What You City Docs Miss

Being a Rural Physician Is Different-Gratifyingly So

 

In cities, more and more of us are getting used to getting medical care that treats us as a collection of parts. We see a podiatrist for our foot, an ENT for our ear, a cardiologist for our heart, a gastroenterologist for our gut. If we’re lucky enough to have a primary care doctor, we still expect to see him or her exclusively in the office. But in rural areas, you’ll probably see a general practitioner, not a specialist, and you’ll meet your doctor at school plays, the supermarket, or on the sidewalk. And what’s it like for the doctors? What do they experience in the hinterlands that city-slicker doctors don’t? In advance of “Does Rural Healthcare Have a Future?“, a Zócalo event in Fresno, we asked several rural doctors to share their experiences.

Adjusting to the Mississippi twang

The drawl was unmistakable. It was long, rich, and seemed to have stories untold in it. More important, I had no idea what my patient had just said. It was my first week working in rural Mississippi as a family doctor, and all the warnings that my colleagues in Detroit had given me kept ringing in my ears. I could not seem to get a decent history from him. Was I doomed as a family doctor? Was it ridicule that I heard in his voice?

Time passed. I stuck around and built a practice that was as varied and challenging as any I had imagined. Slowly, I was integrated into the workings of the small town and countryside–the football games, the crawfish boils, the school plays, and graduation. That was the backdrop of all clinic encounters, the context for the pictures being described.

The work seemed to flow from clinic to hospital, from homes to school clinics. The key context was that of the “community.” I was like an essential monument in town–“Doc.” It seemed like I had come a long way from fearing “The Drawl.” And then, in the middle of shrimp season, I heard a voice through the back door of the clinic. It was the patient with the strong drawl again–this time I understood it–dropping off a gift, several pounds of fresh shrimp, “for the Doc and the clinic.” We got to talking, and he mentioned that he was thankful that I was taking care of his kin–a cousin with depression, a grandson with asthma, his Maw-maw with arthritis, and his Pa with a “bad heart.” I looked at the clinic appointments. I had seen 6 generations of his family in the past month. I thanked him for the gift: that night, my family cooked up those delicious, fresh-caught gulf shrimp.

Fewer silos, more community, more comprehensive primary care–these are what I remember of my time as a rural doctor. As we discuss the future of health care delivery, I think about building community and planning for local needs. We need to understand the backdrop, the colors that enrich the lives of the folks we work with.

Dr. Shailendra Prasad is an assistant professor in Family Medicine and Community Health at the University of Minnesota. He also works with the Rural Health Research Center there. He has worked in underserved rural and urban areas as a physician for the past 20 years.

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Great are the joys, great are the pains

When I moved to far-northern New Hampshire to practice family medicine, my wife, Pat, and I were fresh out of residency. Pat had been raised in rural Vermont, so she knew the terrain. I had been raised outside of New York City but had long known that my heart’s spirit was in the mountains. I was a hiker and climber, not yet a hunter or fisherman, and I longed to learn. Fly-fishing, in particular, sounded wonderful; it seemed like an athletic dance, a communion rather than a contest. I wanted this and waited for my chance.

Fortunately, the business and civic leaders in rural New England towns know the importance of having the right doctor in place. The local bank got us started with a reasonable loan and a mortgage, and the bank president himself, who was also on the board of the local 35-bed hospital, helped us get established. His name was Ron Carpenter, and, as luck would have it, he was also a fly-fisherman. Ron offered to take me out that spring, when the season began.

That first winter was the worst in a decade, with 18 inches of snow by Thanksgiving and a number of weeks in January and February when the temperature didn’t climb above zero. Mud season and maple sugar season and town meeting took forever to arrive, and the early daffodil buds seemed impossibly beautiful. Ron and I made plans for my first fly-fishing trip, and I began to dream fish dreams. Until that Tuesday night when the phone rang, and Pat and I somehow knew from the ring that there had been an untimely death and that we, as deputy medical examiners, would have to help the cops clear a death scene.

At first, I wasn’t sure it was Ron. The driver’s face was mangled beyond recognition. He’d been taking the baby-sitter home and struck by a drunk yokel driving on the wrong side of the road as they crested the hill. But I knew for sure that it was Ron when I saw his son Jonathan, dead but still beautiful, in the back seat.

In rural practice, our roles as doctors are interwoven with our friends, our patients, our colleagues, even our adversaries. Usually, there is joy when delivering their babies or satisfaction in easing their passage to death after a life lived long and well. And occasionally it hurts more than seems bearable. Thirty years later, I still wait for the right moment to learn to fly-fish.

Don Kollisch is a family physician who began his career in rural New Hampshire. He has taught and practiced at UNC-Chapel Hill and the Dartmouth Medical School, and now works as a Deputy Dean at the Sophie Davis School of Biomedical Education at The City College of New York, a medical school with a social mission.

