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Tuesday Sep 24, 2019

How Can I NOT Be Rural Enough?

If I had to describe my practice in one word it would be "rural." There are a ton of other descriptors I could give, but most of them go back to the fact that this is a rural area.

[rural road]

Government agencies have declined my applications for rural health programs because my federally qualified health center doesn't meet their definition of "rural." The roads I take to visit my patients in Clay County, W.Va., tell a different story.

It took me a long time -- I'd say three years -- for most of my patient population to believe me when I told them I'm not leaving. My first conversation with most patients started with, "So, are you going to leave just like every other doctor who has ever been here?" Five years later, I still spend time reassuring patients of my intention to have a long career in my current office.

From day one, I reassured people that I came to Clay, W.Va., intending to retire here. I readily admitted to patients and to my colleagues that it was a rather naive plan. Most physicians change jobs multiple times in their lives. I'm not sure data showing the percentage of doctors who spend their entire careers in the same set of exam rooms even exists.

There is a perception across the country that if you are working in a rural area, you are likely there for loan repayment. And, historically, that was true. There are some well-known family physicians (think Robert Walker, M.D., here in West Virginia) whose names are recognized throughout their states by their peers and medical students alike. Doctors were wooed from out of state by loan repayment programs, usually sponsored by the National Health Service Corps, and flourished in the areas in which they worked. And that generation, let me say, had much smaller debt-to-income ratios than we do today. Yet the program worked. It brought motivated scholars to areas that didn't have physicians. And they didn't stop at seeing patients in their exam rooms. They became pillars in the education of medical students and residents. They grew community-based projects that made impacts in public health.

Many doctors who benefited from such programs have retired or are retiring, and they are sometimes replaced by nonphysicians who are receiving loan repayment money. Yet physicians in my generation, even if we go to rural, underserved areas, don't appear to be receiving loan repayment like our predecessors did.

I recently did an interview with Medscape(www.medscape.com) about rural hospital closures, and the reporter asked me why I am willing to work in a rural county with no hospital, a poverty rate near 30% and no grocery store. He also asked what would help entice more doctors to work in rural areas.

I've always found it comical when I try to explain why I like living and working in rural West Virginia. People who live here understand, obviously. But people who have never been here, and some who have, say they absolutely do not see how I do my job where I do it or how I manage to live here. They always ask what in the world I do for fun. They can't imagine not sitting in traffic, not having more options than they can count for picking up dinner or not having multiple gyms to choose from on their way home from work.

It is hard to explain to someone why you love where you are. But at least once a week, one of my patients tells me a story that I literally wouldn't have thought was still possible in the United States. For example, I have patients who carry water from a creek to homes that lack running water. And such stories aren't unique to West Virginia.

I did a rotation in Montana where the rural patients were just as successful at blowing my mind with their mechanisms of injury, their social struggles and their ability to survive profound poverty. But those in positions to affect policy evidently do not understand the details of rural living. Not only do current policies and programs fail to recruit enough doctors, they miss the mark with patient care, as well.

Patients in rural areas often fall through the cracks of social services and are extremely hard to treat via traditional pathways. Just to name a few, there are barriers of geography, communication, transportation and trust to overcome. Other patient populations share many of these challenges, but rural populations have some unexpected characteristics, such as a feeling of isolation even in the presence of other people.(www.ruralhealthinfo.org) 

And then there are more puzzling barriers. After the 2010 census, my clinic lost the ability to do telehealth diabetic eye exams for Medicare patients because the Health Resources and Services Administration deemed Clay County not rural. There is no transportation system or assistance program for Medicare patients here. It made no sense to me that something like a diabetic eye exam -- something that insurance companies push, measure and penalize us for not doing -- would be eliminated as a service that could be provided remotely. At the time, I couldn't even face the concept of calling Clay not rural. I just focused my anger on the fact that my most vulnerable elderly or disabled patients would not have access to diabetic eye exams even though the telehealth equipment was sitting in my office.

Fast forward to a few months later, when I received an email from NHSC, which is a HRSA program, encouraging me to apply for a new rural Substance Use Disorder Workforce Loan Repayment Program.(nhsc.hrsa.gov) I had already applied for the standard NHSC loan repayment program, but the timeline is long, with an application deadline in February and an award notification (or denial) in September.

