Rural Exposure - A Doctor In Forks -- National Service Brought Care To Peninsula Town

FORKS - Stephen H. Kriebel is denied the daily anonymity that most doctors take for granted. As he pushes his cart down the aisle of the local market, often someone will approach him with a medical complaint they'd like diagnosed on the spot. That's just part of being a rural physician.

Almost all his patients know where he lives. And he is unable to escape his patients who are less than pleased with a medical outcome. A woman whose son was born palsied and who unsuccessfully sued him shops at the same grocery store. Her child goes to high school with Kriebel's son, Westin.

Kriebel's house, which has 80 windows and no curtains, sits on a spacious 15 acres, part of which is riverfront. The house is so close that he's able to leave his practice and eat lunch at home.

"The silver lining is that everyone is protective of you," he says. One night a car broke down at the end of his driveway. A man driving by - Kriebel knew him only slightly - called when he got home to make sure that everything was all right.

Forks is separated from Seattle by 140 miles and nearly 1 million acres of national park. Forks the town has 3,000 residents; the nearest big town - Port Angeles, a community of 20,000 - is 60 miles away.

The only thing that grows with great enthusiasm around Forks is trees. In the heart of a former logging economy that has disintegrated, the town has been able to sustain itself economically through two prisons which have been built in recent years close to the town. Forks has also benefited from being in a physically beautiful setting, a scant 15 miles from the Pacific Ocean, that is beginning to lure tourists.

Two important developments helped place Kriebel in Forks for the past 20 years. The first was the emergence in the early 1970s of family practice as a distinct medical specialty. Family practice arose as a response to the narrow specialization in medicine that had been taking place for some time and is designed to produce highly skilled generalist physicians who can provide a broad range of treatments.

The second was the development of the National Health Service Corps, a government program designed to place doctors in medically under-served communities. This program is now under assault from Republican budget-cutters in Congress who want to reduce its budget by 50 percent. They assert that the program has had little effect on bringing physicians to rural communities.

However, the corps has had a significant impact on the health care in this Olympic Peninsula town.

Kriebel grew up in a suburb of Philadelphia and went to medical school at the University of Pennsylvania. He's long been prone to take the unproven course. "I knew I wanted to be in family practice right from the start of medical school," he says. "My advisers said I was crazy to go into family practice. They said it was a flash in the pan. Of course, that just urged me on all the more. When I told them I wanted to do my residency in the West, they were even more appalled," he says.

When Kriebel started medical school in 1968, the Vietnam War was at its zenith. Medical school was about the only deferment left for him. To Kriebel, an end to the war seemed a long way off.

Under most scenarios he would have likely finished medical school, served a brief internship and then been sent to Vietnam.

The National Health Service Corps was established while Kriebel was in medical school and provided an additional deferment from military service. "I was on the fence about the war and didn't really believe in it," he says. So he signed up for the corps; the Vietnam War ended virtually the day Kriebel graduated from medical school.

Kriebel had signed a contract and intended to honor it. He did his residency at the University of Washington, which has a program designed to expose medical students to rural health care. "We (he and his wife, Lela) loved the Northwest and decided to find a National Health Service Corps site not too far from Seattle." They had passed through Forks while on a hiking trip; there had been a sign that said, "Doctor wanted."

Says Kriebel, "I chose Forks nine months before the end of my residency and took extra trauma and orthopedics to prepare. Even then it was obvious that urban practice was much more limited. Today, urban practice is much more a matter of triage and referral. I didn't see it as much of a challenge and, for that reason, less interesting. I felt very confident going into Forks and looked forward to the challenge. It certainly turned out to be that and more."

Today, there are five doctors in Forks, though one doctor's family has grown disaffected with living there and is leaving. In 1975, when Kriebel was sent to Forks, he was the only physician in town. As he quickly discovered, being in a medical frontier alone meant being the only thing that separated acutely ill patients from life and death.

Kriebel replaced a doctor who had been in town since the 1950s. A curmudgeonly giant, Edwin Liebold would deliver a baby and accept a chocolate cake as his fee or tend to injured animals brought to his office.

