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Wednesday Jul 27, 2016

Bringing a Small Town Approach to Urban Practice

Growing up as a sickly kid in an urban environment gave me a necessary connection with family medicine at a young age.  

We simply referred to the family medicine clinic as "the doctor's office," and I never knew that the group that took care of me and prevented my asthma flares was a well-integrated team of family physicians and nurse practitioners.

Looking back, my situation was probably an outlier, because much of the care delivered in our area was provided by subspecialists. If you were pregnant or needed a women's health exam, you went to an OB/Gyn. Most kids had a pediatrician. Your grandparents with complex conditions saw internists who subspecialized in endocrinology, or gastroenterology, or some other specific body system. 

Perhaps this ingrained expectation that one would see a subspecialist was viewed as a sign of evolution to more sophisticated care, and some patients likely equated subspecialty care with higher quality care. However, this kind of fragmented health care delivery never made sense to me. My family felt more at home with the general practice doctor we grew up with.

My experience was also different because it forced me to be in the doctor's office frequently. For many, exposure to the health care system was more limited. For those fortunate, healthier individuals, a doctor's office visit represented little more than one more bill to pay in my poor, urban community. That does not kindle positive feelings.

In the city, a feeling of anonymity followed me everywhere I went. There was a sense of safety in choosing my level of engagement, even when it came to medicine. During my childhood visits to the doctor, there was little conversation beyond my terrible asthma. There was nothing like the level of dialogue with the physician that patients routinely expect today. My parents never questioned the doctor and simply took their medications, as did I. Even in that setting where we felt comfortable, we would not expect to discuss topics such as social determinants of health.

No matter how good the practice, it can be difficult to create a bond with patients. This can be due to factors such as time limitations, cultural differences or -- as in my case -- different expectations. I became a family physician because I understood the link between my personal well-being and the environmental effects surrounding me. I also saw the value of having continuity in an environment that is already fragmented for poor urban families.

I was certain that this concept was novel. However, I was deeply moved by the commonality of need when I worked in a rural community in my first job after residency. I recently switched jobs, moving from a rural practice to a more urban area. I went from being an hour away from a subspecialist to having one next door. Here, my patients walk or take the bus instead of needing a car to get everywhere. Yet despite the numerous differences between the two practice settings, the need for a family doctor hasn't changed.

Everyone deserves to see a familiar face when they need care. The patients in my rural practice underscored for me the value of having an enduring relationship with a primary care doctor. Don't we all want that situation? Like a flowing river, the world of health care is constantly changing, but as a family doctor, I can represent a common denominator for my patients. Taking this approach fosters a level of honesty and transparency that can mean the difference between early care and prevention and misuse of resources.

Even so, the lower a patient's socioeconomic ranking, the less likely it is that he or she will have the privilege of continuity. Everyone wants the highest level of care with the least amount of hassle. In the small town where I worked previously, my patients did not have the luxury of proximity to tertiary care, so they depended on me to be that link. I quickly discovered that I could safely and accurately manage the vast majority of ailments from my office. My subspecialist colleagues appreciated the collaboration, which left them time to care for more advanced and appropriate referrals. Urban practices can benefit from keeping more treatment in-house as well.

My new patients are both relieved and surprised that I can take care of their joint injections, diagnose and treat their depression, remove a suspicious mole or perform an endometrial biopsy from one office. Having such accessibility of treatment options adds value to their time as a patient.

Everyone needs an advocate. As a family doctor, I take ownership and pride in the care I give my patients. I am a resource for them and push for the care they need. What patient would not want that? Access to quality care is not defined simply as distance from care. Access also is reflected in the level of resources one has to address basic needs.

Advocacy could mean a call to a child's teacher to discuss the student's inattention as a result of domestic violence or lack of food at home. It could surface as taking time to coordinate care. From a systems standpoint, advocacy is reflected by telling legislators my patients' stories.

Everyone needs a home, as well. In a medical home, patients find support, safety and quality of care. At its foundation, that is what primary care is all about. People are not statistics -- although with the pressures of meeting quality measures and increasing productivity, it can be tempting to forget that fact. Patients need to know that we have their backs. They benefit from knowing that if I send them to a subspecialist, they will return to me. No one can get lost if they know where home is, and each medical home can use a different model to meet the needs of the community.

At its heart, small town medicine creates a level of partnership with and ownership of the patients and community served. There is a level of accountability that develops when you can see your doctor at the grocery store or on a walk. Although I cannot necessarily recreate this to a tee for my new patients, I hope to bring a sense of familiarity to my patients and give them a new sense of expectation and value to their time.  

Rural medicine is far from basic. It taught me how to be a great physician, and most of all, it taught me that all patients need the same basic things to become the best that they can be. I can be that link.

Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.

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