Practicing medicine in remote Alaska

January 22, 2019
Erick Trickey

The benefits and challenges of providing care on America’s last frontier.

When John Cullen moved to Alaska, he didn’t expect to stay. “I had planned on going someplace I could do obstetrics,” he says. Cullen, MD, FAAFP, grew up in Phoenix and rotated into Valdez (population: 4,000) for his third year of residency in 1994.

But Cullen and his wife fell in love with Valdez, a remote coastal town surrounded by water, forests, mountains, and glaciers. “There’s not many places where you can ski and sail on the same day,” he says. “It’s spectacularly beautiful.”

Today, 24 years later, Cullen is president of the American Academy of Family Physicians, and he still practices family medicine in Valdez. As one of four doctors in town, he covers some emergency department shifts at Providence Valdez Medical Center. There, he’s treated patients after avalanches, chain saw accidents, fishing mishaps, and falls into crevasses. He’s also treated severe hypothermia: “I’ve brought two people back from a core body temperature of 70 degrees.” Sometimes, he’ll put emergency patients on 45-minute plane flights to Anchorage. But if a storm prevents flying-Valdez gets 300 inches of snow a year-he’ll have to keep them stable until the sky clears.

Cullen’s private family practice covers everything from strep throat to back pain to pre-op physicals. He delivers babies, some by cesarean section, and performs some other surgeries. “In our community, you have to have a very broad scope of practice,” Cullen says.

All across Alaska, the nation’s largest yet third-least populous state, physicians enjoy careers much like Cullen’s-filled with the challenges of remoteness and extreme weather, the joys of small-town community, and more independence than their peers in the Lower 48. Practicing medicine in Alaska can be more difficult at times, but it offers rewards that come with using a wide range of physicians’ skills.

“The people here are very tough,” Cullen says. “Sometimes, just making sure they get enough care is difficult. They want to soldier through.” Once, a patient with a severe pelvic fracture flew himself into Valdez’s airport. People have hiked out of the wilderness on broken legs. “Ninety-three-year-old grandmothers are still splitting wood in their cabins,” he says. It’s difficult to talk them into coming into town to see a doctor and even more challenging to get them to rest while they’re recovering, Cullen says.

For some Alaska doctors, traveling to the state’s tiny villages is part of the job. Every three months, Katie Tsigonis, MD, leaves Fairbanks in a Chevy Suburban to see patients in two tiny villages in central Alaska: Minto (population: 210) and Manley Hot Springs (population: 89). She’s a doctor for Chief Andrew Isaac Medical Center in Fairbanks, which serves Alaska Native communities across the state’s vast interior. Her 300-mile round trip by land on Alaska Route 2 is unusual compared to most of her fellow clinicians’ travels. They fly to the Native communities they serve because no roads go there. “The struggle is always: How do we give the same care out in rural Alaska, a fly-in only small village, that we give at a more central location like Fairbanks?” Tsigonis says.

In Minto and Manley Hot Springs, Tsigonis does electrocardiograms (EKGs), delivers babies, implants intrauterine devices, conducts sports physicals, immunizes kids, and educates families on end-of-life care. “The patients are so amazingly lovely,” Tsigonis says. In Manley Hot Springs, she stays at a cabin owned by a woman whose husband was a prominent dog musher. In December, she attended the Christmas program at the 59-student Minto School.

Tsigonis’ employer serves 30 villages in Alaska’s interior: from Tok, near the border with Canada’s Yukon Territory, to Anaktuvuk Pass, north of the Arctic Circle. For reference, the U.S. Postal Service once named Anaktuvuk Pass as home to the nation’s most remote post office.

Tsigonis used to fly into Stevens Village (population: 78). “In the winter, you wear your snow gear on the plane, because you never know what’s going to happen,” she says. “Someone has hopefully plowed [the landing strip], and usually someone picks you up on a snow machine, or a sled behind a snow machine, and takes you to the clinic.”

The clinic has no running water because the ground is too hard. Doctors bring their own food and bottled water, since there’s none to buy in the smallest villages-and they pack a few extra days’ worth, in case they’re “weathered in,” or stranded by a storm.

Back at the main clinic in Fairbanks, Tsigonis and fellow clinicians also take phone calls from trained health aides in each village, local residents who have a deep rapport with their neighbors. The aides can insert IVs, perform EKGs, and take pictures to share with the doctors via the clinics’ cloud-based electronic health records system. The village clinics all have emergency lifesaving medicine, including epinephrine for anaphylaxis, injectable morphine, and diazepam to stop seizures. Most village clinics have Pyxis MedStation systems, which doctors can signal remotely from Fairbanks to release medication.

