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In the shrub steppe of Grand Coulee on the banks of the Columbia River, Wash., the town’s two family doctors practice at an unrelenting pace, working on call every other night and every other weekend.

In the coastal town of Port Angeles, the doctor shortage is so acute that a clinic is turning away 250 callers a week seeking a physician.

George and Lynne Rudesill are two of those people. Since learning earlier this summer that their primary-care doctor in Sequim was retiring, the couple have scrambled to find a replacement. Their calls are being met with waiting lists hundreds of people long or advice to call again in a month.

“I’m going to have to drive all the way to Silverdale or Bremerton to see a doctor,” George Rudesill said, citing cities that are about 70 or more miles away from home. “This area is in a medical crisis right now.”

Rural areas have long been strapped for doctors, but now the Affordable Care Act (ACA) is further straining those limited resources. More people with insurance means more people will want to connect with a doctor — just as aging baby boomers require more care and the doctors are retiring.

But the 2010 health-care overhaul also includes measures to begin correcting policies that for decades have churned out a disproportionate number of specialists and urban doctors over rural family physicians. The ACA has funding this year for 550 residents in underserved rural and urban areas nationwide. In Washington alone, 28 primary-care doctors each year are completing their training in these communities thanks to ACA dollars, ready to practice where they’re needed most.

“It may be a real answer to many of the issues of getting primary-care physicians into underserved communities,” said Dr. Rob Epstein, of Family Medicine of Port Angeles, in an email.

Yet just as ACA initiatives are showing results, key incentives and investments to boost family medicine are scheduled to end this year and next. But there’s a chance the programs could survive. Shortly before Congress’ August recess, Sen. Patty Murray introduced legislation to save them.

Health-care providers and national organizations support Murray’s effort to expand and make permanent the residencies in underserved areas.

“Renewing it would make a big difference as to what’s possible for Washington,” said Dr. Nancy Stevens, director of the Family Medicine Residency Network at the University of Washington. “It’s much harder to get people to go into the rural places where we need them. You really need to create residency training spots that are in those areas.”

Rural docs are a rare breed. They treat everyone from wailing newborns to fading elders, setting bones, performing C-sections and shocking hearts into rhythm. They’re exalted, but sometimes exhausted, and it’s a path few doctors these days are willing to take.

For 16 years, Dr. Andy Castrodale has practiced rural medicine in Grand Coulee, a town of 1,000. He grew up on the nearby Colville Reservation, attended the UW School of Medicine and did a residency and fellowship in Spokane. Castrodale savors the idiosyncrasies and rewards of his career choice.

“I watch my own kids playing soccer or baseball and you realize you’ve delivered half the team,” he said. “I can look at people in town and know that I’m the reason that they’re alive. That’s humbling.”

Few doctors are ready to follow Castrodale. Only 3 percent of matriculated medical-school students say they plan to practice medicine in a small town or rural area, according to a recent survey by the Association of American Medical Colleges.

Why The Shortage

A double whammy has hit rural areas.

First, the shortage of primary-care doctors extends nationwide. About 34 percent of U.S. doctors practice primary and family care, while the rest are specialists. Research shows a ratio closer to 50-50 would provide better care and improve health overall.

Second, there are numerous hurdles to recruiting physicians to rural areas.

The work can be intimidating, with long hours and frequently being on call. It can be difficult for a physician’s spouse to find work in a place with limited economic opportunities. Finding a work-life balance is a struggle.

“Rural medicine can be pretty fun, but it can be quite demanding and this generation is less inclined to work quite as hard as previous generations,” said Dr. John McCarthy, assistant dean for regional affairs at the UW School of Medicine. “They don’t give up their life as readily.”

While Seattle and its suburbs have more than 11 primary-care physicians per 10,000 residents and so far are keeping pace with growing demand, in the northern swath of the Olympic Peninsula that number shrinks to fewer than eight, according to 2011 data. An area covering Grand Coulee’s Grant County as well as Chelan, Okanogan and Douglas counties has just over six — more than 1,500 potential patients per doctor.

One of the biggest challenges to boosting the rural physician workforce is the funding of residencies. Once a doctor finishes school, a supervised, three-year residency to hone his or her skills is typically required. Research shows that where a doctor does this training is a strong predictor as to where he or she will practice.

