(Editor's note: Family physicians provide 42 percent of care(www.ruralhealthweb.org) in rural communities. AAFP News is highlighting some of these FPs in a series that focuses on why some family docs choose to practice in small towns off the beaten path and how they provide high-quality, comprehensive care to patients of all ages -- often with far fewer resources than their urban and suburban colleagues.)
Scott Anzalone, M.D., shown here in his rural Logan, Ohio, clinic, says he grew up in a small town and knew he'd return to a small town to practice medicine. "When I decided what I was going to do with my career, I knew family medicine was the right choice because I wanted to make the biggest impact possible on my patients and my community."
For Scott Anzalone, M.D., a solo family physician in Logan, Ohio -- population 7,500 -- his farm eight miles outside of town serves as a retreat from long days at his clinic. "I often go from the office to shoveling manure," he said.
But since patients have his phone number, Anzalone occasionally fields a Saturday or Sunday evening phone call. Anzalone tells it straight to those callers: "I've been working out in the field all day, but if you don't mind the way I look, meet me in my kitchen."
Yes, this rural doc has sewn up more than few patient lacerations at his kitchen table.
In a recent interview with AAFP News, Anzalone talked about the realities of rural medicine -- both the joys and the frustrations.
StageCoach Family Medicine
This FP has close to 4,000 patients ranging in age from 2 days to 97 years, and he offers full-scope family medicine minus obstetrics.
His practice is housed in one of the town's historic buildings, The Stagecoach Inn, so named because, for a time, owners offered rooms to traveling stagecoach passengers. Anzalone purchased and refurbished the building nearly a decade ago, and StageCoach Family Medicine was born.
- Scott Anzalone, M.D., a solo family physician in rural Ohio, reveals the joys and frustrations of owning an independent practice.
- Anzalone enjoys serving his patients and his community and showing medical students all that rural family medicine entails.
- His workdays are long and full, and he is stressed by the extra work associated with electronic health records, paperwork and finances.
Business is good -- some would say too good. "It's getting harder because I'm turning people away every day," said Anzalone.
In fact, he's stretched so thin that he has begun the search for a partner. But he knows it won't be easy. There's a shortage of primary care physicians in this region, a problem made worse by older docs retiring without replacements.
Add to that the surge of hospitals and health care organizations buying up independent practices.
"I'm the last man standing in private practice in Logan -- perhaps in Southeastern Ohio," said Anzalone. "Everyone is afraid to go into private practice; they don't think it can be done."
Anzalone begs to differ. With a staff of six -- one nurse practitioner, three medical assistants, a clerk and a receptionist -- he rarely refers a patient to a subspecialist.
"My goal is to care for 90-plus percent of patient problems; it's a one stop shop," said Anzalone. His solid family medicine training prepared him to do high-risk obstetrics, dermatologic procedures, colposcopies, biopsies, vasectomies, endometrial biopsies, endoscopies, colonoscopies, loop electrosurgical excision procedures for cervical cancer and more.
Many of his patients either can't or don't want to make the 50-mile trek to Columbus, Ohio, for a consultation. On certain occasions, however, Anzalone must insist.
"Sometimes I have to be firm with patients: 'No, I can't do your heart catheterization.'"
The downside to that extensive procedural menu is a long workday that invariably starts and ends with the electronic health record (EHR) and often includes a swing by Hocking Valley Community Hospital for a procedure that can't be performed in the office. Occasional inpatient visits or house calls add to an already packed schedule.
Back at the clinic, patients are waiting -- as is an avalanche of paperwork and administrative details such as prior authorizations.
"I'm always playing catch-up. I don't get lunch until I'm done for the morning, and I don't leave my office at the end of the day until everything is completed. Otherwise things just start piling up," Anzalone said.
About nine years ago, Anzalone reluctantly gave up the obstetrics portion of his practice. "I loved OB," he said. "It will always be the best part of family medicine for me."
Scott Anzalone, M.D., shown here with one of his youngest patients, says although he no longer delivers babies, he still retains a large pediatric panel. "It's a small town. I've got kids I delivered who are graduating from high school and having their own babies."
But when malpractice insurance topped $60,000 a year, Anzalone knew he couldn't continue. "I had to do about 70 deliveries a year just to break even," he said.
Soon after, the hospital closed its obstetrical unit, leaving pregnant women to travel 30 to 40 minutes to Athens or Lancaster to deliver, a situation replicated in many of America's rural communities.
Anzalone continues to teach obstetrics, and he co-manages his patients' pregnancy-related medical conditions, such as hypertension, diabetes and gestational diabetes. "I take care of the baby after it's born and Mom after the six-week checkup. I still do everything I used to except 'catch' at 3 o'clock in the morning," he said.
Patients 'Almost Like Family'
Life as a solo rural doc is non-stop exhausting. So, what keeps Anzalone in the game?
