Aurella Smith, right, talks with Mary Silva at the Sutter Amador clinic in Plymouth. Smith is in the Rural-PRIME program, which seeks to put more doctors in rural practice.
PLYMOUTH – If you really want to know what it’s like to be a rural doctor, clear your mind of all that “Northern Exposure” stuff. That’s just TV. The reality is more like the big city than you might think.
“Patients are patients,” says Dr. Catherine Leja, prepping for a busy morning at Sutter Amador Hospital’s clinic in Plymouth, “here or anywhere.”
Aurelia Smith nods knowingly. But Smith, a University of California, Davis, medical student serving under Leja in an eight-week rotation in Amador as part of the university’s Rural-PRIME program, punctuates that nod with a sly smile hinting that there might be a kernel of truth to the hayseed stereotypes.
“Someone got bitten by a raccoon that was trying to get her chickens,” Smith says, recalling a recent patient. “You wouldn’t see that in Sacramento.”
Nor is a third-year medical student in an urban milieu likely to experience the joy of having patients bring them, as tokens of appreciation, eggs and fruit they have harvested – or even wine that they’ve made.
And there’s this: “In a city,” Smith says, “the odds of you running into a patient you’re treating for high blood pressure out eating french fries are a lot lower.”
So maybe there can be a folksy, down-home feel to practicing country medicine. But there are also challenges – from a lack of reimbursement from insurance companies for Medi-Cal cases to a shortage of specialists available for referrals and a paucity of nightlife for younger doctors – not nearly as attractive as those eggs-and-wine perks.
Such perceived negatives, along with the fact that newly minted doctors often need big-city salaries to repay five- or six-figure student loans, have resulted in a severe shortage of rural practitioners in California and nationally.
Research by the California Health Care Foundation says 16 of California’s 58 counties do not have the recommended ratio of 80 primary-care physicians per 100,000 residents. Only 9 percent of doctors work in rural communities that are home to 20 percent of the state’s population. Moreover, the average age of the state’s rural doctors is 60, close to retirement for most.
UC Davis’ Rural-PRIME program was created three years ago to train doctors in rural and other underserved areas such as immigrant and low-income communities. The medical school has teamed with health care providers in Truckee, the Fresno County town of Reedley, Shasta County and the newest locale, Amador County, to offer future practitioners a taste of rural medicine – and maybe some homemade wine.
Urban-rural prejudice?
That’s how Smith found herself living for eight weeks in Jackson and working in nearby Plymouth this fall during her UC Davis family medicine rotation. She had already logged a pediatrics rotation in Truckee and a surgical stint in Sacramento and was about to return to Tahoe for the ob/gyn phase.
Students in the program hail from large metropolitan areas (New York City, San Jose), big-city suburbs (Fullerton, Arcadia) and smaller or isolated cities (Manteca, Redding). But Smith, 32, has lived in cities big and small – born in Iowa, raised in Los Osos (a town of 14,251 near San Luis Obispo) and educated at the University of California, Berkeley – and has made a commitment to practice in a small town.
“I don’t like the big-crowd thing, where it takes two hours to get anywhere,” she says. “In Berkeley, it wasn’t quiet, ever, and you couldn’t see the stars at night – things like that you find you miss.”
But medical students also quickly find there are conveniences that rural doctors miss having, simply because of remoteness.
“Physicians train in urban areas and get used to consultants at their beck and call – and get used to having high-tech (equipment),” says Dr. Robert Hartmann, a Sutter Amador physician for 21 years and mentor to UC Davis medical students. “So they have a fear of rural areas. It’s mostly fear of the unknown. What we’re trying to do is dispel that uneasiness.
“There’s a sense that people in rural areas don’t practice medicine of the same quality as those in the city. Part of it is an urban-rural prejudice. We are hampered by some of that. If someone comes in the ER and they need an acute angioplasty, they aren’t going to get it here. But you learn a broader spectrum of medicine being out here.”
Hartmann, who doubles as the county’s health officer, and Sutter Amador CEO Anne Platt say they have been trying for two years to hire an internist. (The previous physician left to work in a larger market because, Hartmann says, her lower rural salary could not hasten the repayment of her hefty student loan.)
The hiring has been tough going. But they hope mentoring UC Davis students might help with recruiting.
