The Rural Internship in Private Practice (RIPP) program began in 2007 with a goal of introducing dental students to the many benefits of a rural practice — a quieter, more simple life, better schools, less violent crime and access to land, space and nature, and the chance to work with generations of families. To some, the simple life had lost its allure. Across the country, rural areas had a more difficult time attracting dentists away from dense metropolitan zones, and it was hoped that the RIPP program would play a role in reversing the trend in Washington State — or at least serve to showcase the charm a small town has.
The program takes first year students and places them with dentists in rural communities across the state. Typically, the students observe the first week and assist whenever possible the second week. For the mentors, it’s a chance to reconnect with a fresh-faced enthusiasm and curiosity about dentistry, and it’s a chance to really show off the fantastic benefits of a rural practice. For the students it’s a chance to see how a practice is run, glean knowledge from interaction with the dentist and the staff, and take in the refreshing quiet the city can’t offer.
This year, Dr. Jason Keefe of Kettle Falls, Wash. hosted Lindsay Booth, while Dr. Denny Homer welcomed Stona Jackson in Okanagan, Wash. It’s a little voyeuristic, this program, a chance to peer into the life of another, but what an opportunity. Students — even first year students — already have an inkling of what to expect in the practice setting, but this is a more holistic, immersive approach. The dentists participating in the program gain, too — as Dr. Keefe says, “The good thing about the program is taking an old guy like me and putting him in touch with a young person who is really excited about dentistry. Additionally, my son is off to college next week in a pre-dental program, and it was great for him to be able to meet Lindsay so that he could pick her brain about dental school.”
He continues, “Lindsay has a natural curiosity about technology, and we happen to have a very modern office with lots of very high-tech stuff, like 3D imaging and an E4D machine to make crowns in the office.” What she lacked in familiarity about the tech she more than made up for in interest, and Keefe soon found Lindsay investigating in her spare time.
Exploring his options
Stona Jackson explained that taking his wife and toddler son to Okanagan was as much about exploring options as anything else, saying, “I think it’s important to see all sides of dentistry before you choose where you’re going to go with it. While I know I want to be a dentist, I don’t know if I want to specialize or open my own practice. With the RIPP program, I got to test the waters and see what a rural practice was like without having to change my life too much.”
Prior to enrolling in dental school Jackson was synthetic organic chemist, making small molecules from scratch for the UW’s antibiotic discovery lab. The work wasn’t wholly satisfying though, and he began to look around for something else to do. It was his wife, Safia, who recommended he look into dentistry, sensing he’d enjoy it. From that day forward, Jackson says he began to seriously consider the field, doing a lot of shadowing and studying for exams and creating the opportunity to become a dentist.
Regardless of where he decides to start a practice, Jackson has plenty of time to decide — once he finishes dental school, he’s committed to the Army for four years of active duty. “I couldn’t swing going to dental school even at the UW, which is extremely affordable. I’m married with a child, my wife is in the PhD program at the U, so it just wasn’t possible.” By joining the military, Jackson was able to pay for his education and his training, saying, “The dentists I’ve spoken with have indicated that it took them three or four years after graduating to feel really capable, and I wanted to be sure that I got really good training afterwards, that I didn’t end up spending my time looking for a job and trying to make ends meet.”
So, would he do it? Is rural dentistry really an option for Stona Jackson? Hard to say. First off, he has seven years before he has to decide, and it’s impossible to guess where his military career, short as it is, will take him. Secondly, like so many dentists with families, there are often other careers to consider, namely his spouse’s. But, he found that there was much to like about the quieter setting, and won’t rule out a rural practice once he gets out of the Army.
So what did he take from his two weeks in tiny Okanagan? For starters, he was impressed with Dr. Homer’s broad practice, which includes endo and oral surgery, and with the up-to-date office and equipment. More than that though, is the quality of work he witnessed in his time with Dr. Homer, saying “I was really impressed. He was a great teacher, and told me things I might not have learned in ten years on my own. But one of the things that most impressed me was that he explained that many of his patients drive more than an hour to him, passing other dental offices on their way — which really told a story about the quality of work he does.” Homer responds, saying, “One of the things I have tried to do is offer my patients all the services they can get in the city, so they don’t feel they have to travel to have their dental needs met. Because of that I’ve been able to attract from a broader area because people do tend to get dialed into the services you’re offering.”
While the beauty of the area was undeniable, Jackson noted that, “The middle of winter in a tiny town might present itself very differently. We saw the best part of Okanagan — the summer months in a guest house in a cherry orchard — and it was incredibly beautiful.” He was grateful that he was able to bring his family along for the experience, noting that if more people knew it was an option, they might be interested if applying for the program.
