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Monday Aug 06, 2018

Rural Locums Provide Balance for Urban Doc

I have this undercurrent running through me where I'm somewhat concerned that I'll never grow up. I'm never going to get a real job. I won't hold still, establish a commute, put pictures up in a cubicle. And I'll never be able to hold down a job as a lifelong career.  

But I also think I'll be OK.

Out of residency, I set out on a somewhat atypical career. I got no signing bonus. No relocation incentive. No guaranteed vacation. No retirement contributions. No health insurance. Although I have a generous, state-sponsored loan repayment program, I don't have a guaranteed salary. I pay for my own licensing, and CME money doesn't come as a use-it-or-lose-it allowance.

I started my own business in the world of direct primary care (DPC), and I dabble in locum tenens on the side.

I grab locums shifts on occasional weekends in rural hospitals across Missouri, Kansas and Colorado. My DPC patients have known from day one that I don't guarantee 24/7 in-person availability. I assure them I have my phone. (I'm a millennial. I can't live without it, I guess.) And they can always call, but it may be a little while if I'm elbows-deep in a chest tube insertion.

There is a whole host of reasons that led to this decision, but the biggest one is this: Family medicine keeps getting squeezed into a smaller and smaller box. Over the past generation, subspecialists have claimed more and more of what was once our turf. Procedures, chronic disease management and diagnostic workups are referred out because we simply don't have the time we need for them in our squeezed office visits. As more years insert themselves between where I am now and the breadth of training I had in residency, I find myself pushing back against the sides of that box, trying to keep that space open for the widest scale of practice.

The combination of rural practice via locums and my DPC clinic allows me to continue to use the full spectrum of skills I learned during my training. It also allows me to escape the traditional slog of outpatient medicine in favor of a setup that aligns patient and physician incentives -- without the meddling of third parties -- through DPC. And, when paired, these two elements provide a decent income for a family physician.

To some, the schedule of being on the road or bouncing between hospitals seems chaotic. Others shudder when I mention I provide ER care or that I do a wide breadth of procedures in my clinic. Still more wonder what it means to have an unpredictable paycheck. But I'm OK with all of it; it works for me.

After receiving a last-minute plea from my locums agency to provide weekend coverage in Goodland, Kan., in May, I signed up for the shift and started the six-hour drive across the state. (I live 100 feet from the Missouri border, and Goodland happens to be one of the last cities you drive through before hitting the Colorado border.) During the following 72 hours on call, we triaged no fewer than four members of the local third-grade class, all of whom wanted to know if they could still go on the next day's field trip to the Denver Zoo. Two walked out with staples to close their head lacs. One just needed a little reassurance after doing the splits too vigorously at a dance recital. And the last one had a UTI.

Much to their excitement, each one was cleared for the trip.

And that was as exciting as that weekend got. We cared for a few people who needed help as they passed through town on I-70. I admitted a so-called frequent flyer for cellulitis. But the weekend resulted in no transfers from our critical-access ER to larger hospitals. We didn't have any myocardial infarctions, no cerebrovascular accidents, no trauma. I got seven hours of uninterrupted sleep each night, which is absurd.

I've had many shifts where I drive away both amazed at human kindness and reinvigorated with a love for the art and science of medicine. These are moments like finding a fetal heartbeat while triaging first-trimester bleeding in Washington, Kan., and being able to cautiously reassure patients who feared the worst. Or the time in Holyoke, Colo., when we brought all the patients outside -- both of them -- to watch fireworks on the Fourth of July. (One was going home the next day and the other was moving into hospice for terminal cancer. Why shouldn't they see the fireworks?)

But some shifts aren't as pleasant.

Once, our little ER on the high plains of Western Kansas received seven of nine family members involved in a rollover accident. One had been taken elsewhere, and one died at the scene. As the only physician in the ER, triaging and caring for the surviving family members and subsequently relaying the news was one of the hardest shifts I've ever had.

There was a 96-hour shift in Eastern Colorado when we saw three missing persons, two suicidal individuals and three people under the significant -- though not life-threatening -- influence of drugs. We also were brought two transient people who were making their way across the country partly by saying just the right words to catch rides via ambulance. I felt like I was running a mental health hospital or some sort of detox facility with a prison ward mixed in. This was not what I had hoped to do with my time in the ER, but it's what came through the door.

I was later reminded of that night on a different shift when, just after midnight on a Monday, I simultaneously cared for an intoxicated, suicidal 16-year-old while also trying to figure out what to do with the bedbug-infested ER regular with a longstanding drinking problem and a sweet parrot perched on his shoulder who seemed not to have a chief complaint (although the parrot had relieved itself on the man's shirt).

Then there are the shifts where I don't get to sleep. Decision-making gets harder at that point, and you don't get relief until you finish your shift. That's just how it is.

And there are those shifts that push your medical skills as a physician. A recent short shift in Memphis, Mo., challenged me as I simultaneously managed a woman hemorrhaging from a miscarriage who was quickly transitioned to the care of a local OB/Gyn (who doubled as the hospital's CEO) and a man in complete heart block who needed to be flown out ASAP but had to wait until a tornado passed through town.

Regardless of the challenges and stress they bring, I love these experiences. As my DPC practice has grown during the past 18 months, I've realized that I really don't want my practice to grow so large that it squeezes out my ability to take these shifts. The rural locums settings and my urban DPC setting allow me to do everything I love in medicine; doing both keeps me balanced. They allow me to work at the full breadth of my training, which is what I want to do.

I'm a family physician, after all.

Allison Edwards, M.D.,(www.kansascitydirectprimarycare.com) founded and cares for patients at Kansas City Direct Primary Care;(www.kansascitydirectprimarycare.com) provides locums coverage at rural hospitals with Docs Who Care in Missouri, Kansas and Colorado; and is volunteer faculty at both the University of Colorado and the University of Kansas. You can follow her on Twitter at @KansasCityDPC.(twitter.com)

Posted at 04:57PM Aug 06, 2018 by Allison Edwards, M.D.

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