But historically, federal dollars for residencies mostly have been spent on teaching hospitals often located in cities. The newly minted doctors are working with sophisticated technology, surrounded by specialists. The notion of shifting from that environment to a rural clinic or hospital requiring much more self-reliance is daunting.

The result? More urban specialists, fewer rural family doctors.

“Do We Have To Move?”

The Rudesills were delighted when they moved to their airy, country home on the Olympic Peninsula nine years ago. There was plenty of open space for the English Springer Spaniels they raised as show dogs.

The couple, both 64, did find health care for problems including George’s heart disease and occasional outbreaks of a skin condition called rosacea, plus Lynne’s arthritis in one knee and high cholesterol.

That changed recently when their family doctor announced his retirement and as wait times to see the dermatologist began lengthening. The Rudesills are getting anxious.

“Do we have to move so we can find a doctor?” Lynne Rudesill asked.

Urgent-care clinics and the hospital ER are available and, in the absence of more primary-care doctors, that’s where many people are likely winding up. Another option is driving hours to an urban provider.

Family Medicine of Port Angeles is one of the primary-care practices the Rudesills tried, but staff there are telling 250 people a week to call back in case a space opens up.

Karen Paulsen is the clinic administrator and answers many of the upset callers.

“I feel a lot of compassion for their situation,” she said. “They’re ill, they need care.”

The practice is trying to squeeze in everyone it can. Their doctors have appointments booked every 15 minutes and work in teams with advanced registered nurse practitioners (ARNPs) and physician assistants (PAs) to share the workload.

Incorporating ARNPs and PAs into a practice is an increasingly common strategy in rural areas and elsewhere.

At Family Medicine, even the workspace is designed with collaboration in mind. The teams of providers sit in clusters of desks in a high-ceilinged open space, an arrangement where questions and discussions can flow freely and everyone is easy to find.

The group built the facility in 2009 to optimize efficiency. It’s clean, modern and inviting, but the clinic has had little success of late recruiting new doctors. Their staff situation worsened in recent months after they lost four MDs when two moved, one retired and another died.

Their dream is to create a new medical residency at the clinic — to train a doctor who might then decide to stay.

Renewed Focus On Rural

Before the Affordable Care Act, there were university, state and federal programs to encourage the production of more primary-care and rural doctors. But with the law’s new residency program comes a sharper focus on this mission.

The ACA’s Teaching Health Center program is funding 550 residents nationally, including training sites for doctors or dentists in Puyallup, Ellensburg, Yakima, Toppenish, Auburn, Spokane and Tacoma and the surrounding area. Rather than funding large teaching hospitals, the money targets smaller facilities serving rural, lower-income or minority residents including tribal members.

“It is helping to train physicians in rural or underserved communities,” Murray said, “and they’re staying there.”

Murray’s bill would extend the residency program until 2019 at a cost of $420 million. It otherwise ends next year. Additionally, Murray wants to use $75 million to fund the development of new training programs, bringing more attention to underserved sites.

The legislation — called the Community-Based Medical Education Act of 2014 — would ultimately grow the number of residency slots to 2,050 and make them permanent. By slightly cutting Medicare reimbursements at teaching hospitals, the savings would pay for the residents beginning in 2019.

The goal of these efforts is to produce more doctors like Christina Marchion.

Marchion, who grew up in Anaconda, Mont., graduated from the UW medical school, did her residency in Idaho and just finished an OB fellowship in Spokane. While a student, she spent time at a Lewistown, Mont., clinic, working alongside a rural doctor with whom she formed a connection.

This month, she’ll return to the 6,000-population Lewistown to practice alongside her mentor.

“My love of the idea of true, full-scope family medicine is greater than the insanity that it takes,” Marchion said.

She’s eager to practice in a rural setting where she can deliver babies — a perk most urban family doctors don’t enjoy. Plus, part of Marchion’s $300,000 student debt will be repaid through a loan-repayment program Montana uses to recruit providers.

Marchion can imagine staying in Lewistown for decades, but knows that another doctor recently tried to make it work and lasted only six months. All the same, she’s ready to give it a try.

“If I really believe in this,” Marchion said, “in underserved and rural medicine, this is my best shot.”