Alaska AFP Provides 'Gathering Place' for Far-flung Physicians

It's fair to say that family physicians who practice in Alaska have a healthy respect for weather conditions that can isolate towns and even cities in the dead of winter.

"I'm looking out my kitchen window, and the snow comes up to the base of the window," says John Cullen, M.D., president of the Alaska AFP, describing the scene outside his window in a phone interview with AAFP News Now. "But given that my kitchen is on the second story, you can just imagine how much snow is out there," says the Phoenix native, who came to Alaska for the third year of his family medicine residency training and never left.

Cullen's town of Valdez is buried under 26 feet of snow in a winter that has been harsh even by Alaska standards. It's mid-January, and a series of avalanches has closed the mountain pass that connects Valdez to Glennallen, the closest town, which serves as a pick-up point for patients who need air transport to Anchorage. Smaller planes that take off and land in Valdez have been grounded for four days because of poor weather conditions.

Still, Cullen can drive to his clinic, which is located just a mile away and which sits only 50 yards from the local hospital. He and his partners provide "full-spectrum family medicine" to the locals. In addition to the urgent, preventive and chronic disease care always handled by FPs, Cullen delivers about 50 babies a year -- some by cesarean section -- and performs surgery when necessary.

"Because of the isolation, we have to be prepared to handle everything," says Cullen.

Barbara Doty, M.D., of Wasilla, describes Alaska as a "rugged individualist environment" where, in the winter, residents often get around on "snow machines," or snowmobiles, using frozen rivers as roads. "Slope workers" (oil field workers), she adds, leave their families for weeks at a time and use company planes for the one-hour flight to work.

Consider these fast facts about Alaska: The state is two-and-a-half times bigger than Texas and claims a land area of more than 570,000 square miles. Alaska has more than 722,000 residents, nearly half of whom live in Anchorage, the state's largest city. Juneau, the state capital, is nearly 1,000 miles from Anchorage and accessible only by air or sea (presenting a challenge to those who want to be politically active on a face-to-face level).

It's easy to see why the 367 members of the Alaska AFP -- who dot this vast geography like tiny push pins on a wall map -- rely heavily on their chapter for support.

Doty, a member of the AAFP's Board of Directors, puts it this way: "We use the chapter as a gathering place, because we have such disparate practices and we're so far-flung. Chapter meetings are a way to share ideas and anchor our professional relationships."

"The chapter was -- and still is -- my professional lifesaver," says Katy Sheridan, of Soldotna, a native of Alaska who graduated from a residency program in Maine in the 1990s and then returned to her home state to practice family medicine.

Once settled, Sheridan had the social support of family and friends -- and ample invitations for holiday dinners. "But I really felt professionally isolated in a lot of ways," she says.

"I started going to the state chapter meetings and, subsequently, met family doctors from around the state who became my lifeline and career support," says Sheridan, who served as chapter president for two consecutive years beginning in 2004.

The Alaska AFP holds two educational meetings a year: a winter update in March and its annual Scientific Congress in June. The chapter also sponsors an Advanced Life Support in Obstetrics (ALSO) course every fall at the Alaska Family Medicine Residency in Anchorage, the state's only medical residency program.

Residency Director Harold Johnston, M.D., told AAFP News Now that ties between the program and the chapter are strong. For example, faculty members help teach the ALSO course, and a resident serves on the chapter's board of directors. A good number of residency faculty members also are active in chapter leadership.

Residents are encouraged to get involved in both the chapter and the national AAFP, to the extent that the residency program pays full membership dues for all 36 residents.

Residency training in Alaska is rigorous. "We have to focus on areas of training that prepare residents for that low-tech practice that they are likely to find in the 'bush'" said Johnston. The bush areas of Alaska are towns and villages -- some with as few as 50 people -- that are accessible only by boat, plane or snowmobile.

Because of the unique demands placed on family physicians in Alaska, the residency program focuses heavily on obstetrics, orthopedics, pediatrics and emergency medicine. It also features three and half months of required rural rotations, a two-part transcultural rotation that teaches residents about Alaska history and culture, and a workshop on winter survival skills.

The payoff is that 80 percent of residents stay in Alaska after they graduate; it's the highest in-state retention rate in the nation. And 50 percent of those graduates practice in rural communities -- also higher than the national average.

"After spending three years in Alaska, if you were at all interested in the first place, it's very likely that you're going to want to stay," says Johnston.

Indeed, coming to Alaska for training -- and then settling in for good -- seems to be a common story.

Marin Granholm, M.D., of Anchorage, is one of the 80 percent of residents who stay in the state. Originally from Salt Lake City, Granholm entered the residency program in 2000, graduated in 2003, and worked in Bethel in an Eskimo community close to the Bering Sea for eight years.

Now, she takes care of patients at the Anchorage Neighborhood Health Center and is poised to be installed as the Alaska AFP's next president in June.

Granholm understands the difficulties of keeping members connected and says the chapter has long relied on the Internet, e-mail and conference calls. Chapter meetings often include members calling in from Bethel, Nome, and sometimes Sitka and Juneau.

More recently, Facebook has been a welcome addition to the chapter's outreach to members. "Part of my goal (as president) is to increase communications to our tiny little practices spread out over this large geographic area," says Granholm. She wants Alaska FPs to be more tuned in to issues such as practice transformation and accountable care organizations -- topics that are hot in the "Lower 48" states.

Chapter leaders give much credit for the chapter's success to Marilyn Dodd, the chapter's executive director since 1996. In the past 15 years, the chapter has added nearly 70 new members, an impressive feat for a chapter so small.

In the winter, Dodd manages chapter business out of her home in Clam Gulch, a tiny town on the Kenai Peninsula. When the weather's more amenable -- and when the need arises -- she makes the trip into Soldotna some 19 miles away.

Physicians try to describe the isolation and challenges of practicing medicine in Alaska, but their stories tell it all. One FP tells of providing comprehensive care to a patient with highly complex health problems that, in any other setting, would require the services of a multispecialty health care team.

Another recalls a harrowing three-and-a-half-hour ambulance ride through a snowy mountain pass to deliver two teenage boys with critical head injuries to the next town, where they were airlifted to Anchorage for treatment.

Alaska FPs don't hesitate to call in the Coast Guard for assistance when needed. And they sometimes have to consider where might be the safest place for a woman in preterm labor to deliver and then base their final decision on flight conditions and the availability of airport landing lights.

Family physicians in Alaska speak of the natural beauty of their state and how they wouldn't live anywhere else.

"People love practicing up here," says Doty. "We may work a little harder and we may put in a few more hours, but there's a lot of joy."