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Tuesday Dec 05, 2017

Rural or Urban FP, We Both Handle Gamut of Patient Issues

When Kimberly Becher, M.D., and Venis Wilder, M.D., sat down for lunch at the same table during an AAFP conference, they weren't expecting to have a lot in common. But what the white doctor from rural West Virginia and the black doctor from Harlem found out was that their patients face many of the same challenges, and their broad training allows them to offer similar solutions.

At a time when fourth-year medical students are completing their residency interviews and preparing their rank order list for the National Resident Matching Program, we asked Becher and Wilder to discuss the similarities and differences between rural and urban practice.

AAFP News: Merritt Hawkins surveyed final-year residents(www.merritthawkins.com) earlier this year, and more than 90 percent of respondents said they would prefer to practice in communities of 50,000 people or more, while only 3 percent would prefer communities of 25,000 or less. For communities like Dr. Becher's -- less than 10,000 -- the figure was 1 percent. Do people go into their training with preconceived notions about what they want to do -- and where -- and stick to it? How do you get more students or residents to rural areas so they can experience it?

Becher: We had a program in West Virginia where every medical student had to do a rural rotation. The thought was if you show them what it's like, then they'll want to do it. Sometimes it would work, but sometimes you would have loud complainers, like people who wanted to be ophthalmologists, and they would say this was a huge waste of their time and they didn't want to live in a rural county for that long. The program showed people -- even the people who might not realize they have an interest, or maybe they do but they're afraid -- that it's possible to work with a population that has so many barriers to care and that if you have the right training, you can handle all that.

It's intimidating from a student perspective. They might think, "I want to be somewhere with more support because I'm not confident I can handle all that," but then you throw them in with someone like me, and then they're like, (laughs) "Well, if she can do it, I can do it." It makes them realize they can do it, and they see that I enjoy my job.

A student just rotated with me. He finished a few weeks ago. He said he hadn't laughed that much or had that much fun in all of med school. And we were slammed. It's not like we sat around reading The New Yorker. We were super busy. One day we did nine home visits, but he saw how much fun it is when you have relationships with your patients. There's at least one patient every day that, as they're leaving, says something like, "I love you. Have a safe trip home." And I'm like, "What?" They really bond with you. I don't know that people in big group settings or specialists get that with patients like we do.

Wilder: I always knew I wanted to work in an urban area, but I purposely chose a rotation with the Indian Health Service during my final year of medical school because I wanted to experience a rural environment. I felt like I really needed to know all of medicine and comprehensive primary care because when there's not access based on location, you become the doctor who has to do everything. In the inner city, there are many hospitals and health centers around, but access can still be limited by finances and insurance. People don't necessarily trust every doctor they might encounter. I wanted to be able to do as much for my patients as possible in my office. That rural experience really benefitted me working in Harlem and also where I currently work in the Flatiron District, where the goal is to do just about anything a patient needs, whether it's a Pap smear, skin biopsies, managing pneumonia or helping the patient with their diabetes or high cholesterol.

AAFP News: Dr. Becher, what kind of experiences did you have before you decided on rural practice?

Becher: You know how everyone has this big story about why they went into medicine and why they do the kind of medicine they do? I don't have one of those stories. (Laughs) Our practices are similar. You would think that our patients would have very different barriers, but they really have the same barriers, which are financial and social limitations. I went into practicing in a rural area for the reasons Venis said she did that rotation. You have to be willing to do everything, sometimes things that are out of your comfort zone. I think a lot of times people think, "Ooh, I want to do rural," or they say they want to work with at-risk or underserved populations in an inner city, but I think those end up being the same day-to-day work. On the other hand, I think our commutes are very different.

Wilder: (Laughs) How do you get to work?

Becher: I used to take a dirt road for a big part of it until the flood. Now I don't go that way. It's 30 to 35 miles. I would drive on a back road and then I would turn on a dirt road and go over a mountain. It's like six miles on a dirt road and then I'd come out on a paved road on the other side of the mountain that I would take the other 15 miles to my office. There are zero stop lights. No matter how I go, there is no way for me to go through a stop light.

AAFP News: In 35 miles?

Becher: Yes! (Laughs)

Wilder: Wow. At my last job in Harlem I had a 15-minute walk, door-to-door. My current commute is a quick subway ride with about a 10-minute walk over to the east side of Manhattan.

Becher: Some of my patients have to find a way to get to me. Some of them hitchhike there because they live in the middle of nowhere. But once we get to our offices, we do the same things and our patients have the same struggles. They have problems with food access, won't see specialists because of trust issues and are afraid of being judged for this or that. That's what's really interesting to me about this.

Students don't usually think about, "Where do I want to live?" in terms of a specific place. They have more of an idea of what kind of medicine they think they want to practice, but most people don't have an idea of what city or town they want to work in when they're done. I feel like I have to be the party pooper sometimes because someone will say, "I want to be a pediatric endocrinologist, and I'm going to go back to my small town in West Virginia," and I say, "Well, you can't be a pediatric endocrinologist in that town because there aren't enough patients." I don't know if Venis and I are typical in that we knew where we wanted to be.

AAFP News: Dr. Wilder, what about your patients? Do people have transportation limitations in the city, as well?

Wilder: Not having a metro pass is the biggest thing. That's a huge limitation. The other commonality, besides access, that we see is the chronic diseases we are treating and trying to prevent are very similar -- obesity, diabetes, hypertension, high cholesterol, heart disease. There are many social determinants impacting people -- food insecurity, finances, education, you name it.