A return to the country
For student Lindsay Booth, investigating a rural practice was a return to a familiar environment. Booth is from Bozeman, Mont., and while it’s nowhere near as diminutive as Kettle Falls, Wash., neither is it frenetic like Seattle. She found life there to be “more low key, simpler. You get to see patients immediately, and there aren’t a lot of distractions. And, you get to see the whole procedure, from start to finish.” Like Drs. Keefe and Homer, Booth liked that rural dentists have to have a broad range of knowledge in order to be competitive. As Dr. Homer put it, “There’s no way a specialist like a prosthodontist could ever have a career in a small town, there just wouldn’t be enough business.”
Booth found more than enough positive aspects to the experience to keep rural dentistry in the running for her post-graduation options, but also was clear about the shortcomings, saying “You have to be the type to make your own adventures, because you’re never going to be able to go to a Broadway show in town.” But, she notes, “On the other hand, there will be wonderful, intimate programs that you’d never find in the city.” And, as a serious naturalist, being close to mountains and the lake has an enduring appeal greater than the siren call of the big city. One of the biggest revelations for her was how much she really liked rural Washington “This opportunity really opened my eyes to considering the state once I graduate.”
Booth is a realist though, and understands that a big part of dentistry is treating the people who need your help, so where she ends up will likely have more to do with that than hiking trails vs. skyscrapers. To that end, she plans on researching underserved communities, then comparing the data to see if it is an area that could sustain a new private practice. Her other option would include looking in small communities for dentists looking to expand their practice or retire.
Like Jackson, she’s not really sure where she’ll land when she finishes dental school, but wanted the opportunity to satisfy her curiosity about the daily routine of a rural practice. Because her dad was a dentist, Lindsay was familiar with assisting, and as such was able to jump right in and help at Dr. Keefe’s practice —unlike Jackson, who explained that he was more of a hindrance than help in the first week. But, as Dr. Homer remarked “The RIPP program isn’t really about the students helping out in the office, if that were the focus we’d get second or third year students. This is really about a short immersion in rural life.”
Making Kettle Falls home
Some 20 years ago, when Dr. Jason Keefe and his wife were looking for a place to settle and start a family and a practice, simple economics played a role in him settling in Kettle Falls, Wash, population: 1,500. “We were from the city, but I couldn’t afford to buy a practice there, and I knew that I wanted to have time to not only raise my family, but to play and active role in it as well.” Keefe, an avid outdoorsman regularly takes advantage of the pristine natural setting of high mountains, dense forested land, and close proximity to Lake Roosevelt, saying “I think the woods are absolutely beautiful, I truly like everything about the rural setting. Here, we chase elk, deer and moose down with our cameras, go hiking and take advantage of what nature has to offer. We snowmobile, water ski, swim and boat, and downhill skiing is close by.”
Keefe’s is the only practice in town, and the closest town, Colville, has another five or six dentists. He says, “Being rural, there is an expectation that you have to do everything, as opposed to the city where you might parse out work to specialists. In a small town, you ARE the specialist. You have to know endo and extractions and ortho — otherwise patients would have to travel to another city — and the nearest city is Spokane, 90 minutes away”.
Life in Okanagan
This is the second time that Denny Homer hosted a RIPP participant. A powerful, personal testament to what a rural dentist can achieve, Homer served as WSDA President after being on the board and working tirelessly at the component level for many years.
Homer says the first thing he tries to do is “… fill their brains. I figure out what I can tell them that will really give them a leg up in the business.”
Homer grew up in southern Oregon in a town of about 17,000, and when he graduated from dental school there was a glut of dentists in cities. Thinking that small town practice might give him a jump start, he focused his efforts there. It proved fruitful — but not without serious effort. “You know, in dental school, there wasn’t a single area of study that I didn’t like, and so for me, the biggest bonus is that I get to do so many things.” He continues, saying “I’ve simply just sought out the additional training I needed along the way, whether it was endo, surgical or whatever. There may be a long learning curve to put all of the different disciplines together, but it has been immensely rewarding. Every day is so different that I can honestly say that in 35 years of practice I’ve never been bored. Now that graduating dentists are in a decline, I think there are going to be great opportunities in rural areas.”
The interesting effect Homer has witnessed due directly to his broad scope of practice has been in the standard of care for his patients — “when I first started, “ he explains, “I would have to refer my root canal patients to an endodontist in Spokane, 150 miles away.” Because of the distance, many would opt to have Dr. Homer pull the tooth. Now, because of his training, Homer can address the issue and save the tooth.
Homer likes that in a small town you know people — and they really know you— and eschews the anonymity that city life offers. “Of course, there can be limitations and disadvantages to knowing everyone, but overall it’s great to become really involved with the folks in a small town – whether it’s through the church, or scouting, or the fire department — which are some of my areas of interest. You just don’t get that in a big city.”
Want to find out more about the RIPP Program? Contact Wendy Wilson at 206-448-1914.