Practicing Medicine in Rural America, Part II

July 3, 2009


Erin Ducharme MD

This entry is the second in a three part series where I share highlights from my conversation with my home-town physician from rural southern Iowa. The town where I grew up and he practices, Chariton, is 60 miles south of the state’s capital Des Moines. It boasts one hospital, one high school, and not a single traffic light. This section is dedicated to details about the rural medical facilities, the reimbursements, the call structure and more.  Please also see Part I.

The other night I was eating in one of my favorite New York City restaurants, appropriately named “26 Seats,” to indicate the number of diners that can be accommodated at one time. This, of course, is only one of thousands of packed dining rooms on any given night in this great city, and while for six years I have felt perfectly at home here among millions of strangers, I could not help but think of my home-town hospital, with room for only two more, a total of 28 beds, rarely ever full and certainly no need for a reservation.

The physicians back home spend most of their time in the adjoined clinic and hospital on the edge of our aging 4500-and-dwindling-population town. The hospital is run by the county, largely funded with tax dollars and approved for a total of 28 beds. On any given night three to 15 patients will be treated in the acute care unit including those with pneumonia, diverticulitis, urosepsis, etc. A few more will reside in another section dedicated to skilled care, pulmonary therapy for those requiring nebulizer treatments, and rehabilitation such as after a hip fracture. The OB unit has anywhere from zero to four occupied beds a night. Several more beds are designated for inpatient hospice as well as respite hospice where patients can spend a few nights to give their families a period of rest. Meeting certain criteria including being rurally located, the health care center falls under the designation of “critical access hospital” which improves reimbursements for the largely Medicare patient base, with the goal of increasing rural health care access and reducing hospital closures. Instead of DRG payment, the hospital’s reimbursements are cost-based, “like the old days.” The clinic serves roughly 10,000 active patients. Dr. Hoch is one of five other family practitioners (FPs) at the Chariton Family Medical Center, including two M.D.s and three D.O.s. Additionally two physician assistants (one of whom was my cross country teammate and partner in the 4x800m relay in high school) and one nurse practitioner take call and hold clinic. One surgeon services the hospital performing colonoscopies and other general surgical procedures. Visiting surgeons provide care in subspecialty fields including orthopedics, urology, and ENT. A nurse anesthetist (my best friend’s dad) performs epidurals and other anesthesia services. The hospital has a permanent CT scanner and once a week a mobile MRI machine, which travels to surrounding community hospitals the other days of the week. Interpreting these scans is a radiologist who spends four half-days a week in the hospital; tele-radiology is utilized the rest of the time. The clinic has limited laboratory capabilities including AST/ALT, urinalysis and microscopy, protimes, lipids, streptococcal and H. pylori tests; the hospital, on the other hand, has a full lab with the exception of pathology and cytology.

Dr. Hoch estimates that the pay offered in Chariton falls within the upper 10 to 15 percentile for FPs nationwide which helps attract physicians to these rural communities where the family doc’s work never seems to end. Here FPs round seven days a week on their hospital patients, stop by the nursing home across the street for regular care of the elderly tenants, and hold clinic five full days a week (Dr. Hoch takes Wednesday afternoons “off”). The three senior physicians take overnight call with the PAs and NP one night every week while the newest two alternate between one and two nights a week. Each takes one weekend call every five weeks. Three of the five FPs deliver a total of about 100 babies per year. To put this birthrate in perspective: nearly two decades ago my family was featured on the front page of the local newspaper because my brother was the hospital’s first baby of the New Year-born on Jan 21st!

Dr. Hoch had been the fourth physician delivering babies but he recently retired from obstetrics (five years later than he had planned!). When asked what happens in the case of an emergent cesarean Dr. Hoch said that years ago he decided it was not worth waiting for a surgeon from Des Moines (60 miles away) to arrive so he asked a surgical colleague to teach him the operation which he subsequently performed, as needed, for decades and has taught to other physicians in the practice (two of the current FPs learned the skill in residency). Although he appreciates the extra sleep at night, he has noticed that his clinic practice has aged considerably now that he no longer has the pre-, peri-, and post-natal visits or the ensuing well baby checks.

Over the weekend, 36 hours of emergency ward care is contracted to an outside medical service and a given number of 24 hour weekend ER shifts is made available to the FPs for extra pay which can add another $15,000 in income for the year. The ER is considered low volume with an average of 5 to 20 patients per day. In addition to motor vehicle accidents, drug overdoses, and other standard ER visits, a not- uncommon presentation in rural communities is the victim of a farming accident, ranging from digits lost to hay elevators (as experienced by my grandpa as a young farmer) to concussions (and worse) after being thrown from a horse or kicked in the head while milking a cow. When I was growing up the father of a classmate was found dead after getting caught in the moving parts of a farming machine, my grandparents’ neighbor-boy was left a paraplegic after a crush injury from an unsecured one-ton hay bale, and a family friend’s toddler was consumed in the rotating grain auger.

While traffic through the innumerable Bellevue clinics and hospital on any given day likely rivals the volume seen in an entire year in small town Iowa’s equivalent, it is clear that for the few physicians working in these rural medical centers, the job is demanding and in many ways, unending.. In the final section of this three part series I will discuss privacy issues, the incorporation of an electronic medical record system and make a few final comments on the differences between big city and tiny town medicine.

Dr. Ducharme is a 2nd year internal medicine resident at NYU Medical Center