"Doc Julie" Helps Build Health Care Services in Rural Washington State

When Julie Moran, M.D., was an adolescent in suburban Connecticut, she was inspired by the warm-hearted, humorous tales of the English veterinarian, James Herriot, and wanted to be a country vet when she grew up.

Moran ultimately decided that the two-legged representatives of the animal kingdom were more her calling after working as a home health aide while an undergraduate at Cornell University in Ithaca, New York. She relished driving around the beautiful countryside of upstate New York to visit people in their homes, help them sort their medicines, cook meals, and do light cleaning. Most of all, Moran recalls, "I just really enjoyed sitting down and listening to people's stories, so I began to consider medicine."

It seemed like an even better choice when Moran spent a month, while a medical student at University of Pittsburgh, doing a rotation at an NHSC site located deep in the mountains and "hollers" of West Virginia. She blossomed under the wise tutelage of a small town doctor who'd practiced there for many years. "I worked with him for a month and absolutely loved it. It reminded me of the James Herriot books that I read when I was a kid." She accompanied him on his daily rounds, which included "whisking in the door of this 10-bed hospital and delivering a baby on the doorstep, doing general surgery—all of this stuff that I didn't think family doctors did anymore."

Moran was so inspired that she went back to work with the same physician the following summer for a 3-month elective. The University of Pittsburgh didn't have a rural medicine program elective, "so I kind of made one up and decided that's what I wanted to do in my career," she notes. "I got bitten by the bug."

She also seriously considered overseas medical missionary work. "I didn't want to be the TV stereotype of the rich doctor," Moran explains. "I wanted to do something useful and enjoy my work." She spent several months at a clinic in Calcutta, India, but, while greatly moved by the experience, Moran found the language and cultural barriers too daunting.

Instead, upon graduating from medical school in 1995, Moran entered into a family practice residency program in Loma Linda, California, to prepare for her dream of being a country doc. The dream came to fruition in 1998 when she heard about a new clinic being formed in Deer Park, a town located in the scenic lakes and forest region of Washington state, about 20 miles south of Spokane. It reminded her of her home health days in upstate New York, with apple orchards, trees, and horse farms. She fell in love with Deer Park's small town aura and its proximity to the urban amenities of Spokane.

Moran was equally excited about the career opportunity presented to her. Along with three other doctors, she worked on the mission statement, corporate logo, and name of the new clinic. She was also involved in setting up insurance plans, employee procedures, nursing guidelines, and "all kinds of things that they didn't teach me in medical school," she says. "It was really exciting."

Another attraction was that the clinic was able to receive approval as an NHSC site. That distinction enabled Moran to qualify for the NHSC loan repayment program, which she first learned about during her medical school rotation in West Virginia. NHSC-sponsored debt relief was a key factor in her decision to pursue rural medicine, Moran notes, "because I paid my own way through school, and wondered how could I possibly repay my loans and still do what I wanted?" NHSC provided the solution to that dilemma.

Admittedly, Moran says beginning a new practice in a rural setting had its challenges. The clinic struggled financially for the first few years and conditions often seemed primitive to her. "When I first arrived, I was trying to repair a laceration and asked the nurse to get me a syringe of lidocaine, and she brought me this antique metal syringe with a glass plunger," Moran smiles. "I remember thinking 'what have I gotten myself into?'" Even the Calcutta clinic she'd worked in had disposable needles! She was also dismayed to learn that the tiny, local Deer Park Hospital didn't have the capability to perform "stat" emergency blood tests but had to ship everything overnight to Spokane.

"I sat down with the medical staff and asked 'okay, this is the twenty first century—how can we bring this hospital up to the standard of care that is expected everywhere else?'" Moran said. The hospital responded positively to her challenge. "It's been really fun to watch the hospital grow." They've since bought modern lab equipment and retrained personnel to take on new tasks.

Things also eventually turned around financially despite the shaky local economy. The Deer Park Clinic was able to stabilize and retain its core of three doctors, two nurse practitioners, and a physician assistant. Between 30-40 percent of their patients are on Medicare and Medicaid, she notes, and since many doctors in Spokane no longer accept Medicaid, some patients drive from the city to Deer Park. The clinic also sets a sliding scale fee system for the many local farmers and ranchers who pay with cash.

Moran quickly got over her initial surprise at the informality and status of physicians in a small town. "The wonderful thing and the bad thing is that everybody knows you," she comments. "You're the town doc—a local celebrity. They call me by first name out here. It annoyed me at first but now I'm Doc Julie and that's the way it goes."

The life of a country doc, especially in the spread out western region of the U.S., is very hard work, but Moran finds it professionally rewarding. "I've kept in touch with a broader variety of skills than I would've if I'd practiced in a suburban area," she finds. "I do general surgeries in our OR (operating room). Up until recently I was doing a lot of OB (obstetrics), including some pretty high risk OB. The doctors in Spokane know that I'm practicing in a rural area, and they'll teach me things that a specialist in Connecticut wouldn't teach me, because they wouldn't want to give away those referrals."

It also forces providers to hone their diagnostic skills to a fine point, Moran believes. When she treated cardiac patients in Loma Linda, Moran could send them across the street to a large hospital. "Here, I have to call a helicopter, and that's a big expense for the patient, so I darn well better be sure of my diagnosis."

As a mother of two young children and the only female doctor in the area, Moran has also developed a mentoring role with her young female patients, especially new mothers. "I look at these young moms and their children and I say 'this is where it starts,'" she explains. "If I get this mom on the right track, her children will have a chance." Not surprisingly, Moran also loves pediatric practice; she advocates breast feeding and provides patient education on immunization. Moran is also working hard to combat the lack of fluoride in the local water supply. "That's another crusade—I'm trying to get the moms to get all their kids on fluoride drops or tablets," she says.

In recent years, she's begun teaching a new generation of health practitioners and medical students who come to Deer Park Clinic for rotations. She remembers the importance and inspiration she found in West Virginia and advises students, "The more time you can work with somebody who has done this, the better, particularly with the older doctors. They're the ones who have stuck it out and that enthusiasm is contagious. I'm still motivated by what I experienced in West Virginia. When I'm tired or caught in a tight spot, I ask 'how can I be more like them?'"