FORT GAINES — Karen Kinsell is the only doctor in town.
She has run the Clay County Medical Center in the same building for the past 22 years — more than half of that time she has been the only medical provider in the entire county. The nearest hospital is 20 miles away, and the only pharmacy in the county closed a little more than a year ago.
The clinic has four exam rooms that funnel up to 25 patients in and out each day with a small paid staff — many who have served the clinic for more than half a decade.
Patients pull out lunch bags of pill bottles, sometimes a dozen or more and detail new or worsening medical conditions — a fall down stairs, trouble breathing or, much of the time, ongoing suffering from a chronic illness.
Clay County is one of the most impoverished areas of the state with more than 40% below the federal poverty line — more than three times the national average. Fort Gaines sits on the Chattahoochee River, its residents — about a thousand — can wave across at their Alabama neighbors.
If would be difficult to recruit another physician to work in Fort Gaines, Kinsell said.
Past the brink and in the thick of what some are calling a “rural health care crisis,” many rural Georgia residents have been pushed to driving extreme distances for medical care — or living without it at all.
Bringing health care to rural areas faces myriad of challenges — from a lack of Medicaid expansion to big-name pharmacies running independent pharmacies out of business — all while the few doctors already in those areas are reaching retirement age.
“You’re recruiting a physician that from the start can deal with and work well with the quality of rural," Jimmy Lewis, chief executive officer of Hometown Health, a network of hospitals, said. "They must be prepared for a smaller population to live in, and must be prepared for the amenities, or the lack of that goes with being a rural doctor.”
An aging workforce
A July 2019 article in the New England School of Medicine showed that from 2000 to 2017, the number of physicians younger than 50 years old living in rural areas decreased by 25%, and by 2017, more than half of rural physicians were at least 50 years old. More than a quarter were at least 60.
By comparison, in urban areas only 39% of physicians were older than 50, and only 18% were older than 60.
Kinsell has considered retiring. She hopes she could get there by 70.
Working on a volunteer basis, she’s not sure what she’ll do. She could go into private home care or back to an urgent care but her patients are keeping her in Fort Gaines.
Kinsell is fueled by two protein shakes a day, taking no lunch break. On a Tuesday in January when she was out with the flu, the clinic closed completely, making up the extra appointments the following day.
“There’s an awful lot of people who depend on me,” she said.
The aging rural physician population is not unique to Georgia. The average age of physicians across the board is 51 years old, according to census data.
Dalton Dr. Don Thomas retired from his practice two years ago due to a combination of hand tremors and Parkinson’s disease. Thomas worked past retirement age. If it weren’t for the hand tremors, he said, he might be at the office today.
Thomas said there was one thing he didn’t expect with retirement — after 58 years of running his practice, he still wakes up every morning feeling the need to get to work.
"I delivered babies in 1960 that I still treated 58 years later," Thomas said.
But doctors who choose to work in rural areas face the challenge of often being a one-stop shop for impoverished patients who can’t afford or travel to specialty care.
Challenges of serving rural populations
Wanda Alphord sits in the back rows of her church, so she can make a quick exit if needed.
Alphord, 55, has an undiagnosed condition that causes her to pass out at random. She never knows where she might be — in church, at the grocery store or in her home. The fainting spells and essential tremors caused by lesions on her brain have taken away her ability to drive. She lives in constant anxiety, unsure of when it might happen.
For 30 years, she held the highest position a woman has ever held at a nuclear power plant on the border of Georgia and Alabama — but her condition forced her to stop work six years ago.
“It’s really hard to be a strong, independent woman all your life and wake up one day and you’re lying there, and you don’t know how you got there,” Alphord said.
Combined, Alphord and her husband have a $623-a-month income. They’re both unable to work — after her husband threw out his back — and live off of a small stipend of disability. Their insurance alone costs them $900 a month, waiting on approval for Medicare — driving them deeper into poverty.
Kinsell spends much of her time with patients going through clusters of medications — searching online for the lowest pharmacy prices, coupons or coverage options. She has to get creative.
A recent Georgia law has allowed hospitals to recycle unused prescription drugs; Kinsell takes advantage of this practice. Sometimes patients qualify for prescription assistance programs and nonprofit services that offer free disease screenings, but often they don’t.
The difference between a price of $10.99 and price of $11.75 could mean a lot.
Kinsell charges her indigent and impoverished patients a $10 flat rate, which she doesn't want to change.
When the last pharmacy there closed in 2018, Kinsell’s patients became reliant on either mail-order prescriptions or finding a way to drive long distances. A few pharmacies provide home-delivery services, but not on a frequent basis.
The number of home health-care companies that work with the clinic has dwindled — pulling out of service of patients for various reasons. The clinic has no diagnostic capacity — no X-rays or complex lab work.
Sometimes, Kinsell said, her nurses are shipping out to do in-home wound checks.
“You really have to know, OK, is this worth this person driving 40 miles to get to the emergency room, waiting half the day, not able to afford the charge, or can we safely care for them here,” Kinsell said. “Really in these hyper rural areas you need someone with more experience and training than someone with less.”
Treating rural patients isn't just a matter diagnosing and treating their conditions — but also explaining their conditions to them.
Healthy literacy education initiatives have been a key way health-care advocates are reaching rural patients, from HIV to maternal health awareness.
