Roughly 65% of rural counties face a shortage of primary care physicians, according to a Centers for Disease Control and Prevention (CDC) report. In some states, like Montana, the crisis is particularly acute. Research shows that a rural background is one of the strongest predictors of becoming a rural physician, yet the number of medical students from those communities has declined steadily over the past fifteen years. Today, fewer than 5% of U.S. medical students come from rural areas, contributing to a widening gap in access to basic health services.
But Billings Clinic has a different story to tell.
Since launching its internal medicine residency program in 2014, Billings Clinic has graduated 75 physicians, with half now practicing in rural communities. The program’s outcomes stand out amid national trends, where only 11% of physicians work in rural areas.
“I've never seen as much interest as I have over the past year in our residents remaining in the area,” said Dr. Steven Gerstner, program director of the Internal Medicine Residency Program at Billings Clinic. “The residency program has maintained the internal medicine department at Billings Clinic. Without the residency and the faculty we have attracted, we would be in very dire straits.”
That success sparked more growth. In 2023, Billings Clinic launched Montana’s first-ever psychiatry residency, welcoming its first cohort in 2024.
In the last 30 years, Montana has ranked in the top five states for suicide rates across all age groups. Youth alcohol use in the state significantly outpaced the national average, alcohol-related deaths have nearly doubled in the state in the past decade, and over half of Montanans live in communities that do not have adequate access to mental health providers.
“We have patients from eight hours away or six hours away who have to come [to Billings Clinic] because there are no other services for inpatient acute care in their communities,” said Dr. Mariela Herrera Rojas, the program director of the Billings Clinic Psychiatry Residency.
“There is a very high need to address mental health issues, but we are very under-resourced and there are a lot of shortages," Dr. Herrera Rojas said. “That's what we want to address through the residency program. What is it that we can do to address these shortages of addiction psychiatrists, child psychiatrists, and other providers?”
The psychiatry program was funded, in part, by The Leona M. and Harry B. Helmsley Charitable Trust, a global philanthropic organization, which has given over $23 million to the Billings Clinic, including funding the development of its residency programs.
“In Montana, the need for psychiatrists is huge,” said Walter Panzirer, a trustee for the Helmsley Trust. “One of the worst disparities across the United States is in Montana, and you look at all the behavioral health problems. It just seemed like a natural fit to further expand Billings Clinic’s residency program into psychiatrics.”
A Rural Health Success Story
Billings Clinic serves a large region that includes eastern Montana, the western edges of North Dakota and South Dakota, and northern Wyoming. Residents see patients from across rural communities both at Billings Clinic and in rural rotations they complete across Montana.
Every resident completes at least two rural rotations in communities such as Lewistown, Livingston, or Hardin, a structure designed to both expose them to rural practice and encourage them to stay in the region long term.
Ashley Dennis, Ph.D., director of Billings Clinic’s Office of Medical Education, said that this immersive experience prepares residents for the realities of rural practice.
“The more opportunities that residents have to get out into rural communities, the better for, ultimately, them practicing in those spaces,” Dennis said.
That firsthand exposure to rural medicine teaches residents to think differently about everyday procedures and logistics.
"We did a study recently talking to rural providers who had just transitioned into rural practice about their experiences. Through that, we heard lots of stories, and it's simple things, like realizing, ‘Hey, before I do this procedure, I need to call the blood bank and cross-check that they have enough blood,’” Dennis said. “That’s something you may not consider at all if you're in a place where there are ample resources and opportunities. So, having that contextual awareness changes how you practice as a physician."
Dr. Mette Strand graduated from the Billings Clinic residency program and now practices in Livingston, Montana, where there are only two internal medicine primary care providers. She said both the rural training rotations and the program’s teaching philosophy played a key role in preparing her for rural practice.
“I think it was very valuable for the Billings [Clinic] residency to emphasize rural health during our training,” Dr. Strand said. “They would always give us scenarios, asking what if you didn't have that consult service available? Or, what if you are on your own? They were always prompting us to think about how it would be to practice in a rural setting without the resources that we had.”
As a rural internist, Dr. Strand can care locally for patients that might otherwise have to travel far distances to see specialists. She now manages diabetes for patients who previously had to see endocrinologists, treats advanced chronic obstructive pulmonary disease (COPD) cases typically referred to pulmonologists, and cares for patients with liver disease once handled by gastroenterology. In some cases, she can manage these conditions locally right up to the point of transplant referral.
“The trip from Livingston to Bozeman or Billings can be hazardous, especially in the wintertime. And many of our elderly patients do not take that trip all winter. We also have patients struggling to afford gas or have help to go back and forth to those places,” Dr. Strand said. “By being able to offer internal medicine here in Livingston we are able to ensure better follow-up and treatment for these patients.”
Dr. Elizabeth Schiedermayer also graduated from the Billings Clinic internal medicine residency program and now practices in Anaconda, Montana.
Dr. Schiedermayer said that while she came into residency already committed to practicing outpatient care in a rural setting, the Billings Clinic residency program offered her the opportunity to anchor her career in rural primary care.
“They actually give you a primary care clinic. The rural rotation was really excellent, and they made space in our busy schedule to do that and value that,” Dr. Schiedermayer said.
“I really like blue collar, rural people, and I like taking care of them,” Dr. Schiedermayer said. “It's a privilege to take care of my neighbors.”
In a sea of stories about geographic disparities in medicine, Billings Clinic is forging a path to train and retain rural providers. Already, three of the upcoming Billings Clinic graduates have signed on to stay with Billings Clinic.
“Our hope in building residency programs is to keep people in the community,” Dennis said.
For Dr. Strand, that mission is coming full circle as she prepares to train future rural doctors.
“I have my first resident coming after the new year,” Dr. Strand said. “I’m really excited about that opportunity.”
This story first appeared in the Daily Yonder. Read the original here.
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