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Tuesday Jan 15, 2019
Beat the Clock: Why I Chose Direct Primary Care
Tuesday Dec 11, 2018
Why I Love Working in a Community Health Center
Luis Garcia, M.D., spoke with several colleagues who work in community health centers, as he does, about what makes these practices so rewarding for family physicians. Read what they had to say in this Fresh Perspectives blog post.
Tuesday Oct 30, 2018
Why We Need More Physician Entrepreneurs
Monday Aug 06, 2018
Rural Locums Provide Balance for Urban Doc
Tuesday Jan 02, 2018
New Year, Same Issues. Why Does Health Care Cost So Much?
Tuesday Dec 05, 2017
Rural or Urban FP, We Both Handle Gamut of Patient Issues
Tuesday Aug 29, 2017
Health Care Debates Don't Have to Be Heated
Tuesday Jun 20, 2017
Putting Patients at the Center of My 'Clinic of the Future'
Tuesday Jul 12, 2016
Support, Flexibility at Home, Work Vital to Success in Rural Practice
I have been reflecting on this blog for several days now, waiting for a rare down moment to write about what being a rural female physician means to me. Tonight, as I finally have some time, I realize that the unique challenges of rural practice make life unpredictable and possibly difficult for other physicians to relate to.
My husband (and practice partner) had rounds this Sunday morning at the hospital, so he dropped my daughter and me off at church and headed to work. At church, I received a phone call telling me that I also was needed at the hospital for one of my obstetric patients. I let my daughter's Sunday school teacher know I would be leaving but that my husband would be back to pick her up.
DMW PhotographyMy husband, Michael Oller, M.D., and I enjoy rural practice in Stockton, Kan., where we live with our daughter, Lyla, and mastiffs Mitch and Mosi.
My husband came back to church to get me, dropped me at the hospital, finished his own work and returned to church to pick up our daughter. A favor from a friend later and we each had a car at the hospital so my husband could take our daughter home while I stayed to deliver a baby.
It might sound crazy, but these are situations we frequently encounter. With supportive partners at home and at work, as well as support from friends and our community, however, they always work out. I sit here tonight having helped bring a beautiful baby into the world but also having had to give up a large part of my Sunday. I consider it a worthwhile trade.
The impetus for this blog was a study published in the May/June issue of Annals of Family Medicine(www.annfammed.org) that sought to "understand the personal and professional strategies that enable women in rural family medicine to balance work and personal demands and achieve long-term career satisfaction." The study was based on a survey of 25 rural female physicians in 13 states.
The authors identified three things study participants considered imperative for successful rural medicine careers:
- supportive relationships with spouses and partners, parents, or other members of the community;
- reduced or flexible work hours; and
- maintenance of clear boundaries between their work and personal lives.
The United States has a severe shortage of rural physicians, including a dearth of female and minority physicians. The lack of female physicians limits access to care for female patients who would prefer a female clinician. Rural female physicians are more likely to attend births(www.ncbi.nlm.nih.gov) than our male peers, which is an important part of practice in many rural areas with a shortage of obstetric care.
Many rural physicians choose this path because it allows them to maintain a broad scope of practice. However, this broad scope often also leads to long and unpredictable hours that vary greatly from week to week. (Today's delivery was the third this week for me, leading to longer hours than usual). Creating the support system necessary to meet patients' needs while also supporting our families takes great effort.
What attracts women to rural practice? The majority of the physicians surveyed had rural life experience. However, there are others, like me, who turned their attention to rural practice after experiencing it in a rotation. I graduated from the University of Kansas Medical School, where a rural rotation is required, and I continue to firmly believe that such experiences matter greatly in the choice of future practice.
We must continue to model for medical students what is great about our specialty, and those of us who practice in a rural setting need to be willing to precept students. It is a rare month when my partners or I don't have a medical student in our practice, and often more than one of us have students at the same time. I am proof that having a female rural medicine preceptor can take a practice setting that had never even been on your radar and make it your career. (That preceptor is now one of my practice partners.)
There are many challenges of rural practice. As the Annals study points out, rural physicians have fewer community resources, work more hours and care for more patients compared with their urban peers. This produces added stress and, at times, feelings of isolation. In the study, physicians with young children and those new to rural practice described feeling the stress of maintaining balance most acutely. The guilt of leaving family to care for patients and, conversely, spending time with family at the expense of time in your practice, are frequent sources of stress.
Those with good work flexibility reported highest satisfaction. For many in the study, this meant reduced work hours, especially when their children were young.
Supportive relationships are also key. Several of the women in the study reported male partners maintaining primary responsibility for managing the household and caring for children. Many had situations similar to mine -- married to physicians in the same practice. In all of those two-physician partnerships, one or both partners worked part time.
Work partners are also important -- other physicians who are willing to help out when family obligations and emergencies arise. We are expecting twins in the fall, and although I don't know exactly what our work schedules will look like when they come, I know that owning our own practice gives us the flexibility we need.
I received an email from my practice partners this evening saying they have devised a back-up call schedule that covers the weeks leading up to the twins' due date. This is the kind of cooperation that makes rural practice, with all of its additional stresses and challenges, sustainable.
Clear boundaries were identified as key for satisfaction. Limiting work and protecting personal time were seen as essential for personal well-being. Work partners often played an important role in this. In my experience, setting expectations for patients can be hard but is extremely important in rural environments; examples include respecting physicians' days off and time with family (i.e., not approaching them with medical questions in a public place).
