A View from the Backroads

    Rural Dentists Share Lessons From Remote Practices

    By Vanessa Salvia

    Four dentists who have built practices in far-flung areas of the Northwest share what they love about their work, how it’s different from maintaining an office in a big city, and what they’ve learned from small town life that can make anyone’s business more manageable and enjoyable.

    Dr. Tyrone Fernando Rodriguez, DDS, SmileSonrisaS Dental, Moses Lake, WA


    Dr. Tyrone Fernando Rodriguez began his pediatric dental practice 13 years ago in San Antonio, Texas. He worked in his home state for two years before a community health clinic in Yakima, Washington recruited him to be the area’s first board-certified pediatric dentist. He worked as a faculty member at the University of Washington for three years, training other dentists in pediatric care. He then joined a group office, where he stayed for two years before launching his own practice in Moses Lake.

    “Moses Lake is in the middle of the state,” says Rodriguez. “Its claim to fame is it’s the No. 1 potato-producing county in the nation. It’s pretty rural.”

    In San Antonio it felt as if there was a dentist on every corner, Rodriguez says. “That’s the challenge in big cities, especially cities with a well-known dental school. You’re surrounded by dentists. How do you differentiate yourself?”

    In the beginning, Rodriguez did it by partnering with folks who had more experience, which worked well. That’s not really an issue where he is now. But he has found other ways to make himself stand out from what little competition he has.

    “I wear a cowboy hat when I see my patients, so a lot of my patients think that there’s a cowboy who fixes their teeth,” he says with a laugh.

    After going into private practice, Rodriguez opened clinics in Selah, located 100 miles from Moses Lake, and Omak, a little farther than that. “But I was spread too thin,” he says. “My idea was to have the associate general dentists refer me the special cases, but that was challenging. Between the dentists that were already there and the community health clinic, they didn’t like to send their patients to another office.”

    As of last year, Rodriguez is down to just one location. “It did work out financially, but it was all that time on the road and the time away from family,” he says. “General anesthesia and sedation appointments start very early in the morning, so if I have to drive two hours to get there I’m leaving at 4 o’clock in the morning.”

    The patient groups he sees have life circumstances that make his job interesting. Many people who live in this agricultural area are afraid to seek health care due to fears about their immigration status. In addition, the Hispanic community has a belief that cavities can be flossed or brushed away. “When they do come in they’re in dire straits,” he says. “It’s more complex than just keeping people’s mouths healthy.”

    His practice also sees Ukrainians who are very wary of X-rays due to the Chernobyl incident. “Anything to do with radiation is frightening,” he says. “It takes them getting to know you, gaining their trust and educating them.”

    Rodriguez says he’s a better dentist now because he’s had to learn so many new skills. “You have to be a Renaissance dentist to go to a rural setting,” he says. “But health care in the rural setting is a beautiful thing. It helps so many people.”

    Dr. Jesse Cole, DDS, Scobey, Montana


    Dr. Jesse Cole describes himself as a small town guy. “I grew up in Alaska. Mom and dad were school teachers in the bush when I was a kid, so I was looking for a small town environment,” he says.

    Scobey certainly delivers that. It’s 15 miles south of the Canadian border and 80 miles west of North Dakota. The nearest town of any considerable size is Billings, which is 350 miles away. Most of Cole’s 4,000 patients are farmers, ranchers and oil workers.

    Cole’s first concern about moving to the town wasn’t whether he’d find enough patients. It was whether his wife and six children would be happy there. Turns out, they were.

    “The main challenge is attracting good help,” he says. “Professional assistants and associates are difficult to attract and keep.”

    The other challenge is that Cole must maintain and service his equipment himself. He has backups of equipment so that if one piece goes down, he can turn another one on. He worked as an engineer before graduating from the Arthur A. Dugoni School of Dentistry at University of the Pacific in 2006, and that background comes in handy when something does break.

    “I can take care of pretty much all the mechanical things, and I know enough about the computer and software things that we can either fix them ourselves or over the phone,” he says. “And it helps that we know our software people and our UPS person very well.”

    Dentists in most large cities have labs nearby to make things like crowns and dentures. But his practice does everything through the mail. He only works with labs he’s gotten to know and trust.

    Cole’s location makes him a one-stop shop, and there are advantages to that. “People want their dentist to be able to do whatever they need,” he says. “I do oral surgery like wisdom teeth removal, but a lot of dentists wouldn’t be comfortable doing that. In a remote area you’re going to have the opportunity to do a lot of different kinds of dentistry that you might not do in a city setting. Once people accept you and trust you then they just want you to help them and not send them to someone else a long way away.”

    Not long ago, Cole opened a satellite practice with a dentist named Franco Ferrara in Sidney, which is about 120 miles away. The plan was to find a third dentist. “We thought that would be just right, three dentists between two practices,” says Cole.

    Ferrara helped Cole catch up on his backlog of patients. But before long, they could tell two doctors were too many for the practice. Now Ferrara is buying Cole out. “I’m back to being a lone ranger,” he says.

    Dr. Jim Libby, DDS & Dr. Justin Libby, DDS, The Libby Group Family Dentistry, Anchorage and Dillingham, AK


    Father-son dental team Drs. Jim and Justin Libby maintain practices in both Anchorage and Dillingham, Alaska, which is 400 miles southwest of Anchorage in the heart of Bristol Bay. Jim first moved to Dillington, a town with 2,300 people, when he was four years old. He opened a dental practice in his spare bedroom the year he graduated from the Loma Linda University School of Dentistry. The following year he opened an Anchorage practice, intending to move there. But he soon found that the bedroom practice in Dillingham earned more in a week than his Anchorage practice made in a month. “It was hard to cut ties with it,” he says.

    That’s not to say maintaining a rural practice is easy. There are no roads in Dillingham. It’s a logistical challenge to move all the materials and equipment they need between Dillingham and Anchorage by ship or aircraft. Flying is a huge part of their daily lives.

    Finding qualified staff who will stick around in a remote area can be problematic. The rural practice had a long-time hygienist who also lived there. When she retired a year ago, they struggled to fill that void.

    Despite the trials of maintaining a business in a rural area, Justin has no qualms about his decision to keep his father’s original practice alive. “People do ask me why I do this,” he says. “And of course it has to be sustainable monetarily in order to keep going, but a lot of it is that I truly love that area and serving the people.”

    He’s also learned some valuable lessons that are applicable in any town or business. The first is that it’s vital to maintain a good reputation. “Word spreads quickly about the type of person you are, how you treat people and how much you care about those you are treating,” he says. “You have to care for people like they are family.

    “Practicing in a rural setting also requires being efficient,” he adds. “From the ordering of supplies to the treatment planning and execution, every team member must be efficient. Dad will oftentimes be mounting all of his own study models and creating wax rims for dentures, all while doing hygiene exams and treatment. Dental labs, suppliers and equipment specialists are all 400-plus miles away, and it’s up to the team to be efficient so that the patient receives great care and the practice is sustainable.”

    There’s one big benefit to practicing in Alaska. Commercial fishing and hunting are such a huge part of the culture that many businesses close up shop in summer and fall. Over his career, Jim has consistently taken six weeks off in June and July to fish. Justin and his brother Landon, a dentist in southern California, leave their practices for three weeks during fishing season. This opportunity makes all the other struggles infinitely worth it.