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Patients are friends and friends are patients

Rural physicians have an advantage over our urban counterparts: we know our patients in multiple contexts. Cindy Jones isn’t just the 42- year-old with hypertension that has recently been difficult to control. She is also the mother of Jacob, who is having trouble in school and is currently benched because of grades, and the wife of Bill, who recently lost his job when the employer he works for pulled up stakes and left the community. Jacob and Bill are probably also our patients. And our neighbors. And our children’s schoolmates and teammates. Seeing our patients both in and out of the office means we already know a lot about them and have a strong sense of their backstories when they come in as patients.

Knowing our patients outside the office also means that the barriers between physicians and patients are lower. Patients feel comfortable asking a minor health question at the local ball game or in a Facebook message or text. While some city physicians may feel uncomfortable with the idea of contact with patients outside the office, in a rural setting it is uncomfortable not to talk to patients in the community. I have often told my urban colleagues, “If I am not friends with my patients, then I either won’t have friends or won’t have patients!”

Lowering barriers and increasing context means that physicians can provide better care. Care can be timely, so minor problems don’t become major. Care can be individualized, so patients receive treatment specific to their circumstance. (In Cindy’s case, it meant that a talk with a local therapist did a lot more for her blood pressure than one more medicine in her pillbox.) Most of all, care can be comprehensive, so patients are treated across the spectrum of their health and in the context of family and community values.

Dr.Jen Brull is a family medicine physician in solo practice in Plainville, Kansas. She obtained her medical degree from the University of Kansas School of Medicine and completed family medicine residency training in Topeka, Kansas.

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Goodbye, Old Walls

Before I moved to the Berkshires, a rural area in western Massachusetts, my training and experience as a psychiatrist took place in urban settings, where I rarely encountered patients outside of my practice. However, in a rural area, contact with patients in the community is constant and inevitable.

The encounter that inspired this poem occurred after my first day of work at Berkshire Medical Center, our local community hospital. At the time, I was a distance swimmer and in the pool every day. This is the second poem I wrote in honor of William Carlos Williams’ famous poem “Spring and All.” Williams, who was a doctor-poet, is one of my heroes. “A new world naked” is perhaps the best-known line from the poem.

“Spring and All,” Revisited (Again)

My mentors taught me anonymity,
to be a blank screen, to reflect
and hear the space between
my patients’ words and their sighs,
to notice the moment our eyes lost contact.
And when I had learned my lessons well,
I moved to a small town hospital
where I drove to work one cold March morning,
like the time Doc Williams stopped
on his way to the contagious hospital
and called spring “a new world naked.”
Oh, the secrets I heard before I peeled
off my white coat and crawled
through the water at the local pool,
my flesh cleansed in the chlorine water,
my last patient of the day soaping up
when I entered the shower, how he reached
through the spray for a handshake,
a new world, naked.

Richard M. Berlins most recent book Secret Wounds, published by BkMk Press, won the 2010 John Ciardi Award in Poetry and was selected by USA Book News Awards 2011 as the best general poetry book of the year.

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Delivering the right kind of care in Greeley County, Kansas

When I left my family medicine residency program, I went in search of a position where I could be the old Marcus Welby-style generalist, the doctor who did it all, from prenatal care to palliative medicine and everything in between. I’m also board-certified in preventive medicine and public health, and I wanted to work in community-oriented care. I loved the city where I’d trained, but it was very difficult to find an urban practice that fit all my interests. With the increasing dominance of medical specialists, city people think Marcus Welby died a long time ago, as their bodies have been reduced to the sum of their parts-a heart, some kidneys, an intestine-each part with its own doctor.

From Portland, Oregon, I took my family to Greeley County, in the most sparsely populated area of Kansas. Our town of 800 had one grocery store (closes at 6:00 p.m., plan ahead!), one bank, one pharmacy/general store, a weekly newspaper, and an 18-bed hospital. I joined a group of four other family medicine physicians, and together we addressed the health care needs of people in a 2,700-square-mile section of our state. My family was welcomed and supported, my work was appreciated, and, as for my broad interests, well, let’s just say that I was never bored. I delivered babies and witnessed final breaths. I managed diabetes and set broken bones. I fished foreign bodies out of eyes…and some other places.

I did eventually move back to Portland, where I’m now helping to teach the next generation of family medicine physicians how to provide truly comprehensive, patient-centered care. The truth about the American health care system is that we don’t actually have a system. Dr. Welby faded into the background, mocked and underpaid, while the high-dollar proceduralists became what the public thinks of as “Doctor.” The most cost-effective, high-performing health care systems in the world rest on a strong foundation of family-oriented primary care, and it’s about time America returned to its roots and did the same.

Robyn Liu, MD, MPH, is an assistant professor of family medicine at Oregon Health & Science University and the New Physician member of the American Academy of Family Physicians Board of Directors.

*Photo courtesy of BluegrassAnnie.