I would say one thing about family medicine in an inner city or urban area is that people think that it's limited in scope, and in some ways, it can be because there is more access to hospitals than in rural areas, but in certain communities people feel like they don't have access and in many ways are limited by insurance. It will surprise you how much you end up doing. One thing I see is the number of referrals that are placed to specialists and then look at the percentage of patients that actually go to the specialist, and it's slim. Some people don't feel comfortable going to the big hospital or going to someone they don't know. They would rather stay with someone familiar to them who they trust. I had a patient who needed a procedure for carpal tunnel. I told the lady, "I haven't done this in a while, and I'm going to have to go look at a video or something." I told her that up front in case she wanted to go to a specialist. She said, "No, I trust you, Dr. Wilder, and I want you to do it." I had another lady who had sickle cell. She wasn't going to her hematologist and had fallen out of care for a while. She said, "Please take care of me. Read whatever you need to read to get up-to-date." There's a lot of that.

Becher: Yeah, I have patients who say, "If you can do this, I'll do it. If you can't do it, I'm not doing it." The only thing I've 100 percent said, "No, I'm not doing it," to was to the patient who wanted me to drain a pleural effusion at their house. (Laughs) They said, "I'm not going back to the lung doctor. You can take care of it." I said, "No, I can't. You have to go to the hospital." They ask you to do crazy things.

Have you managed a bunch of patients with type 1 diabetes?

Wilder: Yes.

Becher: And did you expect to do that coming out of medical school and residency?

Wilder: I didn't. That's when you call a friend, read or watch videos. It makes you a better doctor. You take your job seriously because you know it's about people, helping them and being the best doctor you can be. People see that and trust that you will help them.

Becher: You have to be flexible, and like Venis was saying, if you haven't done things in a while, you have to brush up if someone asks you to do something. You're the patient's solution.  

Wilder: I've felt that pressure before, too. It's made me more of an advocate. In my past job, I was a medical director but also ended up being director of quality. That was helpful because you see many of the same things over and over. You can possibly effect more change at a higher level.

When you live in a community, you're part of the community, you're eating at the same places, you're walking among people and you're a neighbor; you realize a lot of the diseases we're managing can be prevented, and there's policy at the organization level, community level, city government level that needs to be put in place. I feel like I have to know who the politicians are and get to know them and the heads of stores and organizations. I feel like having those relationships and developing those relationships are important. I just started doing that, but it's something I've become more attentive to because the goal is to change the conditions people are living in.

Becher: We've talked to the grocery store, now that we have one, about specific things it should stock. I'm also on the board of a big organization in town that employs people who do home health work. They help people who otherwise couldn't live independently. It's the same organization that delivers food to people, like Meals on Wheels.

There aren't as many opportunities where I am. There's not as much going on and not as many things to sway as there would be in a city, but I agree I have gotten involved at the organizational level outside my practice in things that influence the health of the community.

AAFP News: What advice would you offer to students trying to decide their match rank order list, or even physicians looking to make a change but maybe they've only worked in one kind of setting? What would you tell them about stepping outside their comfort zone?

Becher: When I talk to people about residency programs, I always tell them they need to pick a program that is going to be the most rigorous and push them the hardest. When you're looking at programs there are a lot of variations, even in the numbers of patients the hospital service will carry and things like that. Venis might not agree with me, but I advise people to go to really busy programs that might seem overwhelming because they're going to throw the most at you. If you're going to do some sort of underserved rural or inner-city work when you're done with your training, you need to have seen it all. You don't want to see it for the first time when you're like me in the middle of nowhere. I push people. If a program feels overwhelming, I tell them that's where they should go. (Laughs)

Not everyone agrees with me on that. But I interviewed at a program that had low volume and a ton of fellows within the system, so family medicine residents didn't do as much because they had so many fellows. Granted, you could do rotations with them, but their residents didn't manage as much on their own as you do at some other programs where maybe your service is running the show.

AAFP News: Dr. Wilder, what's your response?

Wilder: I would say go to the program where you can get the best training based on the type of medicine you want to practice and the populations you want to serve. For me, I wanted to practice in a big city, and I wanted to sharpen up my Spanish because to me the primary populations I wanted to serve are black and brown. I speak English and I understand black culture, but I wanted to sharpen up my Spanish, so I went to the Columbia program in Washington Heights. In that program, I was exposed to the Dominican community. I learned Spanish, and I got solid training. We were in a big hospital, but our family medicine inpatient service was at a satellite hospital in the city. We ran our own service but we also had direct access to attendings. I received great training from attending specialists who I would have to directly speak to in order to do a consult. They would teach me and I was eager to learn. That was really important.

One of best compliments I got at my first job after residency was from a resident who said, "You are really comfortable with sick patients. If I have a complex patient, I'm coming to you." That was a direct correlation with my training because I knew how to take care of things like difficult diabetes and uncontrolled hypertension because I had done it year after year in residency and had managed it in the hospital and had talked with specialist attendings to know how to correct it in an efficient way.

The bottom line is that you should go where you can get best trained in what you are interested in. For me, that meant being a great clinical provider, great community advocate and being able to relate to the community I wanted to serve.

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va.

Venis Wilder, M.D., is a board-certified family physician who practices in New York City. She is a community health activist working at the intersection of primary care and public health.

Posted at 01:10PM Dec 05, 2017 by Kimberly Becher, M.D., and Venis Wilder, M.D.

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