With all the problems facing healthcare professionals today, perhaps the most challenging arena of all is providing primary care in rural areas. Despite those challenges, however, several Alabama physicians also tout the advantages of choosing a rural setting.
"There's a lot of personal satisfaction in practicing medicine in rural Alabama," said John F. Simmons, Sr., MD, who practices in Geneva. "We get to practice the whole gamut of medicine. Here, if you see a rash, it's not easy to send the patient to a dermatologist, or to send someone who's wheezing to a lung specialist. You get to make the decisions, which is both challenging and rewarding."
Despite the rewards, Simmons said it is still difficult to recruit new physicians to rural areas, where restaurants, shopping and cultural activities are more limited.
"But the biggest challenge is time," he said. "There are great opportunities in urban areas for family doctors to work 38 hours a week on salary with no call and no weekends. I probably average 80 hours a week."
Julia Boothe, MD
"Students graduate with essentially a mortgage worth of school debt, and they are hesitant to go into rural practice where you might not make money for a couple of years," said Julia Boothe, MD in Reform, Alabama. "Historically, rural hospitals would hire the providers, but their business plan is so unsteady now, they can't recruit like they could 10 or 15 years ago."
General Shane Lee, MD of Marion, Alabama, in Perry County, has not been successful recruiting physicians to join his practice, and he uses nurse practitioners to help keep up with patient load. "Thank God for nurse practitioners," he said. "I was one of the first guys on the block to partner with them. I was getting destroyed and it was the only way I could get help."
Transportation is an additional challenge for rural patients and caregivers. "People here have to use clandestine taxi service and pay someone $10 to get to the clinic," Lee said. "I've had to give people gas money before."
The transportation issue creates problems with compliance on some tests such as mammograms and colonoscopies. "We see about a 20 percent compliance on colon cancer screenings," Lee said. "You have to drive 30 miles on rural roads to see a surgeon. And you have to have someone drive back with you, usually at 5:30 in the morning. Nobody wants to do that."
Boothe said transportation is also a huge issue in Pickens County. "I've learned to ask if patients have someone to take them to the clinic or specialist, and if they can afford to pay whatever that person will charge. We were not trained to do this in medical school."
In some cases, even getting to a drug store can be a challenge. "Most of our local pharmacies are very good," Boothe said. "But a lot of my patients have insurance plans that require them to use Walgreens. The nearest Walgreens is 45 miles away."
Transportation is only one part of the problem when it comes to drug stores, where independent pharmacies, like rural hospitals, are closing their doors and insurance policies are dictating the use of chain stores. "It's hard to call up the pharmacist and chat with them about patient compliance when it's a 1-800 number," Lee said.
Electronic health records and internet connections are also challenges for the rural physician. "I'm on a first name basis with our local internet provider," Boothe said. "We pay $1,000 a month for internet service, because we have to have a certain upload speed for EHR. That doesn't include the cost for IT, and I have to pay for a tech to come from Birmingham."
"EHR is horrendously difficult," Lee said. "My computer has been down all day, so I can't do medical records. That means another evening at the clinic, because IT has to drive 30 miles to see what's wrong with the computer. Electronic medical records have been a real coffin-nail for primary care. Specialists are able to template, but in primary care, we have to manage multicomplexity. You are not just managing diabetes but also depression and other diagnoses. I used to see 60 patients a day and walk out of the door at 5:00. I can now only see 25, and I'm at the clinic until 8:00 at night."
Simmons has opted not to use electronic health records and pay the financial penalty. "Patients like to look at me; they don't want to see me on a laptop," he said. "When I'm in the room, I talk to them." He quoted studies that show a decrease in productivity by between 10 and 50 percent after moving to electronic records.
Despite the struggles, all three physicians agreed there are benefits. And two of the doctors have sons following in their footsteps. Lee has a son in residency who is planning to come back to Marion. "I've encouraged him to give it a shot," he said. "It's not all bad. I live on a farm and have a four-mile drive to work. My staff is superb and my patients are loyal. You never get bored professionally."
Boothe agreed. "I can do all the procedures I've been trained in and can apply those. You never know what's coming in the door next," she said. "It's exciting."
Simmons' son joined him in practice two years ago, a decision he made while still a senior in high school. He had seen the impact of the clinic on generations of families, and he told his dad, "I want to do what you do."
"As a rural physician you are part of a community and you can make a difference," Simmons said. "I've never missed one of my kid's ball games or programs or graduations. I feel blessed and would choose the same path again."