Physicians in Alaska say a deep sense of community tends to outweigh any feelings of isolation. “Almost always, the answer you get when we talk amongst ourselves is that personal community is so strong in smaller places,” she says. “You actually end up being way more connected to your neighbors.” Some of that comes from the necessity of mutual aid. “If someone breaks down on road and it’s minus 10, minus 20 [degrees] out, you stop,” she says.

Tsigonis grew up in Valdez and Wasilla, Alaska; attended medical school at the University of Washington in Seattle; and completed her residency at a Mayo Clinic program in Wisconsin. “Seattle and Wisconsin are wonderful, but the sense of community can’t compare.” Despite Fairbanks’ distance from other cities, isolation isn’t a problem for her.

The downsides of Alaska’s remoteness from the Lower 48 have virtually disappeared thanks to technology, she says. Online shopping has eliminated the difficulty of not having a lot of stores. Fairbanks, Alaska’s second-largest city (population: 31,500), has an international airport. In the summertime, there’s a nonstop to Frankfurt, Germany: an 8-hour flight over the North Pole.

Whether they’re independent practitioners or employees, physicians often find themselves practicing a wide range of medicine in Alaska. Specialists are uncommon outside Anchorage, the state’s most populous city (population: 298,000), with more than 40 percent of the state’s total population. Anchorage is also home to the state’s only medical school and university hospital, as well as the state’s largest hospital.

Katie Tsigonis’ mother-in-law, Jean Tsigonis, MD, has been a family doctor in Fairbanks since 1981. “You’re probably always practicing at the top of your license, doing things you were taught but didn’t think you would ever do,” Jean Tsigonis says. Fairbanks has a few specialists, but no super-specialists: neurologists, but no neurosurgeons; internists who know pulmonology, but no pulmonologists.

A self-described old-fashioned family doctor, Jean Tsigonis takes on a lot of patients and procedures that family doctors in bigger cities would hand off. She delivers babies, performs colonoscopies, provides hospice care, handles infertility cases with the advice of consultants in the Lower 48, and cares for people with chronic conditions and comorbidities, including diabetes, congestive heart failure, and dementia. With less than four hours of sun in Fairbanks in December-“it’s just a bump, a low-lying sun”-she also treats a fair amount of seasonal affective disorder.

Other family doctors in her clinic have taken on niche work. One does laser vein treatment. Another doctor focused on diabetes care and insulin pumps, then switched to sleep studies and CPAP machines once an endocrinologist moved to town.

“Today, I’m doing a house call,” Jean Tsigonis says. “Anytime it’s harder for them, I go to them.” Other patients come to her. A missionary who lives in Noatak, 463 miles away on Alaska’s northwest coast, returns to Fairbanks so Jean Tsigonis can deliver her babies. Another patient, a police officer, travels 500 miles to Fairbanks for her annual checkups from Alaska’s northernmost city, Utqiagvik (formerly named Barrow).

Jean Tsigonis’ clinic was an independent practice until 2008, when she and her fellow doctors sold to The Greater Fairbanks Community Hospital Foundation, which also owns Fairbanks Memorial Hospital. As the chair of the hospital’s physician wellness committee, Tsigonis tries to help new doctors in town settle in. “I try to find what their interests are: Are you a sports person? Are you a music person? Are you a churchgoing person?” she says. “Then I try to get them to make friends in those areas, so they feel like this is their home and not just their job.”

Alaskans, including doctors, have strong feelings about independence and control. “If I wanted to run for governor, I could,” Jean Tsigonis says. “You can make a difference up here, still. The numbers are so small that everything I do today has an effect.”

That independence extends to doctors as they react to changes in the business of medicine. “In a way, we are protected a little bit,” she says. “No one’s telling me I have to see patients every 15 minutes.”

Though recruitment and retention of physicians can be a challenge in Alaska, a certain type of doctor thrives there. “It’s a very adventurous lifestyle, so we need to gear our recruitment to people who want to have an adventure,” Cullen says, adding that outdoorsy types are especially attracted to Alaska’s skiing and sailing. Health organizations in Alaska typically offer signing bonuses of $15,000 to $25,000 and relocation assistance of $15,000 to physicians they’ve recruited. The offers can be higher in remote areas: Native Alaskan communities often offer new physicians $60,000 to $70,000 a year in medical school loan repayments, Cullen says. To compete, Valdez City Council does the same.

Practicing medicine in rural Alaska has been “absolutely fantastic,” Cullen says. He’s found it personally gratifying to be a small-town doctor, living in the community with his patients and watching them grow. “Walking into the store, I see babies I delivered, some of them adults. That part is the biggest reward I can possibly think of.”

Erick Trickey is a freelance journalist based in Boston.