Laura Colbert, executive director of Georgians for a Healthy Future, said people living in rural areas are more likely to have low levels of health literacy, compared to urban or suburban areas.
"When people have low health literacy skills, they may have problems reading and understanding even basic health information, like a pamphlet about a health condition," Colbert said in a statement. "The challenges of health literacy among rural Georgians may make it difficult for many to understand their doctor’s instructions, manage their own health conditions, or sign up for insurance coverage.
Kinsell said it is one major challenge to her practice — explaining to patients what treatment they need and ensuring they stay on the prescribed regimen.
“Medical literacy is poor with everybody," Kinsell said, "but among these people, it's just off the charts."
Lewis said doctors serving rural areas need to be capable of working with illiterate or less than literate patients and good at explaining their medical conditions to them.
"You gotta explain it," he said, "and then you got to explain it in a fashion that is simple enough, but ... is enough to get their attention so that they will listen to you."
Recruiting for the community
Rural doctors have to like a certain way of life, Lewis said, walking to the family convenience store, going to high school football games, attending the local church.
"It's the camaraderie that goes with being a part of a rural community," he said.
Health-care recruiters use that exact "camaraderie" to their advantage to encourage young physicians to be a part of their communities.
At the recently opened Philadelphia College of Osteopathic Medicine’s South Georgia Campus in Moultrie, many of the members of their first class were South Georgia born and raised.
Teachers at the college teach rural specific medicine and medicine practices in their classes, Dr. Michael Sampson, chief academic officer of the South Georgia Campus, said in July.
Community leaders say they try to make Moultrie more than a temporary community for their students — but promote the town as the beginning of a life in South Georgia.
“The whole goal of that was to help them make connections in our community,” said Tommie Beth Willis, president of the Moultrie-Colquitt County Chamber of Commerce, who helps with student integration. “We want them to feel like this is their home while they’re here for medical college.”
Monica Morris, director of physician recruitment for Southwell, the health-care system that oversees Tift Regional Medical Center, said recruiting young physicians isn’t the challenge. Getting people to take an interest in rural areas, regardless of their age, is the challenge. Morris said the health system offers student loan forgiveness as an incentive for students to work in the area upon finishing school.
“I’ll tell you from a recruiting standpoint what we’ve done and done well is offer incentives that most larger communities can't,” Morris said.
Morris said misconceptions about rural areas is the biggest stumbling block, one which is generally removed after a potential recruit comes for a visit.
Lewis said local hospitals and governments need to be willing to bolster support of young doctors in training or residency with financial support.
Efforts toward rural physician recruitment cannot be understated.
Elvin Coy Irvin, M.D., chief medical officer at the Archbold Medical Center in Thomasville, said bringing young physicians to rural areas is so difficult it requires the state to get involved.
The Georgia General Assembly instituted a rural physician tax credit which allows doctors in a predetermined list of counties to claim a $5,000 state tax credit yearly, up to five years. Counties qualify if they have 65 individuals per square mile or fewer — determined by the most current census count.
But tax credits and other state incentives aren’t beating the social benefits and pay scale of working in a city.
Irvin said the center makes a point to form relationships with local medical students early on and travel to make personal presentations to young physicians at other programs, job fairs and medical conferences.
“It really is all about finding the right fit with the job description, the culture of our organization and with our community," he said. "We are looking for the young physician who will settle here and bring their family's talents to our schools, our organizations, our churches and our businesses."
Technology bringing some relief
"Telemedicine" has been a buzz-word in the halls of the Capitol both in and out of session. Lawmakers pushing for online medical consultations as a way to fill the gaps of specialized care in rural areas.
"Technology knows no boundaries," Lt. Gov. Goeff Duncan said in a press conference referencing a push for tele-health initiatives, "and it could quite honestly be the greatest gift to rural Georgia."
A House study committee on maternal mortality recommended expanding telemedicine services by providing incentives for doctors to connect with pregnant and postpartum women to combat the state’s extreme rates of maternal mortality.
Lewis said in order for rural hospitals and clinics to attract young physicians, they must have updated technology.
"(Young doctors) require, they demand that there be digital technology of the highest order, and the the electronic health record or otherwise, so that they are fully using their education," he said.
Lewis, who is also a member of the Georgia Partnership for Telehealth, said telemedicine is "unequivocally" a solution for rural health access.
“There is absolutely no doubt whatsoever, that there is a key and major place for the expansion of telemedicine as an access of health care in rural Georgia," he said.
Archbold Medical Center is using telemedicine to consult with doctors miles away, Irvin said.
“Telemedicine has helped allow the ability to consult with specialized doctors who are not available in rural areas,” he said. “At Archbold, telemedicine is primarily used for neurology and psychiatry, and in some locations, connecting pediatricians to school clinics.”
However, telemedicine has been met with legal questions such as if the doctor on one end of the screen is liable for the patient’s health improving or declining — without seeing or treating the patient in person. The health-care industry hasn't ignored the legal risks of using telemedicine.
"When you're dealing with telemedicine," Lewis said, "you're putting trust and faith, in a video system and a digital communication system."
In addition to Riley Bunch, SunLight Project reporters Desiree Carver, Patty Dozier, Kevin Hall, Bryce Ethridge, Taylor Hembree, Charles Oliver and Eve Copeland-Brechbiel contributed to this report.