Rural Medicine Today – A Doctor’s Perspective
To The Columbia Gorge Community:
The landscape of American medicine is changing rapidly. The rural health care landscape is hit particularly hard by these changes because there are fewer people and locations keeping systems afloat. Most of these problems stem from: drastically diminished access to primary care, loss of many types of subspecialty care, clinic closures and pharmacies under duress.
My expertise in rural health is the product of an entire life as either a consumer of, or physician in, rural areas.
In Northeast Wyoming, where I grew up, a few general practitioners were the entire medical system. The few physicians dealt with the entire range of medical practice from treating infectious disease, to internal medicine, OBGYN, pediatrics and surgery. I never shared that exact vision, but I loved the idea of broad practice, lasting patient relationships and providing care to places that typically have a tough time getting it.
After deciding on General Surgery, I sought residency training focused on rural surgery. Those five grueling years of residency proved to be some of the best of my life. I met my husband who also had a rural upbringing in the upper Hood River Valley. Upon graduation, we made conscious efforts to select jobs and lifestyle in a rural area. After numerous offers, I accepted a position at MCMC in 2015. I have loved the area’s innumerable opportunities for outdoor adventure and beautiful scenery ever since.
The thriving medical community also attracted me to the Gorge.
The availability of broad general medical and surgical services and a relative wealth of subspecialists, with proximity to Portland, has masked many of the challenges of rural medicine. Of course, the eight years of my practice have not been without their challenges. While the pandemic was a catalyst for retirements, burnout and physical/emotional/financial burdens that contribute to personnel leaving the workforce or changing jobs, the trends we have been seeing in healthcare were in motion well before COVID-19.
Rural Health systems serve as a funnel for patients converging from an enormous patient pool. Partnerships change, insurance payor mixes affect what hospitals can offer/afford, and service lines end. There is also a greater demand than ever for medical care. Patients are experiencing difficulties with re-entry into health care due to the reduced number of providers at all levels. Many patients I’m seeing have had to defer their health care, just to survive the struggles of the last few years. The result is more advanced disease presentations. Diseases that could have been more easily treatable if diagnosed during the years when care almost ground to a halt.
In summary, the current national rural health care system features sicker patients, fewer first line physicians and providers, less systemic monies, crowded service lines, insurance hang ups, fewer hospital beds, long delays and frequent inabilities to transfer to higher levels of care. Rural systems simply have less redundancy than large urban centers, it makes the problems visible, faster.
One tangible challenge in my own practice is adapting how to continue to provide excellent cancer care. Excellence in cancer care was a driving force to recruit me here. Even as a general surgeon, over half my practice is surgical oncology, or the surgical removal of cancers. Surgical oncology is one of three pillars of comprehensive cancer care – the other two are medical oncology and radiation oncology.
Medical oncologists create and monitor chemotherapy plans. Surgical and radiation oncology will continue here at MCMC, with no plans to change. However, at the end of February, there will be no regional medical oncology services in the area because the two regional medical oncology clinics have lost their physicians.
Medical oncology, as a field of study, has seen fewer physicians showing interest, with an average practicing physician age of 55 years old. Additionally, only 3% of oncologists practice in a rural community. Like most specialties, medical oncology practices are trending toward sub-specialization –treating breast or lung cancers, instead of “general” oncology. Adapting care for patients over a greater distance to travel and coordinate care will create a new challenge for physicians and patients alike.
Conversations with patients and providers yield the same sentiments –despair, fear, anger, anxiety, and a need to blame. We have all been grieving the losses of many wonderful providers and pathways that are no longer what we knew. Rebuilding integrated pathways between major centers and rural systems is a social imperative. It cannot be allowed to fail.
Major medical centers are necessary to treat patients with true sub-specialty needs but are not designed to absorb the flood of patients now cascading down the Gorge. If smaller systems fail, patients will be pushed downstream into already overflowing larger systems and problems will mount in scale and severity.
To turn the tide and preserve rural health care, adaptation will be critical. Regional centers need to consolidate resources, forge new relationships, get over grudges or perceived competition, find ways to keep care local. That will require integration of technology with more virtual visits with providers at remote locations. It means accepting that we cannot provide all services in all locations. It also means retaining our current generalist providers and recruiting more of them. Without legislative action, systemic collaboration and a fundamental improvement in the support provided to our rural health care systems, the whole landscape will look pretty barren.
The message that I hope can get out is that many of us in the rural medical community are still here to serve you. We understand the new realities of rural medicine and will see these multifaceted crises through, to affect the necessary changes and repairs. As we search for solutions to the crises, I have recently started to feel something else — HOPE. There is already rebuilding in progress for medical oncology and other areas as we speak.
In spite of very real problems, the Columbia River Gorge has a strong medical community. I am privileged to work side by side with a committed team of talented people with conviction and skills to sustain rural medicine. For those who have need to transfer care until a rebuild can happen, we will be here to help you find ways to continue your care. My hope at this difficult moment is that we can work to rebuild our rural system, and ultimately evolving to make it better and more sustainable.
We are still here, working for you, our families, friends, and neighbors. Rural health care is too important to fail.
Caitlin McCarthy, M.D., B.S.