Out of all 50 states in the nation Idaho has the fewest physicians per capita. And out of Idaho's 44 counties, Lincoln is statistically one of those with the greatest lack of health care professionals. For the 3,400 residents of this south-central Idaho county north of Twin Falls, their primary health care is delivered by one man: Dr. Keith Davis.
"Nationwide, the recommended ratio of patients per doctor is about 1,000 to 1," Dr. Davis pointed out. His patient list at the Shoshone Family Medical Center, drawn from surrounding counties as well as Lincoln, numbers close to 7,000 -- more than three times the national average.
A second doctor would be welcome, according to Dr. Davis, but there are currently no prospects.
Nationally, rural areas are desperately short of family physicians. Counties with less than 10,000 population have roughly half as many doctors per capita as urban and suburban areas. And more than 100 counties across the country have no resident physicians whatsoever. Lower than average wages, long hours and the lack of professional support discourages most physicians from rural practice. Country doctors are often on their own in terms of diagnosis and treatment, and that can be intimidating to a young doctor when people's lives are at stake.
Like Dr. Joel Fleischman on the television series Northern Exposure, Dr. Davis started his first practice in a rural community because he had student loans to pay off. By working in Shoshone -- a federally designated health shortage area -- he could repay his National Health Service Corps Scholarship in just four years. But unlike his fictional counterpart in Alaska, Dr. Davis wanted to practice medicine in Shoshone.
"This was my first choice of the places I could have gone," said Dr. Davis, who graduated from the George Washington University School of Medicine in Washington, D.C. His residency at the University of Iowa included specialty training in rural family practice. Fresh from Iowa, Dr. Davis discovered Shoshone to be an aging railroad town with a struggling agriculture-based economy. Situated in a high desert environment on the lava-encrusted Snake River Plain, it suffers from extreme temperatures and unreliable moisture. And yet, for those who have survived its disappointments, the land has also offered bountiful grain crops and produced admirable livestock.
"The main thing that interested me was that the people were so nice," said Dr. Davis, who arrived in 1985 with his wife, Diane, and two children. A third child was born two years later. In Shoshone he would be taking over a private practice left vacant by the retirement of Dr. Royal Neher. As such, he would be on his own with no guarantees.
"I felt like I could be happy staying here," he explained. "If I'd joined a clinic somewhere, there would have been a board of directors that I'd be working for and have to answer to. As it is here, if there's a piece of equipment I need or a test I want to try, I don't have to ask anyone's permission."
After completing his student loan obligation three years ago, Dr. Davis is still in Shoshone with no intentions of leaving. "This is home," he said.
Born and raised in northwest Oregon, the future doctor grew up among farm animals, livestock and rural people. "Some of the hardest work I ever did was cleaning horse barns and bucking hay bales for a dollar an hour," Dr. Davis said.
Each summer during his high school years he worked for a ryegrass farmer near Tangent, Oregon. The rest of the year he spent sorting out his career options. "I liked science and I liked people," he recalled. "For awhile I was interested in chemical engineering, but that involved little contact with people. And then I was interested in pharmacy, but so much of it is just storing and dispensing; you don't get to do much chemistry." Finally, in his junior year of high school, Davis set his sights on becoming a doctor.
"Nobody in my family had ever been a doctor," he said. "I was the first."
Davis chose to specialize in rural family medicine. And though he's since had offers to leave Shoshone and work in bigger cities for more money, the small-town lifestyle and friendly atmosphere suit him fine.
"He's a good doctor," said elderly Jeannie Allred of Richfield as Dr. Davis examined her upper respiratory infection. "He remembers to send you birthday cards on your birthday."
Dr. Davis sheepishly explained that his patients' birthdays are programmed into his computer. "But you take the time to sign them," said Allred. Dr. Davis does take his time. Despite his heavy patient load and long hours, there is nothing rushed or urgent in his manner.
"Doc, do you think it would help me to take some vitamins?" asked Allred.
"Any time you're sick it can't hurt," Dr. Davis responded.
"I've never taken them, but my daughter says I'm getting to the age that I need them," she explained.
In addition to his busy practice, Dr. Davis is actively involved in dozens of community activities. He is president-elect of the local Rotary Club, past president of the Lutheran Church council, vice president of the Chamber of Commerce, and director of the local arts council. He offers no explanation for his community involvement aside from the comment, "I like it here." Politics does not interest him; people do.
As Dr. Davis inspected the ingrown toenail of Gary Russell, who operates the local ambulance service with his wife Melody, the three of them discussed the dedication of a new gazebo in the city park. Dr. Davis helped spearhead the volunteer project and will have the ribbon-cutting honors. A country-western band, Muzzie Braun and the Boys, is scheduled to perform a free concert afterward.
"Are you going to contact the radio stations, or should we?" asked Melody Russell. Press releases have already been mailed out, Dr. Davis responded. Turning to Gary Russell and his sore toe, he advised: "Soak it for 15 or 20 minutes each day while you're reading the paper or something."
Why are family practices like this becoming so rare? Why are so few physicians interested in becoming country doctors? Financially, the cities are much more attractive, Dr. Davis explained. Idaho already ranks 49th out of 50 states in physician income, and rural practices fare the worst. People who live on farms and ranches traditionally avoid unnecessary visits to the doctor, and all too often the necessary ones as well.
"There's no doubt that there are people waiting on conditions that need treatment because they feel they don't have the money," Dr. Davis pointed out. But while a visit to his office costs just $25.50, a trip to the hospital can cost thousands. Since Jan. 1, Medicare has disallowed any extra charges on after-hours office visits or house calls in rural areas, making it more difficult for country doctors to justify those services.
A patient with a bladder infection could easily be tested and treated in the Shoshone office for a cost of about $37, Dr. Davis pointed out. But if the patient needed help in the middle of the night he would charge an extra $25 night charge. Medicare's refusal to cover the night charge encourages patients to go to a hospital emergency room 15 miles away instead, where the same treatment could cost $280. But the patient's direct cost would be nil.
"For a rural area, there is no financial incentive to see these people in the middle of the night," Dr. Davis explained. If politicians are serious about attracting physicians to rural practices they must address the financial inequities and sacrifices involved, he pointed out.
"A lot of the doctor shortage is purely financial," he said. But money isn't everything, as the doctor is the first to admit. "Quality of life is really more important. I like this place. There's no better place to raise a family."