Much of rural America is still blighted in terms of medical care. According to a study released last year by the National Rural Electric Cooperative Association, there are 1,613 rural areas that are under-served by primary care physicians, a 25 percent increase in the past four years. Also, 733 rural areas have inadequate dental care and 505 lack adequate mental health resources.

Under slightly different circumstances, Forks could still be such a community. "We know that we have very bright, capable young doctors," says Lew McGill, owner of Olympic Mountain Bikes and former superintendent of the local school district. "My perception is that the town feels pretty good about the medical care that's available."

Besides its five physicians, the town has one dentist, two nurse practitioners and a comprehensive mental health system supplemented with a weekly visit by a psychiatrist from Port Angeles. The hospital recently completed a $3 million addition.

A major reason the town has been able to build a decent medical infrastructure is because Kriebel was willing to stay once his National Health Service Corps obligation was over.

In the early 1980s - before the spotted owl entered the national lexicon and the forests had been over-harvested - Forks was a boom town. A young, able-bodied male could stand on a street corner and have a job paying $15 an hour in minutes, the stories go. In spite of that, the community's isolation made it difficult to recruit physicians.

The National Health Service Corps was established in 1970. In the early days of the program, physicians who signed up were guaranteed a minimum salary. Today, the program functions largely by allowing doctors to repay medical school loans in exchange for service in under-served communities.

Kriebel was not the first doctor that the National Health Service Corps sent to Forks. Members of the community asked the corps to remove the first physician they sent out.

"It was a disaster," says Dr. Roger Rosenblatt, who at that time oversaw filling corps positions in the Northwest and who now studies rural medicine at the UW. A nurse practitioner was put in place. "I went out there and practiced for two weeks," he says. That's when Kriebel entered the picture.

"We had no sense that we'd put in our two years and leave," Kriebel says. Rosenblatt placed him there and remembers, "Steve wanted to go to the most difficult, remote, challenging place. We thought he was out of his gourd."

It is paradoxical. Rural communities tend to be more conservative. Yet the doctors who serve such communities tend to be more liberal, Kriebel observes. Evidence of that conservatism is ample in Forks. The American Forest Products Action Committee occupies a storefront on the main street. There are bumper stickers in the windows that read, "Are you an environmentalist or do you work for a living?" as well as cutout heads of Bill Clinton and Al Gore pasted to bodies in different sexual poses.

When Kriebel arrived in Forks, he had long hair and a beard. His political views were quite liberal. "I was fresh out of training," he says. "I had no experience with small towns. I'm not sure I was particularly attractive to many people. The first day the office was open I saw 22 patients. The second day I saw 50. The town was in such dire need. I guess I was trying to catch up with demand that was pent-up all those years."

According to the National Center for Health Statistics, a higher percentage of rural residents are in poor health than their urban counterparts; they're more frequently injured at their jobs and live with a higher number of chronic conditions. There are also now more people in Forks who suffer from the chronic effects of poverty. There are the members of the Makah, Quileute and Hoh Native American tribes who long have been well represented among poverty statistics. The area has recently become home to 800 Hispanic migrant workers; there also are many families with relatives incarcerated at the two prisons. What this has meant for Kriebel is that he has to remain proficient in a breathtaking array of medical specialties. When he first came to Forks, he performed vasectomies, biopsies, tubal ligations and caesarean sections.

"It wasn't a big range of surgeries, but some essential ones," he says. Kriebel has also performed autopsies - a task most primary-care physicians never even consider. Today, he is responsible for the day-to-day care of schizophrenics in the community, some of whom he has had to treat during psychotic episodes.

"There's an intensity to rural medicine," says Rosenblatt.

"It's very exciting," says Dr. Richard Dickson, another Forks physician who grew up in nearby La Push. "We get to do so much more."

Two of Airlift Northwest's medical evacuation helicopters are based at Boeing Field in Seattle. They can be airborne within three to seven minutes of receiving a call. Under normal conditions - flying at 160 mph - they can make the trip to Forks in about 45 minutes, 55 minutes if the weather is bad. In spite of the speed, it still places the trauma centers at Seattle hospitals outside the golden hour so critical to the survival of the acutely injured.

