By CHRIS BROCK

TIMES STAFF WRITER

LISBON — When family nurse practitioner Nancy A. Merkley tells new patients looking for her office that she's "in the middle of nowhere," many think she's kidding.

During a late-April visit, dirt kicked up by a plow in a nearby field drifted over cars in the parking lot. It slightly clouded a sign pointing down a dead-end road advertising eggs and worms for sale. It's not exactly nowhere, but the clinic off Route 68 is a place where dedicated patients can procure convenient, quality health care.

Mrs. Merkley has been practicing in the converted garage, which stands out with its blue metal roof, for nearly 10 years.

"When I first took my husband down here, he was going to have me committed," she said with a laugh.

But Mrs. Merkley is used to raising eyebrows. She did so when, as a registered nurse with 15 years of experience, she decided to attend the nurse practitioner program at Community General Hospital in Syracuse. She juggled commuting, a grueling course load and raising a family, and completed the 10-month nurse practitioner program in 1993.

She went to work for United Helpers, Ogdensburg, working with the mentally retarded, and later worked at the Veterans Affairs clinic at Massena Memorial Hospital. In 1995, she accepted a position with Claxton-Hepburn Medical Center of Ogdensburg, working out of its Heuvelton clinic.

The Lisbon native said she was the first nurse practitioner many patients encountered.

"We were a well-kept secret," she said. "We aren't anymore."

A collaborating physician of the Heuvelton clinic suggested to Mrs. Merkley that she should have her own office. She worked through the New York State Small Business Development Center's office in Canton to find a site, find funding and market the rural health care clinic.

The practice, Upstate Family Health Care, opened in 1999. Besides Mrs. Merkley, it included another nurse practitioner and a partnering physician. It was the second in the state with a nurse practitioner-physician partnership, SBDC reported.

In 1999, the New York State Small Business Development Center named Mrs. Merkley Rural Entrepreneur of the Year.

Mrs. Merkley said before she opened her business, patients came across nurse practitioners mainly at hospital-run clinics.

"People have told me I've brought nurse practitioners to the forefront," she said.

That forefront became even more clear by the end of 2000, when Mrs. Merkley was on her own as the clinic's physician and registered nurse decided to explore different opportunities. She averages about 65 patients a week.

She said the patients travel from such areas as Gouverneur, Russell, Madrid, Potsdam and Canton. She said she is seeing more cases of diabetes, hypertension, depression and obesity in children.

"One good thing is I've had more and more patients quit smoking," she said.

She realizes she can't help the sickest of patients.

"There are times when I tell a patient, 'You've got to go to a physician now,'" she said. "Some of them fight it."

THREE ON STAFF

Joining Mrs. Merkley at the clinic is medical assistant Shirley Sibbitts, who was trained as a nurse in her native New Zealand. She started at Upstate Family Health as a volunteer nearly three years ago.

"As far as offices go, it's one in a million," Mrs. Sibbitts said. "The patients become your friends."

Mrs. Merkley's sister, Suzanne O'Brian, handles such tasks as billing and receptionist duties. The jovial atmosphere of the office is evident as Ms. O'Brian tells a visitor, "She can't fire me because then I'd have to move in with her."

But the independent clinic has serious issues to deal with, not including the health of its patients.

In the past five years, Mrs. Merkley has seen a dramatic increase in insurance paperwork. Stacks of it are piled in a back room, down the hall from the two exam rooms, and in the basement of her home. She said that family practice offers the worst insurance reimbursement.

Mrs. Merkley said matter-of-factly that last year, she wrote off $40,000 in patient fees.

"For some reason, some people don't want to pay for something that's not tangible," she said. "They'll pay $20,000 for a new car, but not $20 for a co-pay."

She has replaced collaborating physicians (such a physician is required for a nurse practitioner) five times. Now it's Dr. Adam D. Jarrett of Ogdensburg who is also chief medical officer at Claxton-Hepburn Medical Center

"You're dead in the water without a collaborative physician," she said. "Everything stops."

She would like to see the nurse practitioner profession cleared of that requirement.

"We're trying to get a bill passed to do away with the collaborative agent," Mrs. Merkley said of a committee she's on with the New York State Nurse Practitioners Association."For the most part, a lot of us have a lot of common sense. I wouldn't practice any different than I do now."

She said that the collaborative relationship doesn't make sense at times.

"I have my own malpractice insurance, which doesn't cover doctors, and he has his own insurance, which doesn't cover me," she said.

She would also like to see more insurance companies offer coverage for nurse practitioner visits. She said she would recommend to anybody opening a similar clinic that the site should be rented, and not owned like she owns her building, to cut down on overhead. For example, her blue roof needs replacing and she plans to keep the same color with the new one.

"A lot of people are afraid to go into practice because of the red tape involved," she said.

She said there's still work to be done for nurse practitioners to be more widely accepted. "If there was some type of subsidy for hospitals to put more nurse practitioners in their clinics, the area could be served better," she said.

'PRIVATE ANGELS'

Mrs. Merkley was faced with another, personal struggle. In April 2004, she was diagnosed with bowel cancer, which spread to her liver. She was overwhelmed by community support.

"I didn't want to make a big hoopla about it," she said.

But a benefit jamboree in Morley attracted 500 people. Patients brought food to her home. A box at home holds the more than 400 get-well and prayer cards she received and treasures.

She mentioned two nurse practitioners, Martha Cole of Lisbon and Donna Doyle of Ogdensburg, who volunteered their time to keep Upstate Family Health Care running.

"They got together and helped me out," Mrs. Merkley said. "I tell people I have my own private angels."

Eleven months after her diagnosis, Mrs. Merkley, 54, was back on the job, although nowadays she works about 30 hours a week.

"I get tired," she said. "I've had enough chemo to kill a horse. That's why I'm not working 40 to 50 hours a week."

She said she's often asked if she would pursue the same career track again. "I don't know if I would with the insurance environment," she said. "I'd have to think long and hard."

But those words are tempered by the realization of the "bottom-line" purpose of her office.

"The bottom line is that it doesn't come easy," she said as she prepared to move from her office to the clinic's main office to help with paperwork during a Friday afternoon, a day when patient load is limited. The office is closed Wednesdays.

"There will be lots of struggles, but there will be satisfaction," she said. "When you help somebody out, there's that wonderful feeling."