; you may see multiple medication bottles on the table. Happily home health is very good at helping them with their medications. I do go to Richfield a couple of times a month and work in their emergency department and a lot of that is to keep my skills up just because we do see so many...well we don't see a lot but when we see them we see some rather bad trauma. Just this last summer we had a child who suffered a gunshot wound who we saw here, this was the closest facility. Another young man fell off the rocks here near Teasdale, the EMS called me...we try to pack pagers and you know they loaded me on a four wheeler and we went out down through the trail and up through the trees and worked me over onto a cliff to try to help with this young man. Unfortunately we weren't able to help him but yeah, it's a pretty exciting way to practice medicine.
Interviewer
And with that too, you mentioned pharmacy. Let's talk about the pharmacy and how unique it is.
Jeff Chappell
Yes our pharmacy has been a great blessing to these people. It's been relatively new just in the last several years that we've had a fulltime pharmacist and a full pharmacy here in the clinic. Before a lot of the medications were mailed in, people that came in the clinic couldn't get their medications that same day and it's been truly a great thing. Plus being part of the community health clinic program, the same sliding scale discounts that we can afford those who are underinsured or non-insured and have economic need, they'll get that same break in the pharmacy. I had patients who followed me from Richfield who followed me to Wayne County; when I moved over from Richfield, when I became fulltime here, some of my patients selected to drive from Richfield to see me here I guess because of the relationship which we developed over the years. I think that's what started them coming but what's kept them coming is the discounts they can get through the pharmacy.
Interviewer
Let's touch on dental care as well.
Jeff Chappell
Yes, we do have a fulltime dentist who is not associated with our clinic and another part-time dentist who comes over who have been great over the years to provide dental care for the folks here in Wayne County. But there's been a big demand for Medicaid patients or under or uninsured patients to receive dental care and through our community health clinic program, we've been able to bring in a fulltime dentist. And actually we have another part-time dentist coming in also our dentist Dr. Hinton has been here since last fall and she is already so booked up that we're having another part-time dentist help us to meet the demand of the underinsured, uninsured and Medicaid population. We have a lot of patients who travel from surrounding counties who come here for their dental care actually because it’s a rather unique situation in South Central Utah to have this dentist and the program and resources to be able to provide dental care for those who in the past haven't been able to afford it. And that is such a big problem I think for so many people is dental care.
Interviewer
Can you kind of summarize what the big issues are in the practice of rural medicine?
Jeff Chappell
I think the big issues in practicing rural medicine are getting physicians that will stay. I think that's important. I think a lot of these rural areas have had a fair amount of turnover. I know in the future there are fewer physicians going into family medicine which makes the pool of family physicians that we can recruit into the rural areas is becoming more difficult or it's harder to get physicians in to come into the rural areas and I think that's a big problem, at least getting doctors that want to stay. I think the funding programs that help with their loans help get them here but to get them to stay, that's a challenge. I think the challenges of on-call, I think trying to have a critical mass of doctors and PA's enough to cover each other is important. Call can wear you out and I think that's a big issue. Actually I'm quite optimistic about rural care; I think the advances in technology have made it easier to practice in a rural area. The high speed internet and being able to access records has been...I'm really quite optimistic that the tele-medicine and the tele-radiology, the ability to interconnect I think is making it actually easier to do rural medicine and I'm optimistic. I think the geographic barriers...the people who live in these communities are kind of used to that, that's part of life. I think traveling to go to the doctor really isn't...I mean it may be a hardship for those who aren't used to it but most of these people are used to traveling. As the price of gas goes up it becomes more of an economic issue for them. But I'm actually quite optimistic. I do have students who come in and work with me now and then and it's a great place to practice. I can't imagine anything more interesting and satisfying than being able to take care of these people in this community. They're wonderful people; they're people that would do anything for you. Yesterday after caring for a fellow in Hanksville, he said, "hey you ought to come and bring your family and use my cabin up in the Henry Mountains". You know another patient "come with me, I'll take you on a horse ride in some places that you'll never see". You know, things like that, I mean the people are great and they truly appreciate you! We rarely get called in after-hours for problems and actually the most common call is about 6:00 or 6:30 in the morning when the patient calls and says "gee doc I've been in pain for the last two or three hours and I thought maybe you'd be up by now". So they're a great...it's really great. The people really appreciate you, I think it's a challenging...it stretches your skills. It stretches you physically at times. I think it's a challenge for spouses and family because you're called away a lot and a lot of plans have to changes because of needing to be on call but on the upside it's a...rural living in my mind is hard to beat and the people are just great!
