Practicing Medicine in Rural America

July 24, 2009

 rural

Erin Ducharme MD

This entry is the final in a three part series where I share highlights from my conversation with my home-town physician from rural southern Iowa. Here I discuss the medical conditions which affect this 4500 population town. I also briefly touch on maintaining privacy in a place where “Everybody knows your name (and your business)” and the incorporation of an electronic medical record system.  Please also see Part I and Part II.

Running Water and Computers too

The bread and butter diseases-congestive heart failure, hypertension, gout, arthritis, valvular heart disease, diabetes mellitus, pneumonia, urosepsis-are the same in these rural communities but they don’t see many of the conditions all too familiar to physicians in urban areas. Dr. Hoch has diagnosed one case of HIV in his 30 year career (and not for a lack of testing) and treated less than a handful of others already known to have the infection; in all these cases the patients had moved to the rural community from outside areas. He has seen very few cases of Hepatitis C, no active cases of tuberculosis. And in an almost entirely Caucasian demographic, conditions such as sickle cell disease have only been encountered in textbooks preparing for board recertification. Methamphetamine abuse used to present a major problem but with a successful crack-down by law-enforcement over the past decade the number of users of this and subsequently all drugs has drastically decreased. The community used to have a regional detox center with at least 2-3 court ordered detainees at a time but even that has closed given a lack of need. Dr. Hoch estimates that prescription pharmaceuticals are currently the most commonly abused drug in the area.

When asked about major health care crises throughout his years of practice he quickly recalls a Pertussis epidemic which occurred about three years ago. The wave of whooping cough occurred in the setting of parents failing or refusing to vaccinate their children as well as a nearby Amish population who routinely does not consent to vaccinations. Last year six patients presented with an enterovirus encephalitis, all with small school-aged children. With regard to unusual infectious diagnoses, he’s treated one patient with West Nile virus and last year he had a case of a grandmother taking care of her grandchildren after daycare who developed a severe infection from CMV with hepatitis, pneumonia, diarrhea, and a twenty-pound weight loss.

In my training at Columbia P&S, a constant theme incorporated into the curriculum was the concept of practicing medicine through the lens of multiple perspectives. We wrote countless essays and spent many small group sessions discussing the importance of viewing patients in a broader context: someone’s mother or lover, a gifted writer, a respected teacher. For physicians in rural Iowa, no such instruction is necessary, but here a new problem arises. It seems complying with HIPAA rules would be particularly difficult in these small communities where your patients are your next door neighbors, your son’s teacher, your best friend’s daughter. One day in medical school, I shadowed Dr. Hoch and throughout the morning I saw my former high school janitor, a friend’s mom, and an old classmate; it was all I could do to not recount the H&Ps to my parents that evening.  I beat the temptation not only out of fear of government retribution but mostly respect for the Hippocratic oath. And while they may share a good story here and there, Dr. Hoch and his wife similarly take the privacy of patients very seriously, never discussing confidential or identifying information. Whether it be the influence of my Norman Rockwell upbringing or the example set by one Dr. Hoch, I am inclined to (correctly or not) believe that most physicians in these small areas acknowledge their privileged position and honor their professional code of privacy.

In jest (or not) my Big City friends often ask me if I had running water growing up in southern Iowa, the answer is, of course, yes, and we have computers too. While it may be located on the outskirts of nowhere, the Chariton community medical center is not immune (or adverse to or even last to participate in) the national drive to digitize patient records. In fact, Dr. Hoch and his colleagues have themselves (as opposed to an independently hired team which would be the case in larger hospital systems) organized and spearheaded the overwhelming, time-consuming conversion to electronic health records. They are implementing the changes in phases, having already completed the transition to scheduling all appointments through the computer system. They are currently in the tedious process of electronically scanning thousands of clinic charts and medical records. The project is an expensive one for this small medical center with $250,000 spent just on the software and training. The indirect costs are harder to measure, but just as real. Dr. Hoch estimates that now, before the process is streamlined and familiar, his efficiency is greatly reduced. Before he could see 25 patients a day, yet now he can only schedule about 15 because of the extra time needed to enter visit information into the computer. Obviously, however, these short term pains are hoped to translate into better quality, more efficient patient care over time.

While the differences between rural and urban medicine in the United States are striking, in talking to Dr. Hoch (not as his patient but this time as a fellow physician) I sense the common bond that transcends budgets and demographics and location. We share the privileged, humbling experience of having spent months dissecting a human body; we know that a blowing systolic murmur heard best at the cardiac apex in the left lateral position suggests mitral regurgitation; we speak the same language which is otherwise equally foreign to a banker on Wall Street or a farmer in southern Iowa; we read the same journals and reference the same randomized, controlled trials. Whether treating patients in Washington Heights or Chariton, the anatomy, the physiology, the pharmaceuticals are the same and hopefully, for most of us, so is the goal, to improve the lives of our patients.

They say you can take the girl out of the country, and after all these years I fit in almost better in the city that never sleeps than I do in my home town where last call at the only bar is 11pm. It’s equally true, however, that my rural roots cannot be uprooted. I feel compelled to follow my small-town instinct, to become what I have idealized and internalized as the traditional doctor, based on my rural family physician. In many ways this dream, is just that, an idealized fantasy. I’ve committed to a subspecialty field of medicine, already limiting my options with regard to the size of the town or city where I practice. I’ve also been trapped in the net of academic medicine with a desire to teach budding physicians which generally requires approximation to a major medical center. In the end, I’ll likely settle somewhere in between, a mid-size city or a suburb, practicing medicine in my own unique amalgated style of rural America meets Big Apple-sometimes a “city slicker” (as my farming grandparents used to joke), often the “farm girl” (as my city friends call me), and always the doctor who strives to combine, serve and treat pulling the best attributes from both these polar worlds.

One Response to Practicing Medicine in Rural America

  1. Daniel S Kim on October 27, 2009 at 1:28 pm

    Dr Ducharme, I very much enjoyed reading your 3-part series on rural medicine in Iowa! I hope that stories like yours will help motivate future physicians to serve in rural America, especially as the number of rural physicians dwindle. I myself am trained in rural family medicine and plan to serve in a rural town after my military commitment. Thanks again for sharing the experiences of your own family physician! Daniel S Kim, MD

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