December 19, 2018 11:50 am Sheri Porter – (Editor's note: Family physicians provide 42 percent of care 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.)
With 268,581 square miles of ground, Texas is second among all states in the nation when it comes to total land size. It's also home to nearly 28.5 million people -- 3 million of whom live in rural communities.
Shelley Kohlleppel, M.D., a native Texan, is doing her part to give back by providing health care to about 6,000 patients in her solo family medicine clinic in Lakehills, Texas.
Kohlleppel's road to family medicine is a classic tale of a girl born and raised in a small rural town who entered medical school and then residency with every intention of staying close to her hometown roots.
"I shadowed a physician before I got into medical school," Kohlleppel told AAFP News. "That's where I discovered I wanted to be a family physician."
After graduating from the McGovern Medical School at the University of Texas Health Science Center at Houston and completing the John Peter Smith Hospital Family Medicine Residency in Fort Worth, Kohlleppel stayed in her home state.
"I was able to get $160,000 (paid out over four years) from the the state of Texas for my loans because I wanted to practice in a rural area," she said.
This is the story of her journey.
Shelley Kohlleppel, M.D., has created a solo family medicine practice in rural Lakehills, Texas, that is about 45 minutes from her hometown.
Kohlleppel attended both medical school and residency in Texas.
She received $160,000 to help cover her education loans from the state of Texas, paid out over four years, when she set up shop in a rural community.
Even though Kohlleppel grew up in a farming community near LaCoste, Texas, just 45 minutes away from her current practice, it still took some time to find her footing in Lakehills. Nearly seven years, to be precise.
Straight out of residency, she tried working for a large group practice in San Antonio, but she knew it wasn't a good fit after just one year. Soon after, Kohlleppel bought the then-shuttered satellite Medina Lake Clinic from her employer and launched her solo practice.
She wheedled her way into the hearts of the locals by immersing herself in the community. For starters, she showed up at the town fire department, attended public meetings and began volunteering at various functions.
Next stop, places of worship. "We have lots of churches, so I just started going to all their fundraisers -- getting to know each church and its attendees -- and before long, everyone in the community knew me," said Kohlleppel.
From there, her practice took off. Kohlleppel is the only family physician in town; in fact, there's not another physician of any specialty for at least 30 miles in any direction.
There is one downside to all that comradery. "A lot of people like to call me Shelley instead of Dr. K or Dr. Kohlleppel, and that's been kind of hard. But I do understand, because for many people here, I've become part of the family," she said.
Kohlleppel quickly settled into a clinical practice routine that mirrors those of family physicians across the country -- except her patient panel exceeds Lakehills' total population by nearly 1,000.
She employs a staff of three: two front-office personnel and a recently hired nurse practitioner.
The phrase emblazoned across her practice website -- "Modern Medicine with Old Fashioned Kindness" -- epitomizes the compassionate health care Kohlleppel strives to provide her patients, including the occasional house call when necessary.
"We were trying to get a patient set up on hospice care, and the Blue Cross HMO was giving us some craziness about all the approvals they needed to make that happen. So I went ahead and visited him in his home to try and get him settled until we could get hospice on board," said Kohlleppel.
This family physician is tuned into her town and those who live there, and she's acutely aware of patients who struggle economically. And so on occasion, when a person comes up short on the payment end, Kohlleppel isn't opposed to getting creative.
The new shingles on her office roof serve as an apt example of her willingness to barter, a learned kindness she attributes to her farmer father.
Kohlleppel's full-scope training comes in handy in a town with no other physician. "I do any procedure I can do in clinic -- like toenail removal, lesion removal, fractures, sutures," along with the necessary chronic, preventive and wellness care for all ages, she said.
Above all else, Kohlleppel relishes listening and learning.
"Based on what my patients tell me, I like to talk," said Kohlleppel with a laugh. "That's been my passion from the start. I like to sit down and chat with them -- go through things. Patients tell me their doctors in San Antonio and in bigger practices don't spend that time with them and stick to the 15-minute visit."
Early on, Kohlleppel tried to branch out. She experimented with providing care to nursing home patients in neighboring Bandera, but after a year of traveling back and forth, she realized the clinic suffered in her absence.
With some reluctance, she also passed on including obstetrical care in her menu of services, something she very much enjoyed during residency. Kohlleppel understood that taking on 24-hour call to deliver babies -- when the nearest hospital is 45 minutes away -- wasn't realistic for a solo family physician.
Opening and maintaining a solo practice is not for the faint of heart, and Kohlleppel isn't shy about pointing out the challenges.
The lack of professional support weighs heavily on her. "I have not taken a vacation in seven years, and sometimes, when I have to be out of the office, I feel guilty. What if a patient needs something when I'm gone?"
And being just 40 miles from San Antonio is a disadvantage in that some patients cling to their "city" physicians for primary care and rely on Kohlleppel for urgent care, especially when it comes to pediatric visits.
"I constantly educate families and remind them I am a primary care doctor and can take care of everything for them," she said.
Staff turnover is another prickly topic.
"It's hard to pull from the workforce pool out here. We're about 30 minutes from the outskirts of San Antonio, but a lot of people don't want that daily drive to work," said Kohlleppel.
Furthermore, people living in Lakehills or any of the surrounding towns that pepper the Texas countryside -- including Pipe Creek, Bandera and Mico -- can command a larger paycheck in the city.
Kohlleppel noted that in the not-so-distant past, meeting payroll and overhead sometimes meant she held her own paycheck, a scenario no small business owner ever wants to face.
However, a recent positive change involved switching from in-house billing to an outside billing company with a certified coder on staff. Kohlleppel is now far more confident that she's pulling in the appropriate payment for services delivered.
Kohlleppel acknowledged the hard work it takes to build a solo practice but declared she's in it for the long haul. "I'm here until the Lord says it's time to go, so I'm going to make sure that my practice is stable," she said.
"Once I get my main building paid off, I plan on expanding the clinic and making it easier for my patients and myself."
Her wish list includes growing the practice to include another family physician, physical therapy options for patients and a pharmacy.
In fact, there's no pharmacy in town, and the only delivery option is one pharmacy in Bandera that delivers to patients only one day a week.
"When patients see me, they literally have to drive 30 minutes to the pharmacy and 30 minutes back," said Kohlleppel.
Optimally, someday she'll have available space in her building for a small pharmacy to operate, even if it's for just a few hours a day.
"It would be nice if patients could leave with some antibiotics," she said.
"I grew up as the second of nine kids," said Kohlleppel. "My parents taught me about helping out in the community, giving back to the community and using what you can within the community.
"Sometimes you just have to do what it takes to help people out," she said.