Family Medicine Vital Signs

By: Julia Kammel, MD

Have you ever heard of Bicknell, Utah? Neither had I. During our residency program we each have the opportunity to experience a month in a rural part of the country to learn how medicine is practiced there. I was lucky enough to be placed in Bicknell, Utah. To be honest, when I received my placement I had to do a google search to learn where I was being sent for a month. I found a tiny little town of 300 people in south-central Utah. It was a town that most people probably do not notice as they drive through since it only takes about three minutes to pass through.

I drove down to this tiny little town to find an equally tiny, but adorable 300sq ft place where I would be living for the month. The scenery was breathtaking. It was in the heart of red rock country, as if out of the pages of a country western novel. I could see Butch Cassidy and his gang riding through these hills. As I settled into my new home I began to appreciate the pace of life. Away from the busy streets of the city I could walk to work and count the cars that passed by the house on two hands. Residency life can be incredibly busy and stressful. I had become used to juggling so many things at the same time that I did not realize that my mind was constantly multitasking. Every day in residency is different and if you do not look at your schedule for the next day, it is likely that you may not show up at the right location. As I was walking down the peaceful street to the clinic that I went to almost every day, I had a moment to step away from the high-speed rat race that life can become.

The clinic I worked in was small but well designed. It had a pharmacy, dental office, clinic rooms, and an area to handle slightly higher acuity cases. One physician staffed the clinic with the help of multiple physician’s assistants. The staff included nurses and medical assistants who were very welcoming and friendly. They came in from neighboring towns where many of them had grown up. The community was small and often the patients were well known to the staff. The chief physician himself knew many of the patients as friends that he had grown up within the community. The clinic was a Community Health Center (CHC), which is a government-funded set of clinics that allows patients to receive care at a reduced rate and serves a lower income population. Many of the patients I treated had driven two hours to come to their appointments since this was the only medical care that they were able to afford. At the time of writing this article, Congress has not yet agreed to long-term funding to allow CHCs to continue to provide care. The cut to funding would likely cause about nine million patients to lose access to care.

Rural life was calming and peaceful to me, however, as I learned from my mentor, the decisions that rural physicians have to make can be incredibly challenging. In academic hospitals and clinics, there are always specialists to call when you have a question and ordering a battery of tests to determine your diagnosis is very common. In this clinic, however, we only had a handful of tests that we could run; CBC, Chem8, urine analysis, pregnancy tests, INR, and a few others. For anything else, you would have to send it over the mountains. Your physical exam and history taking skills became even more important. Often times I found myself wishing I could refer to a specialist but most specialists were in the Salt Lake City area and the patients very rarely could be convinced to drive 3-4 hours further to make these appointments.

In addition to the challenges of making diagnoses and limited access to specialists, the providers in Bicknell also managed the weight of the responsibility that came with managing cases of higher acuity. If a patient had a higher risk problem on their differential you had to be quite certain that it was not high on your list as the closest ER was a minimum of one hour away. In the ER itself, the doctor running the ER had to manage all the cases that came in. Unlike in many of the ERs I had worked at in the city where a team of surgeons could be called if there was a concerning trauma coming in, but that was not the case in the Bicknell ER. We were lucky that one surgeon was able to come during one instance. Air transport was often over an hour away so transfers were sometimes not an option.

Being able to be a part of and witness these difficult situations that rural physicians have to manage gave me an incredible amount of respect for their work. Being coddled in the academic world with the latest research updates at your fingertips can make some physicians look down on rural practitioners. However, until you are in their shoes managing the challenges they deal with there is no room to judge. I am grateful for the opportunity to live and work with such amazing practitioners.

Julia Kammel, MD, is a resident in the Family Medicine Division. She received her undergraduate degree from the University of Illinois and attended Georgetown University for medical school. Her areas of interest include sports and wilderness medicine, wellness, and underserved medicine. In her free time, she enjoys nature, rock climbing, kitesurfing, and paragliding.