• Docs Seeking Strong Connection to Patients Could Find it in Rural Practice

    I was sitting in a meeting in Austin, Texas, 90 miles from home, when one of my patients was injured by a piece of metal that blew off a roof. My nurse called and said that this older gentleman's head needed stitches. I asked her to refer him to the nearest emergency room, which is about 20 miles from my office.

    "He says if you won't do it, he's going home," she said.

    Such is life for a family physician in a small, rural community. Patients can be incredibly loyal, especially when you have been around for a while. I couldn't let that patient go home with a three-inch laceration on his head, so I drove the 90 miles home, treated him and drove back to my meeting.

    Rural Texas, like many small towns and farming communities around our country, desperately needs primary care physicians, so I'm happy to precept six or seven medical students each year at my clinic in Castroville.

    Most of them come from the University of Texas Health Science Center in San Antonio specifically because they want to experience rural practice. They see things here they likely would not in an urban or suburban primary care office because, by necessity, I do more urgent and emergent care than my big city peers.

    I was the only primary care doc in town when I opened my clinic 27 years ago. Today, Castroville (population 3,000) has a county health clinic and an urgent care that is open on the weekends. But people still come to me with chest pain, strains, sprains, fractures and just about everything else a full scope practice could expect.

    My nurse, Donna Winters, and I both grew up in this area, and I've known her since we were kids. Donna and my office manager, Cheryl Fournier, both have been with me for more than 25 years, and I suppose we've seen it all.

    One day, Donna pulled me out of an exam room, although I was with a patient.

    "Come with me right now," she said.

    She led me to another exam room where a female patient was on the table writhing in pain.

    "I have appendicitis!" the patient said.

    Donna looked at me and shook her head.

    "No, she doesn’t," she said.

    The patient, in fact, was about to give birth. It was a breech delivery, but we managed it right there in the office, and both the mother and child did fine. That's not the way it would have happened on the third floor of a professional building in San Antonio, but you have to be prepared for anything in a small town.

    One day, a man came in with a sack and said, "I've been bit by a snake. I killed it, and it's in this sack."

    I told a staff member to put the sack in the nurse's station sink, and I went in to an exam room to look at the man's wound. I discerned that it was not a rattlesnake bite and went back to the nurse's station get a look at the snake. The sack, however, was now empty.

    Like I said, prepare for everything.

    When the medical students come here, I encourage them to consider rural practice. I tell them it can be a wonderful life experience, but I tell them the negatives as well as the positives.

    In a town this small, you have to know that everyone is going to know your business. I've never had an unlisted home phone number. People don't abuse it, but they will call if they need something important. Occasionally, I have had people show up at my door.

    If that level of connectedness makes you uncomfortable, small-town practice probably isn't for you.

    I never have to ask medical students if they are going to practice in a town like mine. My patients do that for me.

    "Are you going to do this?" they say. "We need docs in small towns."

    I tell students that I love being a small town family physician. Hopefully, they will witness some of the moments that make me feel that way.

    I recently lost a patient to esophageal cancer. When the chemo stopped working and things started to go badly, I worked with him and helped him make decisions about end-of-life care. After he passed, his widow asked me when I was planning to retire.

    "I'm not," I said.

    "Good," she said, "because when my time comes, I want you to do for me what you did for my husband."

    When things like that happen, you go to bed at night thinking, "I'm doing the right thing."

    I meant what I told that woman. I have no plans to retire. I see 30 to 40 patients a day. I hired a second physician several years ago, and together, we have more than 6,000 patients. I hope to grow the practice so that I can scale back my hours as age demands it, but as long as my mind and body are fit, I plan to keep doing what I love.

    Hopefully, there will be someone to take my place when I can't do it any longer. Employed physicians account for 60 percent of the AAFP's membership, and less than 20 percent of our members are solo docs. Neither trend bodes well for our rural communities.

    Before I opened my practice in 1985, seven banks turned down my request for a start-up loan. The eighth bank I visited made it possible to build and open a practice. Today, it's even more difficult for young physicians to get started.

    But not impossible.

    If a new physician interested in rural medicine could find one or two like-minded colleagues, the expenses, and risks, of starting a new practice could be shared.

    If you can make it work, it's an amazing life.

    Lloyd Van Winkle, M.D., is a member of the AAFP Board of Directors.


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