Dr. Meagan Carpenter sees an average of 40 patients a day, although that number can reach into the 60s on days when she does rounds at the nursing home.
Breaks from her practice in rural Washington County are rare, though she does stop by a restaurant, Jake’s, during its lunch service. One woman wants her help planning her upcoming 90th birthday party. The waitress tells her she works too hard so she brings her a second piece of cake after she finishes her first. The sheriff, who’s eating at a nearby table, asks her about her recent Disney cruise – the first vacation she’s had in a long time.
“These are not just my patients. We go to church together, the ballpark together and eat at restaurants together,” she said.
Like many rural physicians, Carpenter has a large caseload of Alabamians who often find health care hard to access. Twenty-three counties in Alabama don’t have any local pediatricians. The state’s medical association has estimated that Alabama is short about 3,000 doctors.
An internal medicine specialist and pediatrician at Chatom Primary Care and chief of staff at the Washington County Hospital, Carpenter splits her 23,000 active patient charts with one other doctor and three nurse practitioners.
She gets to work around 6 a.m. and sees about 20 patients before her lunch break at noon. There’s no telling when her day will end. Sometimes she sleeps overnight at the hospital when she has critical cases.
“Rural places push you toward your full potential because of all the challenges,” said Carpenter. “It’s just you, or you and your partner, and that’s all you have to rely on.”
Many of Carpenter’s patients come to her from Clarke, Choctaw and Wilcox counties, where there are no pediatricians, or from Mobile County, where there are several doctors but it can be hard to secure an appointment. She even has patients who come to her from Mississippi.
She treats patients from across backgrounds, including people from the Mississippi Band of Choctaw Indian reservation – the only place in the United States where Marinesco–Sjögren syndrome is found. She treats about four people who have the rare genetic disease, which can lead to intellectual disability, muscle weakness and coordination problems.
The nearest mental health care specialist has a one year waitlist, so she provides those services to her patients as well if needed.
“You have to be all of the things people need,” she said.
Rural physician shortages
Gov. Kay Ivey signed a law this month to help address shortages of doctors in Alabama. The Physicians Workforce Bill will recruit out-of-state physicians to practice in the state, accelerate licenses for international doctors and create an apprenticeship program for medical school graduates.
“From the rural perspective the bill could bring more providers to rural areas,” said Farrell Turner, president of the Alabama Rural Health Association. “That could make health care providers more accessible to rural residents and reduce the time and cost many must now incur to travel to reach providers.”
The state also has a tax incentive program in place, which provides $5,000 in tax income credits to rural physicians. The program is intended to help recruit more doctors to Alabama communities that often can’t compete with larger urban areas.
According to the Department of Revenue, to qualify for the tax credit, doctors must work and reside in a community with less than 25,000 people and a hospital with an emergency room.
But there’s an issue with the law – if someone has an address in a community without a hospital, they don’t qualify, which leaves Carpenter and many other rural physicians out.
Carpenter lives in an unincorporated area of Washington County, called Tibbie.
The hospital where she works is less than 10 miles from her home, which sits on the border of Chatom and is zoned for Chatom public schools. Tibbie is too small to have a gas station, grocery store, or restaurant, so she shops and eats in Chatom.
Chatom, which has a population of just over 1,000 residents, is only about 10 square miles and real estate doesn’t often come available.
“It’s almost as if I’m being penalized for living in too rural of a ZIP code,” she wrote in a letter to the Alabama Tax Tribunal appealing their eligibility requirements. “Am I being punished for not finding a home suitable for my family within such a small geographic space?”
Carpenter previously received the incentive until a rule change in 2020. The new stipulations arose from a ruling in Phillip & Jennifer L. Dean v. State of Alabama Department of Revenue where a judge determined that where a doctor lives and works must both be communities of less than 25,000 people with a hospital.
Her partner, Dr. James Donald, was her professor in medical school and recruited her to join his practice four years ago. She knew she wanted not only to practice alongside her mentor, but also to practice in a rural town.
Carpenter moved to Washington County so she could be integrated in her community – something she thinks is important to being a good doctor. In 2022, she received the Early Career Pediatrician Award from the Alabama chapter of the American Academy of Pediatrics, which is given each year to a pediatrician that has gone above and beyond in their field of practice.
“I know who momma and daddy are, what they died from and what to look out for. I know their children and their extended families and what the ramifications of a bad outcome are. You’re responsible to all of them,” she said.
During COVID, the trust she had with her patients helped get her community vaccinated. Carpenter and Donald were the first to get vaccinated and invited the town to come and watch so they could see it was safe.
While she has no intention of leaving her community, she does worry that when the day comes, she won’t be able to recruit a replacement without incentives.
“Rural physicians are a dying breed. One day I’m going to retire and I want people that are qualified to take my place,” she said.
A 2020 report by the Alabama Office of Healthcare Workforce found that most of the state’s physicians are concentrated in more urban areas, and that while the ratio of doctors to population may suggest there are enough in the state, the distribution leaves many communities without adequate coverage.
All of the counties in Alabama without pediatricians are rural, with populations less than 30,000 people.
“Only a fraction of people who are graduating from pediatric residency go into private practice and very, very few of them go outside of major metropolitan centers because it can be extremely frightening,” Dr. Wes Stubblefied, pediatrician and district medical officer at the Alabama Department of Public Health, told AL.com last year.
“In small rural communities, work life balance is hard to maintain when you’re the only doctor. With the younger generation of physicians, they’re thinking about what their quality of life is going to be. What are my opportunities for outside interests? What if I have a family or I’m thinking about having a family? What does that look like? Are there stable school systems and opportunities for my kids? And you know it’s not wrong to think about these things in addition to all the other access issues.”
A bill to establish a new tax incentive law and redefine a rural community to include unincorporated areas of counties even if they don’t have hospitals, HB283, was introduced this year but failed to make it out of the House.
Carpenter is waiting to see if a judge will rule on her case.
“As the only internal medicine specialist and pediatrician who practices full-time in our county, my services are invaluable to one of the most medically underserved counties in the state,” she said. “I am, without a doubt, the reason this tax credit exists. This needs to be rectified not only for me but for future generations of true country doctors out there who have been punished by wording.”
