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Monday Aug 27, 2018

Putting My Broad-scope Training to the Test

I have lived my entire life in Alabama. Although I moved around the state during my education, including to small- and medium-sized college towns and large metropolitan cities, I spent my entire clinical education and residency in Huntsville, where my residency was a hybrid community and academic center program.

[fill the gaps written on brick wall]

Although there was an internal medicine residency at our campus, the family medicine residents ran the pediatrics, OB/Gyn and family medicine services, which meant we didn't have to compete for learning opportunities. Our hospital was a nearly 1,000-bed Level 1 trauma and tertiary referral center, so we had the best of both worlds. We had all medical specialties both to learn from and refer our patients to when needed.

I chose the University of Alabama at Birmingham Huntsville Family Medicine Residency Program because I knew it would prepare me for practice in a rural area, and it didn't take long for my broad-scope training to be put to the test.

When I graduated, I moved to a small town close to home. I found a hospital in a city that was similar to my hometown in that it had once been a textile manufacturing center, but that industry had long since moved out. Russell Medical Center in Alexander City, Ala., was an attractive place to practice because although the town was small and rural, it had an unusual number of subspecialists.

Alexander City had the following subspecialties when I started my practice: anesthesiology, breast surgery, cardiology, colorectal surgery, dermatology, emergency medicine, gastroenterology, general surgery, hematology/oncology, nephrology, neurology, OB/Gyn, ophthalmology, orthopedic surgery, otolaryngology, pulmonology, radiation oncology, rheumatology, urogynecology, urology and wound care/hyperbaric medicine. It's uncommon to find a list that long in a town of 15,000 people.

As a family physician, I strive to provide care for any issue my patients have. However, there will always be a need for subspecialty expertise when a patient's problems exceed our training and experience, so having such a wide range of subspecialists available was great for our patients. But many of those practices were just a single doctor, so if one physician left, many patients would lose access to that particular type of subspecialty care.

I recently finished my first year of practice, during which we lost our pulmonologist, rheumatologist, neurologist and one of two orthopedic surgeons, and we are currently on our fourth and fifth general surgeons.

Although that may not seem devastating, many of our patients were receiving specialty drugs and treatments from these subspecialists. Since their departures, primary care doctors have had to learn more about those drugs and treatments so we could continue treating those patients without the help of our former colleagues.

The loss of these physicians also has increased demand for subspecialists in nearby towns, with waits for new referrals approaching six months. It also puts a lot more stress on my patients. Many of them are forced to drive much longer distances for care, and struggles with transportation issues already were common.

One of my patients, Glenda, has lupus and was seeing our local rheumatologist when she began coming to me for primary care. At the time, she was doing well and was well controlled on her medicines. The rheumatologist left about one month after I started practicing. Glenda came to me one day nervous about the loss of her other doctor. I assured her that I would take care of her and continue all her medicines in his absence, but I also hoped that she would remain well controlled because the wait to see the nearest rheumatologist was nearly a year.

About six months ago, Glenda's lupus symptoms started to flare up, and she began having more complications. I was initially uncomfortable managing these symptoms and issues, but her treatment couldn't wait, so I read and learned all I could about adjusting her therapy. I was able to lessen some of her symptoms, but there were some treatments for which I lacked exposure or familiarity. We got her in to see a new rheumatologist in about four months. Each time I see her, though, she asks if there is any hope of getting a new rheumatologist in Alexander City because her new one is 90 minutes away.

I know our hospital would like to recruit a new rheumatologist, but that is not an easy task. We are looking at telemedicine resources to help fill the gaps in subspecialty care.

I certainly hold out hope for improved access to subspecialist care for my patients, and I will continue to care for my patients because that is what we do as family doctors.

I heard many times during residency that you learn a lot your first year in practice, and I can say, without a doubt, that this has held true.

Tate Hinkle, M.D., is a family physician in Alexander City, Ala. You can follow him on Twitter @bthinkle.(twitter.com)

Posted at 03:46PM Aug 27, 2018 by Tate Hinkle, M.D.

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