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The adventurers

Maniilaq Health Center, located above the Arctic Circle, takes care of the Native American population spread out over a 30,000-square-mile territory that includes one city of 3,200 people and 11 villages with anywhere from 75 to just under 1,000 residents. The 17-bed hospital facility in Kotzebue, in the center of this network, has no operating room, so emergencies are medevaced 2.5 hours south to Anchorage. They average two a week.

Yet it’s not a pitiful situation to practice in—in fact, just the opposite for Patricia Clancy, MD, who, after 10 years in nursing in the Philadelphia area, headed off to medical school when her four children reached high school age.

But long before she hit the books to study internal medicine, Alaska had captured her imagination. Fired up by long-ago letters from her brother stationed there during the Cold War about grizzlies chasing jeeps, she seized the chance to complete a month-long rotation in the state during her residency in 2001. She learned to cast, helped out at a delivery, and spent an 11-hour day flight-seeing over the state for an insider’s glimpse.

“I was hooked,” she said simply. By 2002, she was back to stay, for a few years at least. And no, she hasn’t seen grizzlies chasing jeeps, although she has seen the shaggy beasts in their natural environment. “I’ve poked a 12-inch hole in the ice and pulled up fish. I’ve been out on snow machine rides and four-wheeled down the beach. I’ve been along when people found mammoth teeth pulled out of the dirt.

“There’s no escaping that you need an adventuresome soul because you have to provide your own entertainment up here. Alaska seems to self select for pretty laid-back, easygoing people, so it makes for great working conditions because whatever the problems are, everybody just fixes them. We figure duct tape cures all,” Clancy jokes.

Take, for instance, the medical care delivery model. Each village has a clinic run by someone from the Community Health Aid Program, CHAP for short. These CHAP administrators are residents of the community and must have a minimum of sixth-grade education and receive basic training in six-week didactic courses over the period of two years so they have skills in assessment, suturing, splinting, and administering medication. These clinics helped change lives in the region after the program was launched in the late ‘70s. According to the State of Alaska Epidemiology Bulletin, life expectancy of Alaska Natives in 1950 was somewhere in the mid-40s. By 1980, that life expectancy jumped to the mid-60s.

Each clinic has a cart equipped with a digital camera, an EKG machine and an otoscope camera so the CHAP can take pictures of patients’ complaints and e-mail them to the physicians in Kotzebue. The clinics also boast two-way video systems in the event a doctor wants to walk a CHAP through an exam or test with the patient while she observes.

“They have fancier digital archiving and radiology transfer than we see in a lot of metropolitan areas,” says Lee Norman, who works with Clancy in her role as medical director of the Maniilaq Health Center. “I’ve seen sophisticated academic medical centers that do not have the capabilities they have in the Arctic.”

This means a typical day for the primary care physicians at headquarters consists of either covering the emergency room from 8 to 12 or 12 to 6, or sitting in the radio room for a shift responding to the telemedicine reports. Four to six times a year, each physician visits an assigned village for a week to work with patients face to face. (Specialty physicians like rheumatologists mainly fly in from the larger cities for clinic summits on a quarterly basis.) Usually just the paramedic and an EMT or nurse handle the medevac runs, but in cases of a premature labor or severe trauma, the physician hops aboard as well.

“The biggest thing is to know yourself,” advises Norman. “I’ll be in an area where I’m very isolated as their caregiver, so what are the things I can do well, and what do I have to relinquish even though it’s expensive to get them down the road to Anchorage?” Trauma offers the perfect illustration. Clinicians must get good very early at recognizing whether they can treat the patient on the spot or simply stabilize and transfer.

“There’s a temptation at times to say, ‘No, let me get a definitive diagnosis and see if this is something that can be managed here.’ That’s a tough one, especially for young physicians because they may not have enough gray in the temples to have done that sort of thing before,” he says. To further compound the challenge, the native population wants to stay as close to home as possible for treatment, whether it be rheumatoid arthritis or chemotherapy, so the city hospitals try to push everything as far out as they can. In Norman’s experience, that alone can really challenge one’s creativity.

But in exchange, physicians get to address more than the predictable coughs and colds. “If you like hands-on medicine, this is an excellent place,” says Clancy. She’s removed toenails, set bones, debrided skin lesions, and performed D&Cs. Some of her colleagues have trained to perform colonoscopies. “It would be hard for me to have a straight internist doctor who didn’t see pediatrics or obstetrics,” she notes.

The patients in this part of the world come from a non-confrontational culture, which on the flip side means things tend to move rather slowly. It also requires physicians to tune in to subtle, non-verbal cues; a little wrinkling of the nose or a slight shake of the head is akin to an Italian throwing his arms up in the air and yelling. Sentences are compact, often one or two-word answers. “I had to relearn the value of silence,” Norman admits. “When I say something like, ‘Alan, do you think this is a good idea?’ I have to shut up while they ponder,” he says. Occasionally, he goes so far as to prod the patient with “Now this is the part where I’m silent and you talk.”

But after you earn their trust, the wealth of family history and information at your fingertips amazes many doctors. And their generosity is overwhelming, says McNeal, who has lived all over Alaska in the 22 years since she moved here—one physician at her hospital has an entire wall decorated in artwork given to her by grateful patients. “You don’t need to go fishing yourself because the patients bring you fish, and smoke your salmon for you, too. Patients love their doctors,” she adds.

It’s not uncommon for physicians in the bush to hang it up after two to three years, so administrators like Clancy constantly seek fresh interest. Clancy arrived to a full house, a pattern the group maintained until August 2004. But at press time, she was scrambling to bring on more family practice doctors to replace those who left.

It’s an understandable reaction. After all, areas this remote do foster a feeling of isolation. And although doctors enjoy liberal vacation time, a snowstorm on Tuesday could ground you just long enough to miss the cruise boat in Honolulu.

“If you like to have dinners with Mom and Dad every Sunday, you better bring your parents up or don’t come to Alaska,” McNeal says.

The natural answer to the shortage would be to foster more Alaskan Native clinicians—a drive that’s in the works but still needs time to bear fruit. For example, in 1971, only 2,000 Natives in the entire state held high school degrees. By the turn of the millennium, that number increased to 60,000. The improvement is commendable, but it hasn’t yet reached the point of producing physicians and nurses. So for the time being, the Lower 48 remains the feeder system.

Even Clancy is uncertain how long her days in the Arctic will last. With children and grandchildren building lives 4,000 miles away, she feels torn between her two loves. Job-sharing in six month increments could provide the perfect answer—as soon as she can find someone willing to swap the same patient list, apartment, and vehicles. “Then I could see me staying for 10 years, easily,” she says. “I just need to find somebody else out there with a restless heart.”

That shouldn’t be difficult in Norman’s estimation. “It’s a National Geographic experience,” he says of his past year in the bush. “Some people open the pages and say, ‘My gosh, it’s bleak, it’s cold, it’s dark for 63 days—how could I exist there?’ Others see a culture unlike anything they’ll ever see again and a chance to care for folks amid a natural wonderment that is unlike anything on Earth.” g