The rewards of family practice in a rural town

Although McAlester, Oklahoma, is a relatively small, rural town, it’s the largest town in southeastern Oklahoma. Well over 100,000 people come through for a number of goods and services, including health care. Growing up 30 minutes outside of town, I understood rural Oklahoma from a patient’s perspective, and I looked forward to seeing it from the provider’s perspective. During a summer rural externship, I spent three weeks shadowing Carol Gambrill, D.O. I learned about the challenges and frustrations, as well as the great rewards, of family practice in a rural town.

Dr. Gambrill’s practice is still in its infancy. Her patient load is still relatively small, which allows her to spend more time with her patients. About half the patients we saw each day were new patients needing a primary care doctor. Many had the same story.  They’d been seeing a doctor for a year or so, until the doctor left town. Physician retention is a huge problem in McAlester. In the three weeks I was there, we lost a family doctor and an OB/GYN, both of whom had decided to move to hospitals in bigger cities.

“I haven’t had a doctor in two years. Will you be leaving any time soon?” Many new patients would ask. Dr. Gambrill’s response was usually, “You have me for at least three years and hopefully forever.”

We spent up to 45 minutes with some new patients. The depth of patient history and discussion in these appointments surprised both the patients and me. Walking out of the exam room, one patient asked me, “Is she like this with everyone? She needs to stay.”

Because many patients come from great distances to see a doctor, they are unable to utilize all the basic community health resources the town offers: wellness center, home health, hospice, counseling, and meals for seniors. One patient, who had been struggling with severe arthritis, was unable to find a form of exercise that didn’t kill her joints. Dr. Gambrill suggested water aerobics at the local wellness center. The patient laughed and told us that if it weren’t for the hour-long drive, she would love to be involved in something like that.

Another patient talked about the negative impact the 45-minute drive to the grocery store has on her consumption of “vegetables and healthy foods.”

When it comes to specialty medicine, southeastern Oklahoma is lacking. One patient came to Dr. Gambrill after the only doctor in his hometown moved away. He had a variety of health problems and needed a primary care physician to keep everything in check, but he lived 90 miles away. He already had a specialist in Oklahoma City for his liver, Tulsa for his heart, and Mena for his eyes. He had recently been hospitalized for heart problems and had home nurse visits three times a week. Dr. Gambrill worked with this nurse to minimize the patient’s trips to McAlester from once a month to once every three months. Unfortunately, this situation is far from unique.

Money is another barrier to adequate medical care for residents of rural Oklahoma. We saw an uninsured patient with severe scoliosis and worsening nerve problems.  While these issues were far outside of Dr. Gambrill’s scope, she understood that the patient, a young woman, couldn’t afford the tests and consults that might find the source of her pain. The woman cried about how difficult it was to drive and care for her child, and I couldn’t help but be frustrated with our inability to help her because of financial limitations. We spent a great deal of time trying to find a neurologist who would see her. We eventually set up an MRI at a local diagnostic center that was willing to arrange a payment plan, and when I left, they were working out transportation.

I had some understanding of rural medicine before this experience, but I did not fully understand the scope of a rural family doctor’s practice. In a single day, Dr. Gambrill did a well-child exam on a 6-month-old child and later discussed hospice care with an 86-year-old cancer patient. She performed well-woman exams as well as addressed acute problems requiring hospital admission. Patients that we had seen for depression one week were seen for sinus infection the next. One patient discussed smoking cessation during an appointment for her daughter’s ear infection. Without immediate access to specialists, Dr. Gambrill often has to work with her patients to find reasonable solutions without referral. She has to know a fair amount of everything to be ready for anything.

I am still uncertain about my future specialty, but I would love to settle in a rural community. I am definitely more interested in family medicine now than I was before this experience.

My impression of rural family medicine after this experience can be summed up by an encounter between Dr. Gambrill and the mother of a 15-month old patient with a host of problems and who can’t seem to stay out of the hospital. Dr. Gambrill was discussing several specialists with the understandably frustrated mother. After making a plan of action including visits to several different specialists in far away cities, the mother asked, “Immunologists, gastroenterologists, rheumatologists… there are so many specialists, but who is the specialist over all the specialties that makes sure everyone’s doing the right thing? Who’s the specialist at the top?” Dr. Gambrill said, “That’s my job!”

Haley Adams is a medical student who blogs at Primary Care Progress.

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