Practicing Medicine in Rural America

June 20, 2009

ruralErin Ducharme MD

Part I. Tales from the barn

In the first of this three part series about life as a small town family physician, I introduce the doc (and rock band member) who spinal tapped my eight-year old lumbar spine to diagnose encephalitis and MC’d my wedding reception; share an unbelievable story about a home (i.e. barn) delivery , and hint at the all-encompassing nature of this still-revered position in rural America.

While my medical career began in the Big Apple and all I’ve ever experienced as a medical student and now intern has been in an urban setting, my core, inner idea of doctoring and my inspiration formed throughout my childhood in rural Iowa. The imprinting happened without design or intent but clearly shaped for me the meaning and significance of being a doctor. Until my first year at Columbia P&S I had not heard of a dermatologist, a pediatrician, an ob-gyn because where I grew up one clinician was all these things. I thought it would be interesting, no longer the patient but now on the other end of the stethoscope, to formally talk to my life-long family physician, Dr. Douglas Hoch, about what life is like as a rural doc.

I flew home for a short weekend in December and at church on Sunday asked Dr. Hoch, who was managing the sound system for the service from the back, if he had time later in the afternoon for me to stop by. After lunch, braving the cutting wind and ice-covered gravel road I walked roughly 40 feet from my parents’ house to the Hoch’s. His wife, Martha, a registered nurse, hugged me as I entered the doorway. She was the maid-of-honor at my parent’s wedding and a few years later helped deliver me. I walked over to the kitchen where Dr. Hoch was chopping carrots, celery, and onion for a Bolognese ragu. I sat, he stood for the next hour and a half as we all chatted. And as we did, I was, as always, in humble gratitude and awe for all he has done for my family and our community. Twenty-two years ago he delivered my brother, he cared for me when I contracted encephalitis, he electro-dessicated innumerable warts from my elementary school fingers, treated both my parents during various hospitalizations and through routine care. He helped my grandma, with an ejection fraction of less than 20%, live to 92 because he continued to treat her as a person who still had living to do and a family who loved her.

I asked him to recount one of my favorite stories about the time he performed a home delivery for one of the many Amish families in the community. It’s a classic tale that I’ve heard many times but it never fails to bring laughter and disbelief. Martha describes how Dr. Hoch sent her out to monitor the progression of labor until delivery was imminent, at which point he would join them. Martha followed the directions to the farm, 20 miles south of town, a destination not yet programmable in the most technologically advanced GPS models, but as she pulled into the gravel driveway she saw only a Morton building. She called Dr. Hoch, “This cannot be it, there’s only a barn here.” “Oh, that’s right, I forgot to tell you that they live in a barn.” She took a deep breath, bracing herself, and entered the steel structure. With no breeze, no fans, and no air conditioning the heat of summer had penetrated and swelled inside the steel building escaping in a stale hot malodorous cloud of manure and unwashed bodies. Inside a solitary wall separated the living quarters from the livestock. Although many Amish women will become quite experienced in labor over their lifetime, averaging seven children, this patient was at the beginning of her birthing years. Because she was primiparous the labor progressed particularly slowly. Throughout the day a curious cow repeatedly thrust her wet muzzle through a paneless window in the wall, a ritual which eventually became quite irksome to a hot, thirsty, tired, uncomfortable nurse Martha. At one point she noticed a large hole in the dirt floor and inquired about its use. This space was the coolest part of the building and meat, eggs, and other temperature sensitive foods were stored here. The milk, however, was kept in the North window, which seemed of little utility in offsetting the ninety degree room temperature. After several hours Martha requested to use the bathroom and was handed a “pee pot,” she politely declined and waited for an opportunity to sneak out to the grassy lawn. The day went on, the sun set and eventually the woman delivered a healthy baby by lantern. Better lighting was needed for Dr. Hoch to suture her perineal laceration. As Martha pushed-on the flashlight she had found in her husband’s doctor’s bag, a swarm of moths and other Iowa-summer arthropods fluttered in the line of vision. Commensurate with the entire experience, payment was made with a handmade quilt.

Even for a physician in southern Iowa, the Amish home-delivery is a unique story, but it highlights the adaptability, resourcefulness, and complete dedication required of the physician (and his family) practicing in a rural community. The second part of this series outlines facts about rural medical facilities, the reimbursements, the call structure and more.

Dr. Ducharme is a 1st year internal medicine resident at NYU Medical Center

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