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Friday Aug 01, 2014

Rural Practice May Pose Challenges, But It's Where I Was Meant to Be

Two years ago, at the beginning of my second year of residency, I signed a contract to work in a rural county in West Virginia. Although I've known where I was going for quite a while, I don't think I really understood what living here would mean until now.

I grew up in what most people would consider a rural area of West Virginia, but my new home is in an even less developed region of the state. You know the kind of area I mean, where you are driving down the interstate and there is nothing to see but trees. There are no gas stations and few restaurants -- it's really mostly just trees. Not only does the town nearest me not have a stoplight, there's no stoplight to be found in the entire county -- nor in an adjacent county, for that matter.

But this is exactly where I want to be. I love growing a lot of my own food and cooking or canning it. I wanted a home where my husband could hunt and my son could fish, and we were fortunate to find just that. The sense of community in these rural areas is genuine and is part of what drew me to work and live here. I did multiple rotations away from my medical school and residency, and those that really stood out for me were the rural ones. It was obvious to me that rural West Virginia was where I was meant to practice. Often, people will live in a larger city and commute to work because that is what resonates with their family or their lifestyle. Not us. We wanted to hear nothing but bugs when we open our windows at night.

There are things that I hadn't considered about living here, however, that quickly revealed themselves. The first neighbor I met warned me that the power goes out often, and that if it stays off long enough, there is no water either (not that I'm all that excited about tainted West Virginia water), because an electric pump brings it up the mountain.

I've also been warned that the road floods, and that I might get stuck at home or be unable to get home if there is too much rain, too much snow, or -- the more common scenario in a West Virginia flood -- too much of both together.

And then there is the Internet, which is only available through a satellite provider. It is expensive, takes eons to download documents and, generally speaking, makes it a struggle to even check my email. Gone are the days of streaming World Cup games or watching programs on Netflix.

Also gone is the option of running down to the local Mexican restaurant to watch a game while someone else cooks dinner; that's because the only restaurants in town are a Dairy Queen that closes during the winter and a carry-out pizza place. Oh wait, there's also a Tudor's Biscuit World, a standard found in nearly every small West Virginia town that I can't even begin to explain.

Don't get me wrong, I am happier than I've been in years. We eat food we cook ourselves for every meal and spend far more time outside. We could spend hours identifying birds and picking blackberries. My son is learning to ride his bike on our road, which might see three cars on a busy day. The moon rises behind two distant mountain ridges that we can see from our deck.

I realize this lifestyle is not for everyone. Although many of my patients and I choose to live in a rural part of our state, many are here by default. West Virginia has the highest homeownership rate in the country at 76 percent. That's right -- we are first in something positive.

It is a multifactorial situation driven, in large part, by a tendency to stay close to home, inherit land and homes, but also because there are not adequate employment and education opportunities for many of the state's residents.

One thing I have already learned is that most of the public health and wellness strategies used in larger cities will not work here. There is no venue for truly large-scale advertising because much of the population -- regardless of financial status -- relies on the newspaper and does not have access to the Web due to limited Internet availability. You can't direct patients to healthcare.gov or familydoctor.org. These patients need doctors, often doctors who will go to their homes, and patient information developed with appropriate health literacy in mind. Even a simple obesity intervention such as calorie-counting is often doomed to failure because many people cook from scratch and there are no food labels.

But these are challenges I embrace. I value the trust my patients place in me, and reaching out to connect with them to find solutions to their health care challenges -- especially those complicated by social, financial or logistical hurdles -- strengthens that relationship far more than any simple treatment regimen. I live here; I understand.

In addition to appreciating rural living challenges, I have been experiencing life without health insurance. I didn't go straight through college and medical school so -- like some of my patients -- I've had periods of time without health insurance coverage in the past. I have always found my advocacy voice for the uninsured to be louder than some, partly because of my first-hand experience with the medical system from an uninsured perspective.

The first time I found myself uninsured, I was 22 years old, had just graduated from college (this was before you could stay on your parents' plan until age 26), and was living in remote West Virginia in the Monongahela National Forest working on a research project as a contract employee. I would run on the rail trails nearby, and one evening, I rolled and broke something in my ankle. I don't know exactly what I broke because I didn't have enough money to seek medical attention. I bought a plastic air cast that I duct-taped into a hiking boot and went back to work because there were zero sick days. So, not only did I experience an injury without access to health care, I still live with the implications of an untreated fracture that didn't heal properly.

At least then it was just me. Now I have a family for whom I had provided health insurance for years, but that coverage ended June 30 when I graduated from residency. Why not just start my new job July 1? Insurance companies take up to 90 days to credential health care professionals, and until that process is complete, I can't see patients. So, just as many other graduating residents who have a gap between graduation and starting work, I again do not have health insurance. Granted, there are safety nets in place; I could extend my prior plan under COBRA (the Consolidated Omnibus Budget Reconciliation Act), if needed, and in West Virginia, we have an extensive network of federally qualified health centers where I can pay according to a sliding scale based on my income. However, a gap in coverage is a gap in access to my primary care health professional and to preventive services for my family, as well as being a huge gap in my peace of mind.

I think I am a pretty responsible person, and I value continuity of care. Yet here I sit with no ready access to health care despite knowing the risks and insurance industry protocols. This situation further fuels my desire to promote the AAFP's vision of transforming health care to achieve optimal health for everyone. We have made some progress but we still have a lot of work left to do, and each community provides its own set of lessons to be learned.

Kimberly Becher, M.D., is the resident member of the AAFP Board of Directors.

Posted at 03:17PM Aug 01, 2014 by Kimberly Becher, M.D.

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