Profile of a Rural FP: Amalia Pineres, MD

Name: Amalia D. Pineres, MD
Clinic: Alma Medical Clinic LLC (Payson, AZ)
Years a Rural FP: 16
HPSA-designated Community? Yes

My journey into rural family medicine started with my father. In 1978, my father moved from the Midwest to rural Arizona to escape his ever-growing allergies, dragging most of his 9 children with him – I was one of them. He set up a family practice in Globe, Arizona. After my residency training in the Midwest, I came back to Globe, Arizona, and joined him in his practice. From him, I learned the details of running a solo practice. I also learned a great deal about dedication – a characteristic he had in spades! While he introduced me to rural family medicine, however, I stayed in it for other reasons. I learned that my particular residency training – which was intensive overall but particularly heavy in obstetrics, hospital and procedures – had made me an ideal rural physician! My training fostered the types of skills that were welcomed in the small mining town of Globe, Arizona. Unlike the experiences of some of my colleagues who settled in more urban areas, I was allowed to do the full gamut of family practice including procedures for which I had done special training such as c-sections, flexible sigmoidoscopy, and postpartum tubal ligations. I did not pursue flexible sigmoidoscopy and colposcopy only because the equipment was not available to me, and I could not afford it just coming out of my residency. On top of this, my husband – a hunter, fisherman, and avid outdoorsman – was well-suited to the rural life. Between his hobbies and my professional skills, we blended well into rural Arizona. His hobbies became my hobbies, and soon I was archery hunting, waterskiing, and fishing alongside him!

I remained in Globe for 13 years, and when my family and I decided to relocate, I again chose a rural town 1-1/2 hours away, Payson, Arizona. I actually stayed in the same county! It never occurred to me to do otherwise. For me, seeing my patients at Wal-Mart, the drive-through of Jack-in-the-Box, or the school office is a normal and everyday occurrence. With rare exceptions, my patients have always been respectful of my private and family time, and when we see each other at baseball games, we talk about everyday life. Sometimes that includes their health issues, but more often than not, it doesn’t. In Globe, most of my friends were my patients. Some physicians might find that a difficult practice, but I saw it as both a natural progression and something hard to avoid in a small town.

Globe and Payson, Arizona differ significantly. Globe, Arizona is primarily a mining town, and the affluence of its residents relies heavily on whether or not copper prices are good. As luck would have it, most of the copper mines in Globe closed within the first few years of my arriving in town. Then the mines reopened after I relocated! In the interim, many of the younger, working-class residents relocated to other towns. Others who remained but lost their jobs were forced to get on AHCCCS – Arizona’s own brand of Medicaid. As a result, my practice was nearly 70 percent AHCCCS. The poverty and unemployment contributed to increasing health issues, methamphetamine abuse, alcoholism, divorce, and mental illness. In short, my patients were sicker, riskier, unhappier, and poorer than the patients my dad’s practice had seen before me. Ever the optimist, I kept telling my husband that things were going to get better. He adamantly disagreed. It was only after I left town that I proved him right. I loved the town and its people despite its drawbacks. My husband and I had built our home literally with our own hands. My step-children visited us and grew up there. My son was born and spent his first eight Christmases there (my patients showered him with presents!). I learned to ride and care for horses in Globe, Arizona. And when I buried my beloved horse, Little John, it was a friend, who just happened to be my patient as well, who helped me bury him and held me as I cried.

Payson, Arizona is a more prosperous town than Globe. Many people come to beautiful Payson to retire and, as a result, the Medicare population is much higher. Others come from Phoenix, California, the Midwest and even Colorado to visit their second homes in Payson. In Payson, it is cooler, and the smells of pine and juniper fill the air. It is still wonderfully rural. In the mornings, I will walk my hound dog Rex and watch him chase rabbits. I am still hoping to run into an unsuspecting bull elk but have not been lucky. And yet I will spot elk at night in my headlights all the time!

We are fortunate to have a hospitalist in town, and I have chosen to dedicate my time and energy to outpatient practice these days. As a result, my pace is slower. I no longer do obstetrics, assist at surgeries in the hospital, or perform my own inpatient surgeries. Gone are the days when I scrambled to get my child off to school, only to run to the hospital and then to the office. I have some time to myself in the morning now. While I do some hospital admissions, especially pediatric admissions, I mostly rely on the hospitalist. My office days are quite busy, however. I see from 20 to 23 patients daily, but at least four of those patients are initial visits and just as many are physicals and paps and pelvics. My patients appreciate the time I spend with them listening to them and do not seem to resent my reliance on a hospitalist. I still try to do as many procedures as I can myself in the office. Procedures are both fun and lucrative! I would never give them up.

Challenges

The greatest challenge I have faced as rural family physician was living with the mistakes that I made as a physician and facing the patients that paid for those mistakes. While I would like to believe that I help so many more patients than I ever hurt, it takes only one really tragic mistake to shake up the world of a small town, rural physician, and practicing medicine is never the same.

Rewards

By far the greatest rewards I have received as a rural family physician are the many relationships and friendships that I have formed. The people that come to my office do me a great honor when they place their trust in me and let me into their lives. When I see a patient on my daily list and I realize that that patient has been to see me three times in the last month, I no longer feel exasperated. What greater compliment can a patient pay to a physician than to return time and time again?

Advice

For those entering into family practice, I recommend that they learn as much as they can and develop as many skills as possible while in their residency. Inevitably, they will not practice all of their skills forever. Better to be prepared, I say A new physician just doesn’t know what skills he/she will need to hold onto until the time comes. Secondly, I recommend they start their first practice with someone already successful at running a business. Despite increases in office management training, none of us are ready coming out of residency. Finally, you’ll never catch up on the memories and events you miss out on if you let your business come before family and friends. Don’t do it! Don’t miss the Christmases, the baseball games, the birthday parties. Take your time off, make less money if you have to, and just say “no” if that’s what it takes. Treasure those moments. They only come once!