“We hardly ever get nibbles,” Hartmann says. “(Job candidates say) ‘You’re rural? You don’t guarantee salaries? You have to take care of people in the hospital and not let the hospital do it?’ It scares them off.
“We’re looked on as anachronistic.”
Smith acknowledges the drawbacks but didn’t think twice about aiming to practice rural medicine. A UC Regents grant and savings have helped her keep student loans to a minimum. As for the salary disparity between rural and urban doctors, she says, “Money’s not my main motivation.”
Making a connection and helping patients are what drives her.
“You get more patients here who want to be self- sufficient,” she says. “They don’t always come to the doctor right away. They wait until something’s really bad and say, ‘I can tough it out. I don’t need medication. That’s for wimps.’ Of course, that’s not everybody.”
Busy day, lots of learning
On a recent Thursday, Leja and Smith have a typical load, about 15 appointments. (A nurse practitioner in the clinics handles about twice that many in a day.) That gives the physicians the luxury to spend more time with patients. Half-hour appointments, highly unlikely in Sacramento, are common in Plymouth.
By lunchtime, the pair have seen a woman dealing with a shoulder injury that has not responded well to cortisone injections, a 14-year-old boy with a 104-degree temperature and suspected of having the H1N1 flu, and a middle-aged woman coming in for a Pap test.
The shoulder injury proves the most challenging. The patient had slipped at work last spring and, when swelling and pain persisted in her right shoulder, Leja referred her to an orthopedic specialist. No ligament or cartilage tear was found, and the specialist ordered physical therapy. When that didn’t ease the pain, Leja and the patient settled on acupuncture as an alternative therapy.
Now, one troubling symptom is an unusual coolness in the woman’s right hand.
“I think it might be RSD (reflex sympathetic dystrophy),” Leja tells Smith. “Feel the temperature difference. It’s pretty stark. But it’s not Reynaud’s (syndrome).”
The patient then shares aspects of her life not directly connected to the injury, and the doctors listen with interest instead of steering her back, big city-style, on point. Leja eventually writes a prescription for anti-inflammatory drugs, and the patient is on her way.
In an adjacent room sits the feverish boy and his mother. He’s wearing an Amador High football jersey and a glum look. He’s missed a week of school, has had a bad cough and a fever for days. Smith and Leja wear masks in case he does have the flu – though Smith already has had a bout with it, two months ago.
Leja instructs Smith to examine the boy. She listens to his lungs with a stethescope, looks over to Leja and says, “He does have some lung crackling sounds.”
Leja concurs but holds off on ordering X-rays.
“Do you want something with codeine that’ll knock out the cough at night?” Leja asks the boy.
Before he can answer, his mother quips: “The rest of the house does.”
After the patient needing a Pap test, Smith leaves the Plymouth office and drives to Sutter Amador Hospital, 12 miles away in Jackson, for lunch (a peanut butter sandwich and her fourth Diet Coke of the young day) and a consultation with Hartmann regarding a patient in the intensive-care unit who has had a tube inserted in his mouth and into his airway to be placed on a ventilator.
“There are teaching opportunities every day out here,” Hartmann says. “We see a lot of fascinating patients. Aurelia can go back to her classmates in Sacramento and say, ‘OK, these rural guys aren’t weirdos.’ “
And, in fact, Smith ends her workday with a three-hour UC Davis class, patched in to a Sacramento classroom via video teleconferencing.
A la “The Brady Brunch,” the screen is divided into squares with the students in Sacramento at top left, two students in Truckee at top right, Smith at lower right and a student in Redding at lower left.
The students hash out their experiences in the field and, when it’s time for Smith to tell of her Jackson stay, she talks about the day the power was knocked out at the Plymouth clinic after a storm and how the staff dealt with the hardship.
“Oh, and my cat had pneumonia,” she adds. “Who knew cats got pneumonia?”
Must be a city cat.
Tags: Aurelia, Chickens, Country Medicine, Doctors Salaries, Dr Catherine, French Fries, High Blood Pressure, Insurance Companies, Medi Cal, Medical Student, Nod, Northern Exposure, Paucity, Prime Program, Raccoon, Sly Smile, Stereotypes, Student Loans, Sutter Amador Hospital, University Of California Davis