"It's the positive relationships I've built with patients through the years. These are my friends -- some are almost like family," said Anzalone. "Sometimes I have to catch myself and stop patients, because we start talking about everything else but why they're in the office.
"But that's one of the benefits, as well. I know the families -- I know Grandma and Grandpa, the aunts and uncles -- and it makes caring for patients easier because I understand the family dynamics," said Anzalone.
A basic family medicine concept for sure, but one that's amplified in a small town.
"I see my patients out and about at Walmart and the county fair. I catch my diabetics in the Chinese buffet line and see the guilt on their face when they look up and see me.
"I'll tell them, 'Now I know why your blood sugars are running high.'"
Patients appreciate that their family physician dresses down, drives a pickup truck and speaks at local events. Anzalone is president of the local school board (for the third year in a row) and is active in his church. Simply stated, Anzalone fits in; he's one of them.
Training the Next Generation
Aside from tending to his patients, Anzalone serves as a clinical associate professor and director of longitudinal clerkships at Ohio University's Heritage College of Osteopathic Medicine in Athens.
He welcomes medical students into his practice at least every Wednesday afternoon and has the same third-year longitudinal student every Thursday for a full academic year.
Anzalone knows how hard programs with rural tracks work to find clinics where students get face time with pediatric patients and hands-on practice with procedures.
When students enter Anzalone's clinic, they get both.
This 1950s-era postcard shows Logan, Ohio's, historic Stagecoach Inn when it served as a branch office of the Quaker State Oil Refining Corp. The majestic structure on Main Street was built as a family home in 1867, but in the mid-1880s, under new ownership, it was used as a stagecoach stop. Today, the building serves as a medical clinic for Scott Anzalone, M.D.
"Students love coming to my office because they get such a vast experience. I'm not one to let them sit around or follow me around like a puppy dog. I give them a lot of freedom to get in there, get their feet wet and try to make decisions -- but with a safety net," said Anzalone.
Autumn Haynes, D.O., a first-year family medicine resident at OhioHealth O'Bleness Hospital in Athens, spoke about her longitudinal integrated clerkship with Anzalone.
"It was, by far, the best part of my medical education. I looked forward to that half-day every week no matter what rotation I was on," she said. In fact, it was the version of rural family medicine that Haynes experienced in Anzalone's practice that inspired her to pursue the specialty.
Kathleen Bertuna, D.O., also of Athens, said that back in 2002, when she was a third-year medical student, she did an eight-week clerkship under Anzalone's tutelage. "The first time I assisted him for a vasectomy, I thought it was the coolest thing that this patient didn't have to drive an hour and a half to see a urologist. I was intrigued by that sort of care offered right there in his office."
Bertuna ultimately chose OB/Gyn as her specialty, but she delivered her first baby as a medical student in Logan in the middle of the night, with Anzalone by her side.
"He showed me the joy of rural medicine and of serving a small community," Bertuna.
Budget Squeeze for All
Independent practices across the country are feeling the financial squeeze that comes with providing health care in 2018, and Anzalone's clinic is no different.
"The cost of delivering care continues to increase, and reimbursement decreases -- everyone has the same problem -- but when you're in private practice in a rural town, it's becoming harder to keep the doors open," he said.
Take the cost of vaccines. "I usually have to come up with $5,000 to $6,000 a month just to keep vaccines in the refrigerator," said Anzalone, and that figure jumps even higher during flu season.
And then there's the EHR. Yes, it provides access to patient charts when he's away from the office, and electronic prescribing is a bonus. But the EHR adds hours to Anzalone's workday and cuts back on his productivity. "Before the EHR, I saw 40-plus patients a day; now I'm stressed seeing 25," he said.
Sometimes Anzalone gets creative. A couple of years ago, when serious chatter erupted about the need for behavioral health care for the town's children, he scored state grant funding for a pilot project.
A Hocking County behavioral health branch office moved into his clinic.
"I provide the medical care; they do the counseling, social work and case management for pediatric and adolescent psychiatry issues. We work together as a team to provide that care to our community," he explained. "The program has gone gangbusters; it's more than paid for itself and is now self-sustaining."
However tight the finances may be in his practice, Anzalone knows money is even scarcer for many of his patients. According to Data USA,(datausa.io) the median annual household income in Logan is about $31,000, so when patients offer to barter for his services, Anzalone accepts.
"I'm looking at my pasture fence. It represents a delivery -- a baby who's now 14," said Anzalone as he finished up a phone interview with AAFP News. He's also bartered with patients for horse feed, haircuts, chicken butchering and two beautiful Amish-crafted rocking chairs.
Despite the fact that the rockers take up a lot of space, Anzalone said he's determined to keep them. "There are names and faces attached to them. They mean too much -- more than any dollar I could earn."
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