When I set up a rural rotation in my hometown of Lewisburg, West Virginia, I thought my experience would be geared towards finding a solution with minimal resources. Lewisburg has approximately 5,000 in population with a 113-bed hospital. I have romanticized returning home to learn from the community physicians and to treat my neighbors.
In the Rural and Wilderness Medicine Track, we had courses on stabilizing and treating in situations where time and tests would not be available. We learned how to stabilize broken femurs, pelvis, ankles and major joints for ligamentous tears. As a group, we spent a week in Craig, Colorado learning the tricks of the trade of rural medicine. Some of the lessons were directed on using common household items for rescue splints and stretchers, as well as suture materials. For example, we transformed a backpack into a stretcher with a neck brace. We made a nail into a fishing hook. A silver mug and a stick with a piece of cloth stabilized a broken femur. We practiced knot tying so that if we only had a rope we would be able to make a stretcher, perform a river rescue, and be able to tie up a horse. Our time in these extra classes were a lot of fun, to say the least.
Rural and poverty live hand-in-hand. West Virginia’s economy has been progressively failing for decades with the strict regulations placed on coal production.1 The largest city is its capital, Charleston, with 49,138 people in population. To put the number into perspective, Pueblo, Colorado has a population of 110,291, making it the 10th largest city in Colorado. The people of West Virginia have been seeking new job opportunities elsewhere so that they may provide for their families. The median income of Greenbrier County is $39,746.3
What I have found in my rotation in Lewisburg is that the biggest battle for rural physicians is with insurance coverage and patient care. In a conversation with Dr. X, my preceptor, she stressed her concerns for the future of healthcare: “We have to get out from under the grip of insurances. I am unable to fully treat in the way that I need to for some patients. It is a disservice to their health, as well as their mental fight.”2 I agree with Dr. X. The treatment and medications are limited regardless if it is a private insurance or Medicare/Medicaid. The different insurance plans and coverage [options] were not part of the curriculum for the first two years. I thought I knew the first line of treatment for certain conditions. When you put insurance limitations in the mix, it adds multiple steps to the treatment plan algorithm. I found that rural medicine was not just what can you do with little materials but more what can you do to fight for your patients care and well-being.2
When I continued to answer the first drug or test of choice wrong to my provider, I was discouraged and felt incompetent. I realized that it was extremely difficult to relate hypothetical cases and board-style questions to real patients. Insurance was a factor but also the complexity of an individual’s case. When you include multiple comorbidities, past history, and their financial situation, the first-line treatment or test may not be an option (or some other modality has to be tried beforehand). Caring for the whole patient took a new definition. I decided to dive in and absorb as much of this experience as I could. My time in a family medicine private practice was extremely humbling. Dr. X is a friend, a confidant, a community leader, and advocate for her patients. She will fight for her patient’s treatment with hope, faith, and trust as the cornerstone of her practice.
I decided to view my family practice experience as a member of the office team. I stopped trying to get the answer right and started listening. If a flue shot needed to be given, I was the first to volunteer. I took my practice wherever I could receive it. I started asking questions for different cases that were more complex. I viewed the patients as people instead of chief complaints. Once I tailored my history taking skills to the specific insurance and patient’s chronic illnesses, I found that I was helping the physician instead of holding her up throughout her hectic day. By the end of my rotation, I felt like a member of the practice, a piece of the machinery that moves without error.
My rural family medicine rotation was not what I expected, but I dove in and took advantage of every opportunity. I realized that insurances and treatment plans will always change but the patient-centered care will stay the same.
1 – Bell, S.E., & York, R. (2010). Community economic identity: The coal industry and ideology construction in West Virginia. Rural Sociology, 75(1), 111-143.
2 – Dr. X. (September 10) Conversation. Lewisburg, WV
3 – US Censu sBureau. (n.d.). Retrieved September 22, 2017, from https://bit.ly/2IAKtCx