Given my lack of actual hope of getting the standard NHSC award, I spent eight hours doing my online medication-assisted treatment training to get my Drug Addiction Treatment Act waiver and applied for the SUD program. My clinic's Health Professional Shortage Area score is 18 on a scale that maxes out at 25. A score of 18 is considered fairly high and is generally considered to be the cutoff for receiving NHSC funding, although I also know plenty of physicians who have been denied loan repayment at an 18 and plenty of nurse practitioners and physician assistants who have received funding with similar scores.

Despite my site's loss of access to diabetic eye exams, I somehow didn't anticipate getting a denial before I even finished my application for the SUD program with an email stating my "site is not located in an area designated as rural." In retrospect, I guess I should have expected it, even though NHSC encouraged me to apply.

I had a similar experience in medical school with a scholarship for students interested in rural family medicine administered by the Family Medicine Foundation of West Virginia. I applied annually for three years, each time receiving a denial, until year four, when I didn't see any reason to apply again. Yet the foundation called to ask why I hadn't applied, so I did, and it sent me another denial letter.

The reality is, you need to expect to pay for your education. You have to want the education and the eventual career regardless of cost because it's not an easy job, even without crushing debt. You have to be happy with the setting regardless of finances because there are no guarantees. But without loan repayment, it is significantly more difficult to recruit to an area of need.

Did I think I would get NHSC loan repayment by working in Clay? Absolutely yes. But did I take this job because of that possibility? No, I took this job for many reasons I've already blogged about. I like it here, and I like the extra challenges this community brings.

And, fortunately, just this week I received notification that I will be a receiving a loan repayment award from my original NHSC application, based on a HPSA score with no rural designation requirement. I've already been here for five years, so loan repayment isn't why I came, but I am definitely grateful. And as documentation and prior authorization burdens continue to increase, combined with what feels like an impossible student debt and increased productivity demands, I have moments of regretting my career choice. Loan repayment helps target at least one component of that.

Back to the reporter who could not begin to understand a day in my life. My commute has involved hitting a coyote and has no stop lights. I lost electricity three times this week. It is common for me to have no running water for consecutive days due to outdated infrastructure, and there is nowhere to buy fresh produce within a 45-minute radius. A reporter from The New York Times asked me where I could buy a copy of the Times and where the nearest Starbucks was, and I laughed. At the time of our interview in 2016,(www.nytimes.com) the nearest stand-alone Starbucks was almost two hours away.

That latest reporter I talked to -- for the aforementioned Medscape interview -- asked what I thought needed to happen to secure a large enough rural physician workforce in the future. And rather than saying more loan repayment money, I said more resources for our patients. More funding for social programs and poverty safety nets. Loan repayment sure wouldn't hurt, but making our jobs less emotionally draining would go a long way.

I help pack food into people's vehicles during distribution events the Mountaineer Food Bank and the United Way hold every other week in Clay. One of my patients recently told me that he drinks an entire gallon of milk within the first 24 hours because he has no refrigeration. He wasn't complaining. In fact, he was grateful to get the food and was impressed by the quantity of the items and the protein sources. And, of course, a few of us pooled some cash, and my community health worker delivered him a fridge.

Although reporters can't imagine living and working where I do, I can't imagine being a doctor who only solves problems inside an exam room. And that is what I think HRSA is missing. Mileage to a state's capital city isn't the only indicator of patients' needs, or even their ability to access resources. And when HRSA considers the percent of people who commute to a nearby county as it makes its determinations, it doesn't take into account the majority of people in an area with more than 50% unemployment. If such agencies want to remain relevant as a means of bringing motivated physicians to areas of need, they need to open their eyes to the people they are supposedly serving.

I called HRSA to discuss this, and I have hope that Clay County will regain its rural designation, but it isn't a fast-moving process. Designations follow census patterns, so after 2020 data is analyzed, we will have an opportunity to publicly comment. By 2023, I anticipate a change. But things like this don't happen on their own. HRSA isn't visiting our patients. (They do sometimes visit our offices, but not our patients.) We have to tell our patients' stories.

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va. You can follow her on Twitter @BecherKimberly.(twitter.com)

Read other posts by this blogger.

Posted at 11:46AM Sep 24, 2019 by Kimberly Becher, M.D.

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