Part Two: Condition Critical
A physician’s fight to meet rural health care needs
Disclaimer: Glenn Hurst is running for Pottawattamie County Supervisor. This article does not constitute an endorsement from PVI or the author.
By Glenn Hurst with Amanda Malaski
All too often we see think pieces about rural America – how they feel, what they believe – written by coastal city dwellers. Sometimes these pieces even discuss rural Americans as the “rural problem,” as though they are just a monolithic nut to be cracked or an electoral puzzle to be solved and not equal Americans with their own lives and stories.
In this series, I will present progressive, rural Iowan lives and stories unfiltered, with as little of my own commentary as possible.
PVI: I admit to being extremely excited when I saw a comment from a physician interested in this series. Health care is perhaps the greatest issue facing our nation right now, so I was ecstatic to be able to share the perspective of someone on the front lines of rural health care.
Glenn: I started practicing in Minden 7 years ago. At the time, I was working for a clinic in Council Bluffs who had what they called ‘outreach clinics’ in the cities of Minden and Treynor in Pottawattamie County. I lived in Omaha at that time. I had just completed a Family Medicine residency at UNMC that was designed for physicians who were planning for rural practice. I took the job with the Council Bluffs group because they had the rural sites which I would serve and the hospital would allow me to do Obstetrics as well as colonoscopy for colon cancer screening. The rural clinics were staffed minimally and the commitment from the Council Bluffs clinic was limited. Minden had a physician 1/2 day each week and Treynor had a physician 1/2 day each week and a physician assistant another 1/2 day per week.
Though it should have been obvious from the start, it became clear that the commitment to these clinics were only to the point that they served the home clinic in The Bluffs. After 2 years of fighting for their existence, I made the decision to leave the group and open a full-time clinic in Minden. This was the more remote clinic and a though a much smaller community it had a long history of a medical clinic in the community. It also had a full-time pharmacy. My family has since built a home on the north side of town and expanded the clinic services to include DOT physicals for farmers who drive trucks, pediatrics, home visits, nursing home care and medical direction, and though I continue colon cancer screening I no longer provide OB services due to being a solo practitioner and living so far from the hospital.
PVI: What challenges do you face providing health care in a rural setting?
Volume is a problem in the rural setting because the population density is much less than an urban setting. This means medications used in the office cannot be bought in volume and they will likely out date which is an overhead issue. It means that remaining competent will not be based on treating volumes of patients with similar conditions but rather from continued education and building relationships with other providers. It also means that relationships with the local emergency medical providers must be closer and there is a cooperation to keep patients safe and healthy.
To address the decreased density of population we have increased our access. Our clinic opens at 7 am so people who send students to school or who work in the city 30 minutes away can be seen in the morning. This allows decision to be made about the work or school day before traveling across the county and then having to return to be seen in the clinic. We also do home visits to our frail elderly patients who are trying to live out their lives at home without having to move to assisted living facilities for the little extra help they need. We have started a school based allergy clinic where we administer allergy shots each week so families do not have to leave work, pick up kids, take them to the allergist, return them to school and then return to work. We treat 5-7 students and faculty at the school and we calculate that our 1 hour of school clinic saves at least 50 hours of work and school time each week. I also follow my own patients in the nursing home and see them there rather than having them transfer via medical van to the clinic. I take new patients at the nursing home since I am already there and I now serve as medical director at several of those facilities.
PVI: What issues do you see your patients facing?
Access to care is the concern. There are only so many hours a day that an MD can be available and with the exponential expansion of our medical knowledge, there are limits to what a family physician can competently manage. This means relationships with specialist are necessary for the rural provider in order to co-manage complicated patient. This is a difficult process that tends to be informal in nature as travel to continuing education programs mean loss of access to the clinic for patients.
Once access is established, the rural patient lives with the knowledge that access is always at jeopardy. Recruiting a physician into a rural setting is extremely difficult, and once one is found retention is a constant effort. I attempt to address this for my community by participating as a preceptor for physician training programs. Students rotate through our clinic from the local medical schools and nurse practitioner programs. I try to develop their interest in private practice in a rural setting while teaching them how to take care of a rural population. Medical professionals tend to practice within 90 miles of where they trained. By having students train here, we are marketing the future opportunity of our clinic and “test driving” potential future providers.
The best place to find my replacement is at the local jr. high and high school. This is because the most likely person to come practice medicine in our community is someone who grew up here. That person is likely in jr. high or high school right now so it is imperative to support those with a medical interest so that they will be ready to join the practice after another 12 years of education. So I offer a scholarship to students who graduate from the local high school who declare themselves as pre-med in college and maintain their GPA. They are also given an internship in our office over the summer where they are paid to work with us and they get exposed to how a physician practice works.
Currently, access to care is also related to insurance coverage. Many patients pay out-of-pocket, meaning they have no insurance. One catastrophe or even a medical scare can put a family in financial jeopardy. Rising drug cost and soaring hospital charges affect the rural patient just like the urban patient.
PVI: It’s clear from Glenn’s story that health care is not the only industry with a lack of access for rural Iowans.
My patients are constantly asked to do more with less. Our town is lucky to have one grocery store. Many towns make due with just a convenient store. I guess in that case, it should just be called; store. Our people pay higher prices and make due with what is available rather than with what they wanted. And things like an auto shop, a salon or a hardware store are not amenities that are just around the corner.
In a 30 mile radius, my practice is the only location with a Medical Doctor. There are certainly no pediatricians or specialists practicing medicine in that area either. I have a great deal of gratitude for those patients who choose to see me but I am not unaware of the fact that I may just be the only choice a person has that day. That is a reality we all face daily.
Knowing this is part of rural reality does not mean that I accept it as appropriate. The people I serve feed this nation. They are the reason our Urban neighbors have an economy at all. Rural Iowa is Iowa! Without agricultural production there is no Des Moines, Council Bluffs or Davenport. By serving in a rural setting I get to participate in this great task of supporting Iowa. I also feel responsible for giving 100% of my skills to it and to attract and advocate for fair service for all.
PVI: What issues, aside from health care, are important to you?
Immigration is an area we must address as a nation. We cannot define our population as either legal or illegal; the shades of immigration are varied and a path to full legal status needs to be addressed for each of these shades. Legal status for immigrants in the country affects the health care system, fair employment, housing and even infrastructure. A broken immigration system built on a broken prison system has led to the immoral separation and incarceration of families without reasonable options for appeal. This also put the legal system on my radar of important issues.
From the medical perspective, we need to increase the primary care pool. One way to do this is to allow immigration of medical providers under the J1 visa program. Expansion of this program is imperative to filling the immediate coverage gap. Steps should also be made to encourage these providers to consider long term commitments to rural medicine.
I am the product of successful immigration. My great grandfather and great grandmother immigrated from Sicily at about 1910. I don’t see immigration issues directly affecting Minden at this time in terms of immigrants in the community with questionable legal status. My desire to address this issue is more linked to gratitude for the opportunity my family has been given than it is to any injustice happening in front of me.
Check back next week for Part Three, which will tell a story of a congressional candidate seeking to reinvigorate rural Iowa.
If you know someone who has a powerful rural voice, or you have one yourself, please contact me at firstname.lastname@example.org.
You can find Part One here: https://progressivevoicesofiowa.com/2017/06/22/rural-voices-part-one/