Corresponding author Julie Phillips, M.D., M.P.H., told AAFP News that rural physicians in the study showed "a really strong sense of devotion to their patients and commitment to their communities." Although it was clear that most physicians in the study loved their work, there were also those looking to change practice because they felt their current situation was unsustainable.
The authors of the study concluded that female physicians considering rural practice may be more satisfied if they seek flexible employment opportunities, choose communities where support is available and build support networks as they select practice settings.
Practicing self-care and setting boundaries are also important skills. These are skills, however, that we are not often taught. Perhaps they could be covered more in medical training, especially in residency. Female physicians entering rural practice need the support of those who have gone before them. These relationships can be fostered through state and national academies, rural interest groups (such as online forums offered by the AAFP), and preceptors encountered during training.
Women need opportunities in residency training to rotate with rural female physicians. Those of us who live this practice style need to be available to serve as mentors and sounding boards. Female rural physicians are more likely than their male counterparts to plan on long-term rural careers, so let's continue to evaluate and work toward making more rural female physicians a reality.
Beth Oller, M.D., practices full-scope family medicine with her husband, Michael Oller, M.D., in Stockton, Kan.
Tuesday Mar 29, 2016
So Long, New York, You Were Exactly the Trial This New FP Needed
As an osteopathic medical student in Arizona, I had a lot of classmates and professors question why I wanted to go across the country to New York City for my residency in family medicine.
The West Coast -- where I grew up -- has a strong family medicine tradition, whereas New York City is perceived to have a strong focus on specialty care. Not only have I met several New Yorkers who did not even know that family physicians exist, I have worked with medical students whose school has no family medicine department and with other medical students who question whether they can find a good job in NYC if they pick family medicine.
So why choose to be in an environment that might, at best, be skeptical of family medicine?
My residency, the Mount Sinai Beth Israel Residency in Urban Family Medicine(www.institute.org) offers a diversity and complexity of patients that is unique to New York. With patients from around the globe, we had to keep a broad differential in mind as we also learned to treat the "bread and butter" family medicine cases.
But there was something far more important to my learning as a physician than the diagnoses that I made. My patients not only came from different countries, had different socioeconomic backgrounds and spoke different languages, they often had differing views of disease processes and expectations of the patient-physician relationship.
In medical school, we learned the textbook ways to diagnose and treat, but in residency I learned how much patients' cultural backgrounds can influence their recounting of symptoms and their relationship with their own body. We know how crucial the history is to finding the right diagnosis, particularly as we try to minimize extraneous and expensive tests that add burdensome costs for our patients and our health care system. When the patient and the physician have wildly different life experiences, language is often not the only barrier that needs to be recognized in order to appropriately diagnose and care for the patient.
After residency, I continued with the same family medicine organization that my residency was affiliated with. I have spent nearly three years in the Bronx with an international patient population, many of whom have language, health literacy and socioeconomic barriers that make it difficult for them to navigate our health care system.
I am surrounded by all the subspecialists that New York has to offer -- several of whom are rated top in their field -- but the majority of my patients simply cannot access them. Their need for a family physician and a patient-centered medical home (PCMH) to support their health and the health of their family is dramatic.
When they enter my clinic and find friendly staff who know their name, speak their language, and do not judge them for a lack of insurance, employment or even basic reading skills, my patients begin to feel hope.
When we ask them questions about their ability to access healthy food and whether they feel safe in their current housing situation, my patients begin to realize that we in family medicine understand how much social determinants of health impact our community.
When our clinic goes to great lengths to obtain records from outside clinics and to call patients to come in for a visit after their recent trip to the emergency room, my patients begin to understand what it means to have a family physician and a medical home.
There are many community clinics throughout the country that have made a commendable effort to gain PCMH recognition and to be part of a safety net for their patients; our clinic is not unique in that respect. But there are times when the degree of disparity between my patients and the affluent patients who can access the "best" care in the nation clearly weighs on my patients. They are deeply aware of what they do not have and what they cannot access. And they are often resentful of the discrimination they have faced because of these disparities.
Working within this community has enabled me to witness firsthand what I learned while pursing my master of public health degree -- that a community's resources and environment can have an enormous impact on the health of its residents. It has been exciting to be part of my local AFP chapter and to contribute to the enactment of bills that can make a real difference in the health of New Yorkers, such as a lower speed limit to reduce pedestrian deaths and expansion of health coverage for pregnant women.
In a few months I'll be moving back to the West Coast, primarily for family reasons. It was a difficult decision, and there are many things about New York -- particularly the people I've come to know -- that I will truly miss. As is true with any major change, my upcoming relocation has given me the opportunity to reflect on my time as a family physician in New York. This is the only environment I've worked in as a practicing physician, and although I have encountered the occasional frustration when dealing with a subspecialist here and there, the overwhelming experience has been better than I even imagined when I applied during medical school.
Family physicians are a diverse group with a diverse set of skills to treat the communities we work (and often live) in. My work during the past several years has taught me a great deal about caring for communities that are in need of creative, evidence-based, compassionate primary care. I have built a foundation that will influence my practice of medicine wherever I go, and for that, I will always be grateful to New York and its patients.
Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services, including osteopathic manipulation, at a community health center in the Bronx, N.Y. She is actively involved in teaching residents and medical students to deliver evidenced-based care to underserved communities.
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