When physicians in Forks confront an acute medical situation, they are put in the position of being virtually the only medical resource available to that patient. Kriebel has been in that lonely place.

In the spring of 1991, two teenage boys were shooting rifles at a nearby quarry. A powder shack drew their attention and they began firing at it. When it exploded, the force of the explosion decapitated one of the boys. The other was critically injured. It was up to Kriebel to sufficiently stabilize the boy's condition so that he could survive not only the wait for the helicopter but the trip to Seattle.

Keeping doctors in rural communities is a perennial problem, one that the National Health Service Corps has been unable to address. According to a study published in the Journal of the American Medical Association in 1992, only 12 percent of corps physicians were in the rural practice they had been sent to after eight years of employment.

"The JAMA study was deeply flawed," says Rosenblatt, though he concedes there are problems with the program as it now functions. "It's hard to predict what a kid in his first year of medical school is going to be like eight years later," he says. "This is the problem of indenturing people when they can't make informed consent."

If students fail to fulfill their obligations, they are required to repay the scholarship at three times the original amount owed.

"They're not selecting the right people for the job," says Kriebel. "The corps sites are the most difficult to fill. When the crunch comes they realize it's not what they want." He favors loan repayment rather than government giving the money on a quid pro quo basis. The physicians in Forks can all make more money in larger communities.

Spouses and children are also significant reasons why rural settings are unappealing to many doctors. The sole movie theater in Forks is boarded up. Then there is the question of meaningful jobs for spouses. Lela Kriebel has had to work hard to create a niche for herself in the community. She has a background in theater and has directed many of the drama productions at the high school and served on the school board. She drove her children the 60 miles to Port Angeles once a week so they could take flute and clarinet lessons.

Lela Kriebel also knows about the time consumed in urban living. "You just do the mental arithmetic of what life would be like hour-to-hour, the time you'd spend in the car commuting," she says.

Kriebel's children have not hated growing up in Forks but recognize its drawbacks. Meredith Kriebel soon will begin her senior year at Oberlin College in Ohio. She does not plan to return to Forks after she graduates. "I didn't think it was so bad," she says. "It wasn't like there was a lot to do but we were really close as a family." It was only recently that Forks got cable television. Before that, most television reception was impossible. "We missed out on popular culture," she says.

Her brother, Westin Kriebel, will probably leave high school a year early and go to college. "There's nothing here for him," concedes his father.

Why has Forks been a rural health success story? "Any rural community requires a special kind of doctor," says Sophie Korczyk, the Alexandria, Va., economist who studied rural health care for NRECA. "They are independent thinkers. They're able to handle a variety of circumstances."

Improving the medical conditions in a rural community is often due to the efforts of one individual. "One person starts it," says Rosenblatt.

The psychiatrist who makes the weekly visit to Forks, Dr. Dave Johnston, was himself a National Health Service Corps doctor. "The only reason I could get to come to Port Angeles was because of Steve Kriebel," says Johnston.

It was Kriebel who got a Rural Health Initiative Grant to set up a mental health and substance abuse program in Forks and who provided sufficient rationale for placing Johnston in nearby Port Angeles.

"The ones who succeed have fiber, grit and determination," says Rosenblatt. He feels his friend Steve Kriebel possesses all those traits.

Kriebel is a tireless advocate for rural health care. He's been involved with the Washington Academy of Family Physicians, the Washington Rural Health Association and the Washington State Medical Association. He serves on the executive committee of the University of Washington School of Medicine admissions committee. All these activities have helped keep him from getting bored with small-town life and practice.

One thing that rural practice provides that urban medicine often does not is the ability to see the results of your efforts. You see people that you've saved every day. People's lives are better for your presence.

Steve Kriebel often sees that young man who almost died in the powder shack explosion.

"It's a series of trade-offs. You give up a lot but you get a lot. You have to be able to put value on the things you gain."

Peter C. MacPherson is a writer specializing in health-care issues. He lives in Arlington, Va.